Who Is “Too Sick to Benefit”?

Abstract

Intensive care units provide focused, aggressive medical intervention to critically ill patients. Physicians responsible for ICU triage must decide which patients are sick enough to require this level of care and which can be managed on the general wards. While some patients are too well for the ICU, intensivists increasingly rely on another category, “too sick to benefit,” when denying ICU admission, even if beds are readily available. Recent studies indicate that between 19 and 37 percent of patients refused ICU admission were declined because they were thought too sick to benefit from it, suggesting that physician use of this category is common in ICU triage. The idea of being too sick to benefit may seem paradoxical given that ICUs exist to treat the sickest of the sick. There is, however, increasing awareness that some diseases progress despite maximal intervention. Although there have been systematic attempts to define these diseases—most notably during the medical futility debates of the 1980s and early 1990s—there is little evidence about which conditions make a patient too sick to benefit from ICU admission. In the absence of a clear understanding of which diseases progress despite maximal care, ICU triage under the category “too sick to benefit” is currently done on a case‐by‐case basis. Contemporary decisions about who is too sick to benefit thus raise a number of ethical issues about what constitutes standard of care, the role of health care providers' judgments of quality of life in triage, and the just allocation of resources. Addressing these ethical concerns requires us to better define the population of critically ill adults who are too sick to benefit—a conceptual and empirical project. In this article, I recommend employing a diagnostic concept from the neonatal literature: namely, a lethal disease.

Ethical language and decision-making for prenatally diagnosed lethal malformations

“…This raises a question about how high a chance of death is sufficient to fit into a lethal category. The cited proportion ranges from 50% to ‘almost all’ [16,19] . There is neither agreement about the correct proportion, nor any obvious way to determine where the cut-off should lie.…”

“…There is a concept in medical ethics that shares some features with that of LM: the concept of ‘medical futility’ [9,19] . Medical futility emerged in the 1990s as a potential way to resolve disputes between patients and doctors about life-sustaining treatment [62] .…”

Medical Futility or Persistent Therapy? A Dispute over the Terms and Definitions in the Polish Context

“…Building a warm relationship based on openness and trust between the doctor (or medical personnel) and the patient (or family or representative) may prove to be a key issue in making a decision on discontinuing therapy (McAndrew, Hardin, 2020;Andersen, Abrahams, Borasio, Carvalho de, Chio, Damme Van, Weber, 2012). Third, palliative care as an alternative to aggressive treatment still seems to be mentioned too rarely in the discussion on persistent therapy and medical futility (Courtwright, 2012). Even though therapy may prove futile for a patient, palliative care is never futile (Jenal, Moreno, 2017, p. 114;Schneiderman, 2011, p. 130).…”

Intensive care unit outcome in the elderly

“…8 The ethical dilemmas and practical problems posed by triage for intensive care are well described. [9][10][11] Second, what do they understand and believe about the ethics of health-care rationing, in particular whether the 'women and children first' moral code of the lifeboat dilemma applies to ICU. If one believes younger lives are more valuable, one would also adhere to the principles behind the 'complete lives system' or economic rationalism.…”