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Does 'futile' care needlessly clog the ICU?

Over a three month period, 11 percent of ICU patients received futile care, according to a new journal article.
Over a three month period, 11 percent of ICU patients received futile care, according to a new journal article. Tim Samoff/Flickr Creative Commons

If a patient in the intensive care unit is receiving futile care, can that hurt another patient’s chances of getting needed treatment? In the journal Critical Care Medicine, researchers from UCLA and RAND Health conclude: Yes.

"Virtually no one worries that health resources that get used in one area, might be affecting the treatment that others receive, and this is a sort of fact check," Dr. Neil Wenger, a professor at UCLA's David Geffen School of Medicine and one of the article's authors, tells Impatient.

"The reality of the situation is that for treatments that many people really need and most people want, there can be limitations," he continues. "One of the limitations is when the treatments are used ineffectively."

Futile care

Before we dive into this debate, let's back up. What's futile care, anyway?

The study says clinicians generally define futile care as "aggressive treatments that prolong life without achieving an effect that the patient can meaningfully appreciate."

Wenger goes into further detail: For example, he says, it's care for "someone who is going to die in the next few days or weeks, but we can keep them alive for days or weeks [more] using a machine, even though we're sure they are going to die."

Measuring futile care

The study's authors find the provision of futile care can have a cascading effect.

Here's how they measured that: During a three-month period, providers assessed 1,136 ICU patients at an academic medical center serving the Los Angeles area, and at an academically-affiliated community hospital.

As part of the study, the clinicians filled out a questionnaire for each of those patients: Did they think the patient was receiving futile care, care that was probably futile, or care that was not futile?

The researchers determined that 98 patients (about 8.6 percent) received treatment that was probably futile, and 123 patients (11 percent) got futile treatment. Those 123 patients received a total of 464 days of treatment.

Of the patients who received futile care in the ICU, 68 percent died before hospital discharge, 85 percent died within six months, and survivors remained "in severely compromised health states," according to the study.

Wengers says some of the study's critics have asked, if the care is futile, shouldn't there be a 100 percent death rate?

"Death isn't the only adverse outcome," Wenger says. "Patients tell me all the time, 'there are many things that are worse than death.'"

The impact

The study documents how other patients' admission from the emergency department to the ICU was delayed, when there was at least one patient receiving futile care in the unit.

It finds that during the study period, 33 patients had to stay in the emergency department for more than four hours after they were officially admitted to the ICU, because the ICU was at capacity and a patient was receiving futile treatment, according to the report.

It also details how other patients' transfers from the emergency department to the ICU were delayed, when the unit was full and at least one patient was receiving futile treatment.

For example, there were 163 transfer requests to ICUs during the study period. Nine patients spent a total of 16 days waiting to be transferred when the ICU was full and at least one patient was receiving futile care. Fifteen patient transfers were cancelled; among those were two patients who died while awaiting transfers.

The authors say they can't determine if the two patients who died would have survived if they'd been transferred to an ICU in a more timely fashion. However, "these potentially adverse events can be traced to bed unavailability due to critical care units providing treatment that was perceived by the treating physician to be futile."

A philosophical question

The authors write that in the medical setting, the adage of "first come, first served" is "not only inefficient and wasteful, but it is also contrary to medicine's responsibility to apply healthcare resources to best serve society."

Wenger says he and the other authors hope their study sparks discussion about the implications of providing futile care. He adds that one solution is to ensure that doctors, patients and their families have high-quality, and more frequent, conversations about a prognosis and what medicine can be expected to accomplish.

"The protocol is advanced care planning, and with very, very good advanced care planning, there would be extremely few of these cases," Wenger says.

We've got a lot of great information about end-of-life planning and choices, including how to access and fill out a Physician Orders for Life-Sustaining Treatment (POLST) form, here.

Has a loved one or friend received what you would consider futile treatment? Have you, or a loved one, experienced a delay in care, due to a full ICU? For those who work in intensive care units: How do you make decisions about who gets treatment? Tell us about it in the comment section below, or e-mail us at impatient@scpr.org.

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