'Rule of rescue' often prevails in critical care units
High stakes life and death decisions are made every day by doctors and nurses in critical care units, but increasingly critical care clinicians are also tasked with containing costs and managing scarce resources in light of rising demands for and costs of care they provide. Physicians are often asked to consider limiting services for their patients to benefit society more broadly. Now, a new study from the Perelman School of Medicine at the University of Pennsylvania indicates that the so-called "rule of rescue" -- whereby clinicians are prone to try to save their own patients as opposed to opening up a bed for a new patient -- often prevails even in the face of substantial social benefit in terms of cost containment and procurement of organ donations.
"Our study suggests that many intensive care unit (ICU) clinicians are prone to provide salvage critical care for identifiable patients with grave prognoses even when doing so measurably contravenes society's interests," said Scott Halpern, MD, PhD, MBE, assistant professor of Medicine and Epidemiology, and the study's senior author. "Adherence to this 'rule of rescue' accords with traditional norms for clinicians of prioritizing one's own patients, but contrasts with recent conceptualizations of medical professionals' social responsibilities."
Although it is clear that critical care clinicians must routinely weigh the need and demand for medical resources in the ICU, few studies have examined how clinicians balance their duties to current patients with the additional responsibilities to promote, or at least not discount, societal interests.
To explore this issue, the researchers analyzed mixed methods questionnaires from 1,122 ICU clinicians in the U.S., 648 physicians and 438 nurses. The questionnaires addressed the clinicians' preferences for allocating their last bed in the ICU to a gravely ill patient already being treated, but with little chance to survive, versus an incoming deceased or dying patient for whom aggressive management could help others through organ donation.
Physicians were more likely than nurses to adhere to the ''rule of rescue'' by allocating the last bed to the gravely ill patient (45.9 vs. 32.6 percent). The questionnaire also revealed that the magnitude of the "social benefit" to be obtained through organ donor management (5 or 30 life-years added for transplant recipients) had small and inconsistent effects on clinicians’ willingness to prioritize the donor, suggesting that clinicians’ willingness to act to promote society’s interests does not depend prominently on the magnitude of those interests.
In the qualitative analyses, the most common reason for allocating the last bed to an identifiable patient (identified by 65 percent of physicians and 75 percent of nurses) was that clinicians perceived strong obligations and fidelity to identifiable living patients.
"Taken together, these mixed qualitative and quantitative results provide empirical verification of predictions that the 'rule of rescue' represents a substantial and persistent barrier to the efficient allocation of scarce resources and may impede efforts to improve patient triage or constrain costs," concluded Rachel Kohn, MD, lead author of the study and a graduate of the Perelman School of Medicine. "Our findings indicate that future research is needed to identify the actual frequencies with which clinicians prioritize individual patients when doing so carries real social costs, and to further explore factors related to the observed variability in allocation patterns among clinicians."
The research is published in the July 2011 edition of Intensive Care Medicine.
