Futile treatment in critical care common, costs can be substantial

Critical care treatment for patients that was perceived to be futile was common and cost an estimated at $2.6 million at one academic medical center during a three-month period, according to a report published by JAMA Internal Medicine.

Physicians often perceive as futile those intensive care interventions that prolong life without achieving an effect for the patient that would be viewed as a benefit. Thanh N. Huynh, M.D., M.S.H.S., of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues sought to quantify the prevalence and cost of treatment thought to be futile in adult critical care.

Researchers asked critical care specialists to identify patients they believed were receiving futile treat,emt in five intensive care units (ICUs) at an academic medical center on a daily basis for three months.

Thirty-six critical care specialists assessed 1,136 patients and judged that 904 (80 percent) never received futile treatment, 98 (8.6 percent) received probably futile treatment, 123 (11 percent) received futile treatment and 11 (1 percent) received futile treatment only on the day they transitioned to palliative care, according to the results.

"The most common reason treatment was perceived as futile was that the burdens grossly outweighed the benefits (58 percent). This reason was followed by treatment could never reach the patient's goals (51 percent), death was imminent (37 percent), and the patient would never be able to survive outside an ICU (36 percent)," according to the study results.

The average cost for one day of treatment in the ICU that was perceived as futile was $4,004. For the 123 patients categorized as receiving futile care, hospital costs (ICU and subsequent non-ICU days) for the care that was thought to be futile totaled $2.6 million, which was 3.5 percent of the total hospital costs for the 1,136 patients in the study, the results also indicate.

"In summary, in our health system, critical care physicians frequently perceived that they are providing futile treatment, and the cost is substantial. Identifying and quantitating ICU treatment that is perceived as futile is a first step toward refocusing care on treatments that are more likely to benefit patients," the authors conclude.

In a commentary, Robert D. Truog, M.D., of Harvard Medical School, Boston, and Douglas B. White, M.D., M.A.S., of the University of Pittsburgh School of Medicine, write: "We offer four suggestions for how clinicians in critical care units should conceptualize and respond to requests for treatment that they judge to be futile or wrong. First, we believe that clinicians should generally avoid using the term futile to describe such treatment and instead use the term potentially inappropriate. … Second, from an ethical and legal standpoint, these disputes are often more complicated than they seem. … Third, clinicians' initial response to requests for treatments that they believe are wrong should be to increase communication with the patient or the patient's surrogate rather than simply refuse the request. … Fourth, if the conflict becomes intractable despite intensive communication, clinicians should pursue a fair process of dispute resolution rather than refusing unilaterally to provide treatment."

"When disputes arise despite sustained efforts to prevent them, a stepwise procedural approach to resolving conflicts is essential," they conclude.