Faculty Bibliography

OBJECTIVE:Intensive care units (ICUs) in different parts of the world provide care to patients with advanced age and terminal illness at different rates and in different patterns. In the United States, ICU beds make up a disproportionate number of acute care beds. Nearly half of all patients who die in U.S. hospitals have received ICU, some of which may be futile. The objective of this study was to examine ways in which the delivery of futile care in the ICU can cause harm to patients other than those receiving the futile care. DESIGN/METHODS:Review of available studies of patient and family attitudes about cardiopulmonary resuscitation and other supportive modalities, including antibiotic therapy, and the relationship of the delivery of such care to the outcomes of others treated in the ICU. PATIENTS/METHODS:Those treated in ICUs and those receiving futile care. MEASUREMENTS AND MAIN RESULTS/RESULTS:Compared with younger patients, the elderly in the United States use more ICU care, at higher cost, have more serious comorbidities, and have a higher mortality rate. Certain populations demand ICU care more than others and often with less benefit than less-demanding populations. In a situation of unlimited resources, the provision of ICU care, even when futile, has been viewed as an individual patient decision with no harm to others within the hospital. However, even with unlimited resources, the use of antibiotics for those who are receiving futile care can be considered unethical by egalitarian theory because it can lead to antibiotic resistance that may make the treatment of other patients impossible. In the setting of limited resources, like in pandemic influenza, or with the potential limiting of resources, in a pay-for-performance environment, the provision of futile care can also harm the hospital population as a whole. CONCLUSIONS:The delivery of futile care is not only an individual patient decision, but must be viewed in a broader context. Societal awareness of this problem is necessary, and better scoring systems to identify when ICU care has limited benefit are needed to address these difficult and challenging realities.

Current guidelines treat palliative sedation to unconsciousness as an effective medical treatment for terminally ill patients who need relief from severe symptoms, yet also restrict its use in ways that are extraordinary for medical treatments. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction.

A number of influential reports on influenza pandemic preparedness include recommendations for extra-autonomous decisions to withdraw mechanical ventilation from some patients, who might still benefit from this technology, when demand for ventilators exceeds supply. An unintended implication of recommendations for nonvoluntary and involuntary termination of life support is that it make pandemic preparedness plans vulnerable to patients' claims for assisted suicide and active euthanasia. Supporters of nonvoluntary passive euthanasia need to articulate why it is both morally different and morally superior to voluntary active euthanasia if they do not wish to invite expansion of end-of-life options during health system catastrophe.

Preparations for large-scale disasters have tended to focus on triage schema, stockpiling of materials, and other logistical concerns. Less attention has been given to the myriad of distressing and almost unthinkable ethically charged dilemmas that will emerge at the bedside during a catastrophe, and how they may be best managed. Yet, it is these bedside issues that may limit or thwart the effectiveness of disaster planning, and, therefore, they ought to be carefully considered.

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients. Patients discharged AMA have longer eventual hospital stays and worse health outcomes. These patients are also less likely to have an established relationship with a physician, tend to have poorer social supports, and are more likely to abuse alcohol and other substances. These discharges are also distressing for physicians and other health professionals. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians question the decision-making capacity of patients who make dangerous judgments to leave the hospital? This article examines the ethical and professional implications of discharge AMA.