The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care

Abstract

IMPORTANCE Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified. OBJECTIVE To quantify the prevalence and cost of treatment perceived to be futile in adult critical care. DESIGN, SETTING, AND PARTICIPANTS To develop a common definition of futile care, we convened a focus group of clinicians who care for critically ill patients. On a daily basis for 3 months, we surveyed critical care specialists in 5 intensive care units (ICUs) at an academic health care system to identify patients whom the physicians believed were receiving futile treatment. Using a multivariate model, we identified patient and clinician characteristics associated with patients perceived to be receiving futile treatment. We estimated the total cost of futile treatment by summing the charges of each day of receiving perceived futile treatment and converting to costs. MAIN OUTCOME AND MEASURE Prevalence of patients perceived to be receiving futile treatment. RESULTS During a 3-month period, there were 6916 assessments by 36 critical care specialists of 1136 patients. Of these patients, 904 (80%) were never perceived to be receiving futile treatment, 98 (8.6%) were perceived as receiving probably futile treatment, 123 (11%) were perceived as receiving futile treatment, and 11 (1%) were perceived as receiving futile treatment only on the day they transitioned to palliative care. The patients with futile treatment assessments received 464 days of treatment perceived to be futile in critical care (range, 1-58 days), accounting for 6.7% of all assessed patient days in the 5 ICUs studied. Eighty-four of the 123 patients perceived as receiving futile treatment died before hospital discharge and 20 within 6 months of ICU care (6-month mortality rate of 85%), with survivors remaining in severely compromised health states. The cost of futile treatment in critical care was estimated at $2.6 million. CONCLUSIONS AND RELEVANCE In 1 health system, treatment in critical care that is perceived to be futile is common and the cost is substantial.

Screening Situations for Risk of Ethical Conflicts: A Pilot Study

“…31,32,[36][37][38] The negative effects of ethical conflicts are widespread for patients, patients' families, and health care providers. Quality care and patient safety are threatened when health care providers are burdened by stressful ethical conflicts that erode interpersonal trust, compromise working relationships, and fragment care.…”

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

“…4 Surveys have shown that clinicians sometimes perceive care in the intensive care unit (ICU) as inappropriate or futile, resulting in high costs and resource utilization. 5,6 Moral distress occurs when individuals believe they are unable to act in accordance with their ethical beliefs due to hierarchical or institutional constraints. 7 Mobley et al hypothesized that the intensity and frequency of moral distress increased with exposure time to futile care, resulting in burnout and emotional exhaustion.…”

The Authors Reply

“…[4] The cost of futile critical care is also substantial. Hyunh et al [5] reported that the cost of one day of treatment in the ICU that was perceived to be futile was more than $4,000. During the study period, total costs of futile critical care were 3.5% of total hospital costs.…”

“…It has been demonstrated that futile care in the ICU is associated with delays in appropriate management of other patients requiring critical care [4] and is related to substantial costs in the health care system. [5] Futile critical care also causes moral distress among nurses and could cause an ethical conflict between the ICU physicians and patient families. [6] Although EOL decisions in the ICU are important, a number of physicians hesitate to talk with families about DNR orders when the patient's condition is acutely deteriorating.…”