The Costs of Nonbeneficial Treatment in the Intensive Care Setting

Health Affairs' July/August issue has an important article on the cost of "nonbeneficial treatment" in the ICU.  It's written by Todd Gilmer, Lawrence J. Schneiderman, Holly Teetzel, Jeffrey Blustein, Kathleen Briggs, Felicia Cohn, Ronald Cranford, Daniel Dugan, Glen Komatsu and Ernlé Young; here's the abstract:

Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care.

The journal is also running two "Perspectives" commentaries on the lead article:

• The Prognosis For Changes In End-Of-Life Care After The Schiavo Case (abstract) by Lindsay A. Hampson and Ezekiel J. Emanuel:
  • Americans have reached consensus that (1) people have a right to refuse life-sustaining medical interventions, and (2) interventions that can be terminated include artificial nutrition and hydration. The one unresolved issue is how to decide for mentally incompetent patients. Only about 20 percent of Americans have completed living wills, and data show that family members are poor at predicting patients’ wishes for life-sustaining care. But despite court cases and national consensus that these are private and not legislative matters, the Schiavo case is unlikely to change practices except to increase the number of Americans who complete living wills.
• Terri Schiavo, Son Hudson, And ‘Nonbeneficial’ Medical Treatments (abstract) by Robert M. Veatch:
  • Two disputed cases about withholding life support (Terri Schiavo and Son Hudson) call for greater public discussion. Confusion arises from intermixing three kinds of cases: those (1) in which demanded treatment is physiologically futile, (2) involving competition for scarce resources, and (3) in which the treatment would likely achieve the patient’s goals although the clinician perceives those goals to be valueless. This Perspective argues that clinicians should unilaterally refuse the first but do not have legitimate roles in blocking access to the second and third. Absent scarcity, patients should have access to effective life-prolonging treatments even if clinicians see no value in them. 

Although the principal study chose a fairly conservative definition for "nonbeneficial treatment" (patient failed to survive to discharge from hospital), Professor Veatch in particular provides an important caution against using the term as a basis for overriding families' choices simply because the treating physician rejects their goals for treatment.  These articles are important contributions to the literature.  [tm]