Dr. Thanh Huynh
Intensive care interventions that sustain life without achieving an outcome that a patient can meaningfully appreciate are often considered futile by health care providers.
Reporting in the Sept. 9 online issue of the journal JAMA Internal Medicine, the UCLA and RAND researchers found that the majority of patients admitted to the ICU received appropriate care but that 11 percent of them received treatments during their ICU course that their physicians saw as futile. The study took place at a single health care system.
Advances in medicine have enabled critical care specialists to save lives under extraordinary circumstances. Still, researchers say, admission to the ICU should be considered a “therapeutic trial,” and when aggressive critical care fails to achieve an acceptable state of health for the patient, the patient should be transitioned to palliative care.
While previous studies of ICU physicians in the U.S., Canada and Europe have shown that such futile care occurs, the UCLA–RAND team wanted to better quantify the frequency and expense of physician-perceived futile treatment in adult critical care.”Recognizing and quantifying the prevalence and cost of futile treatment is the first step toward refocusing medical treatments to those that are more likely to benefit patients,” said the study’s first author, Dr. Thanh Huynh, a clinical instructor of medicine in the division of pulmonary and critical care medicine at the David Geffen School of Medicine at UCLA.
“Futile treatment occurs in hospitals across the country. We have fantastic technology available in ICUs that saves lives, but we also need to address how to use it appropriately when the patient may not benefit from such high-intensity measures,” said senior author Dr. Neil Wenger, a professor of medicine in the division of general internal medicine and health services research and director of the UCLA Healthcare Ethics Center at the Geffen School of Medicine. Wenger is also a consulting researcher with RAND.
The researchers note that in future research, they hope to identify the factors that are driving futile treatment so that such treatment can be minimized. There are many complex issues in ICUs, especially at the end of life. Factors such as misperceptions of prognosis, the wishes of patients’ families or differing views among a patient’s care team may play a role.
“If we can identify the factors that promote futile treatment, perhaps we can also develop the interventions to decrease it and refocus treatments to better serve patients in the ICU,” Huynh said.
The current study took place at UCLA — a single health care system — and involved five intensive care units. Researchers held a focus group involving clinicians who frequently take care of critically ill patients in the ICU to arrive at a common definition of futile treatment from the physicians’ perspective.
The team then developed a survey and asked critical care providers to assess daily for three months (December 2011–March 2012) whether their patients were receiving futile treatment, were receiving treatment that was probably futile, or were getting treatment that was not futile.
The researchers analyzed 6,897 assessments of 1,125 patients. The team found that 904 patients (80 percent) did not receive futile treatment, 98 patients (9 percent) received probably futile treatment, and 123 patients (11 percent) received futile treatment.
The most common reason treatment was seen as futile was because the burdens of aggressive therapy grossly outweighed its potential benefit. Other reasons included: the treatment could never achieve the patient’s goals, death was imminent, the patient would never be able to survive outside of an ICU, and the patient was permanently unconscious. For most patients, there was more than one reason their treatment was considered futile, the researchers said.
The study findings provided insight into which patients were more likely to be assessed as receiving futile treatment. Patients admitted from a skilled nursing facility or a long-term acute care center were likelier to be assessed by physicians as receiving futile treatment, suggesting that patients whose health is already sufficiently compromised are less likely to benefit from critical care.
Of the 123 patients who received futile treatment, 85 percent died within six months, most of them during their hospitalization; the surviving patients were left in severely compromised health states and were often dependent on life-sustaining modalities.
The average cost for a day of futile treatment in the ICU was about $4,000, the researchers found. For the 123 patients perceived as receiving futile ICU care, total costs during the three months of the study amounted to $2.6 million for the five ICUs. Although sizeable, this accounted for only a small portion (3.5 percent) of hospital costs for the full study cohort of ICU patients during the study period.
The UCLA–RAND team notes that future research will involve making similar measurements across various types of hospitals.
The study was supported by a private donation from James D. and Mary Kay Farley to RAND Health. The funder played no role in the design and conduct of the study; the collection, management, analysis and interpretation of the data; or the preparation, review and approval of the manuscript.
Other study authors included Dr. Eric Kleerup, Dr. Diana Guse and Dr. Bryan J. Garber, all of the department of medicine at the Geffen School of Medicine; Joshua F. Wiley of the UCLA Department of Psychology; and Terrance D. Savitsky of RAND Health.