The Opportunity Cost of Futile Treatment in the ICU*

Abstract

Objective When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” While futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided. Design For 3 months, we surveyed critical care physicians in 5 intensive care units (ICUs) to identify patients that clinicians identified as receiving futile treatment. We identified days when an ICU was full and containedat least one patient who was receiving futile treatment. For those days, we evaluated the number of patients waiting for ICU admission more than 4 hours in the emergency department (ED) or more than 1 day at an outside hospital. Setting One health system that included a quaternary care medical center and an affiliated community hospital. Patients Critically ill patients Interventions none Measurements Boarding time in the ED and waiting time on the transfer list Main Results 36 critical care specialists made 6916 assessments on 1136 patients of whom 123 were assessed to receive futile treatment. A full ICU was less likely to contain a patient receiving futile treatment compared to an ICU with available beds (38% v 68%, p<0.001). On 72 (16%) days, an ICU was full and contained at least one patient receiving futile treatment. During these days, 33 patients boarded in the ED for >4 hours after admitted to the ICU team, 9patients waited >1 day to be transferred from an outside hospital, and 15 patients cancelled the transfer request after waiting >1 day. Two patients died while waiting to be transferred. Conclusions Futile critical care was associated with delays in care to other patients.

Preoperative risk stratification of critically ill patients

“…Indeed, Huynh and colleagues identified the following as features of futile ICU treatment: burdens grossly outweigh benefits, survival unlikely outside of an ICU, and treatment cannot achieve the patient's goals [21]. Over 10% of critically ill patients may experience futile treatment, with an associated opportunity cost in delayed treatment to other patients in the emergency room and from outside hospitals [21,22]. Moving from the ICU to the operating room often inverts the ratio of providers to patients, further contributing to a potential opportunity cost of futile interventions in the perioperative environment.…”

Judgment of Futile Care in the ICU

“…To the Editor: I n a recent issue of Critical Care Medicine, Huynh et al (1) reported about the cost of futile treatment in the ICU. They make a valiant attempt to assess the impact of futile care provided in the ICU on patients awaiting ICU admission and costs to the healthcare system at large.…”

Futility and appropriateness: challenging words, important concepts

“…They have an impact on the quality of dying 12. With regard to the ICU, NBTs may result in limited access to treatment for other patients with a greater chance of survival—so-called ‘opportunity cost’ 13. Finally, NBTs are wasteful and costly14 compromising the availability of resources for more appropriate supportive care 15 16.…”