A report from researchers at UCLA is intended to be a wake-up call about the use of medical technologies and tools that if not appropriately applied, "end up extending the dying process, not benefiting the patient in the ICU bed."
UCLA critical care specialists say 11% of 1,136 patients under their care in five intensive care units received aggressive treatment the doctors considered futile, at a cost of $2.6 million for three months, and another 8.6% were "probably" receiving futile care.
That account is in a report by researchers at Ronald Reagan UCLA and UCLA Medical Center in Santa Monica published Monday in the JAMA Internal Medicine.
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The care was not considered futile when these patients were first admitted, "but after the intensive care treatment didn't work, it became clear they weren't going to benefit from this level of care," explains senior author Neil S. Wenger, MD, who directs the UCLA Healthcare Ethics Center.
Wenger says that the report is "intended to be a wake-up call for everyone [who says] that medicine has amazing tools. Medicine is able to rescue people that would have died. But those tools need to be appropriately applied, and if not appropriately applied, you end up extending the dying process, not benefiting the patient in the ICU bed, probably not benefitting the family, and using resources that probably could be better used elsewhere."
Those tools, he adds, "ventilators, dialysis and ECMO [extracorporeal membrane oxygenation] machines, drugs and left ventricular assist devices, things that beat instead of the heart—they work for some people, but not others, and it's when they've done their best to make patients better but they're not better, that these doctors are saying we shouldn't do this anymore; we should be converting to palliative care."
For the most part, these ICU patients "didn't have the capacity to appreciate the care they were receiving," Wenger says. "Some were in a persistent vegetative state, with severe cognitive impairment, or fed through a tube and couldn't interact."
"It does leave you with the question [of] why (these critical care specialists) are continuing to provide this treatment if they're calling it futile."
Sometimes, "families don't want to hear it and don't want to pull back, and doctors feel caught in between. And maybe doctors aren't having conversations quite well enough so families truly understand in a timely enough fashion. In some cases, these patients were very ill before they came to the ICU, but there hadn't been adequate conversations directly with these patients about the goals of their care," Wegner says.
Researchers, he adds, think the problem lies in lack of communication, among and between doctors caring for the patients and between caregivers and families.
"That's our suspicion, that there hasn't been enough discussion even before the patient got to the ICU, and perhaps afterwards."
Wenger says the researchers asked these critical care specialists to assess the patients they were caring for that day, and there were few disagreements when different doctors were assigned to the same patients on subsequent days.
Sometimes when a new doctor rotated on to an ICU, however, "the new doctor would frequently not rate the care as being futile on the first or second day. They said it took them a few days to get to know the patient well enough to make a statement."
As evidence of how futile the care was, of the 123 patients said by physicians to be receiving futile care, 84 died during hospitalization and another 20 died within six months of their ICU stay. The rest were described as having irreversible illnesses including severe cognitive impairment, end stage dementia, anoxic brain injury, persistent vegetative state, or multi-organ failure.
Wenger says that the $2.6 million estimated of cost of care for these 123 patients is probably greatly underestimated, because the estimated $4,004 cost per day of futile care was only calculated on days that physicians described the care as futile. The cost estimate did not include care for patients said to be "probably futile."
Wenger says it's unclear whether the finding can be extrapolated to other academic medical centers, or non-teaching community hospitals, whether profit or non-profit.
On one hand, a hospital system like UCLA's "is where a patient comes to get saved when they're about to die, a hospital that does organ transplants, and it may very well be that those same factors contribute to continuing to try hard even after you feel the treatments aren't useful."
In an accompanying invited commentary, Robert Truog, MD and Douglas B. White, MD, of Harvard Medical School's Department of Global Health and Social Medicine, were critical of the UCLA report.
First, they wrote that the assessments were made by "a single physician making a single assessment about futility," with no information on whether other doctors or members of the care team, including family, shared their views that care was futile.
Second, much of the $2.6 million cost represents fixed costs of running an ICU, "that cannot be eliminated unless critical care beds are closed," so the cost estimates "are almost certainly less."
Additionally, they wrote, "there is ongoing debate about the boundaries of acceptable practice near the end of life. Short of brain death, there are no criteria or rules to which clinicians can appeal to justify decisions to refuse life support, at least when those treatments hold even a small chance of achieving the patient's goals."