Monday, September 16, 2013

"Futile" Critical Care

This is an important new article in JAMA, showing the prevalence and costs of futile critical care.
In this study 20% of the critical care cases studied were deemed to be "futile" or "probably futile", at an average cost of $4,000/day and $21,000 per patient.

The reasons care was deemed futile are telling:

  • 58%- Burdens of treatment grossly outweighed benefits
  • 51%- Treatment could never reach the patient's goals
  • 37%- Death was imminent
  • 36%- The patient would never survive outside of ICU

Of the patients receiving futile treatments, 68% died before discharge, with a total 6-month mortality rate of 85%. Most "survivors": were discharged to long-term acute care or long-term care in severely compromised states, dependent on life sustaining treatments. A few were discharged to hospice or home to die. Most of these "survivors" were living in states that many would perceive as worse than death: dependent on life support or life-sustaining treatments, unresponsive or with severe medical problems.

An important aspect of the burden of futile treatments that was not examined in this study was the suffering that these patients endured during this time. The tremendous burden on their loved ones, particularly when they were likely confronted with many difficult decisions and ongoing stress and uncertainty was also not examined. Yet based on our own experiences and what we have witnessed in the families we have cared for, we can infer the importance of this issue. The author's commentary on this study on the RAND blog can be found here.

The patients and families in this study lost the opportunity for a "good death" experience. Their loved ones lost the opportunity for positive last memories of their loved ones. These last memories , whether positive or negative, are something their loved ones live with for the rest of their lives. When the memories are negative they may have complicated grief, ongoing anxiety or regret.

Timely advance care planning and realistic assessment of patients' status with honest communication are important ways we can help avoid these situations. POLST forms can help translate the wishes of the patient with end-stage chronic illness into medical orders that will be implemented wherever the patient is, avoiding unwanted and inappropriate resuscitation and life-sustaining treatments that lead to this situation. We can help promote education of acute and critical care staff about the costs of futile treatments and the alternative of transitioning to palliative care in a timely fashion in those who are in a futile state, so they and their families can have a quality end of life experience, instead of prolonged suffering.

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