A Shocking Admission: Patient Exclusion From Intensive Care Therapy

Howard, G.

doi:10.1016/s1441-2772(23)01657-5

Critical Care and Resuscitation

2005

DOI: 10.1016/s1441-2772(23)01657-5

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A Shocking Admission: Patient Exclusion From Intensive Care Therapy

G. Howard

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Cited by 2 publications

References 7 publications

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Who Is “Too Sick to Benefit”?

Courtwright¹

2012

Hastings Center Report

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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.

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Who Is “Too Sick to Benefit”?

Courtwright¹

2012

Hastings Center Report

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The self-regulating nature of occupancy in ICUs: stochastic homoeostasis

Varney

Bean

Mackay

2018

Health Care Manag Sci

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As pressure on the health system grows, intensive care units (ICUs) are increasingly operating close to their capacity. This has led a number of authors to describe a link between admission and discharge behaviours, labelled variously as: 'bumping', 'demand-driven discharge', 'premature discharge' etc. These labels all describe the situation that arises when a patient is discharged to make room for the more acute arriving patient. This link between the admission and discharge behaviours, and other potential occupancy-management behaviours, can create a correlation between the arrival process and LOS distribution. In this paper, we demonstrate the considerable problems that this correlation structure can cause capacity models built on queueing theory, including discrete event simulation (DES) models; and provide a simple and robust solution to this modelling problem. This paper provides an indication of the scope of this problem, by showing that this correlation structure is present in most of the 37 ICUs in Australia. An indication of the size of the problem is provided using one ICU in Australia. By incorrectly assuming that the arrival process and LOS distribution are independent (i.e. that the correlation structure does not exist) for an occupancy DES model, we show that the crucial turn-away rates are markedly inaccurate, whilst the mean occupancy remains unaffected. For the scenarios tested, the turn-away rates were over-estimated by up to 46 days per year. Finally, we present simple and robust methods to: test for this correlation, and account for this correlation structure when simulating the occupancy of an ICU.

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A Shocking Admission: Patient Exclusion From Intensive Care Therapy

Cited by 2 publications

References 7 publications

Who Is “Too Sick to Benefit”?

Who Is “Too Sick to Benefit”?

The self-regulating nature of occupancy in ICUs: stochastic homoeostasis

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