Futile treatments in intensive care units.

The provision of treatments that are perceived to be futile is amajorproblemin the intensivecareunit (ICU), leading toburdens forpatientsand families, aswell asmoraldistress for caregivers. In this issue of JAMA Internal Medicine, Huynh and colleagues1 report on the perceptions of intensive care physicians about treatmentperceived tobe futile in 5 intensive care units at an academic health care system. They found that the physicians perceived that the treatment that they are providing is futile or probably futile up to 20% of the time. During a 3-month period, the cost of treatment perceived to be futile was estimated at $2.6 million. We agree that the perceptions of these critical care physicians are concerning.We urge caution, however, in the interpretation and applicationof the findings ofHuynhet al.1With regard to the prevalence of potentially futile treatments, for example, thedatawerederived fromtheperceptionsofasingle physician making a single assessment about futility on each day thepatientwas in the ICU.Wehaveno ideawhether other critical carephysicianswould have agreedwith this assessment, whether other physicians (eg, surgeons, subspecialists)would have concurredwith this determination,what opinions other clinicians on the team (eg, nurses, socialworkers) held about the situation, or—most importantly—theviews of the patient and family themselves. This mode of assessmentstands insharpcontrast tocurrent recommendations that futility assessments be based on an inclusive process that incorporates the perspectives of all stakeholders.2 With regard to cost, the authors estimated that the cost of the treatment that was perceived to be futile (ICU and subsequent non-ICU days) represented 3.5% of total hospital costs for the patients in the study. The relevant question, however, is how much money would be saved if these treatments were not provided. Others have shown, for example, that roughly 85% of the costs associated with ICU care are fixed costs that cannot be eliminated unless critical care beds are closed.3 On the basis of such findings, the true savings of not providing life-prolonging treatment to the patients in the study by Huynh et al1 who were perceived as receiving futile care are almost certainly less than the amount calculated by the authors. These more modest potential savings should be compared with other potential targets for cost savings (eg, excessive imaging, laboratory testing, prescribing) before the decision is made to prioritize the elimination of potentially futile treatments. Such assessments are controversial and often have divisive effects on clinicians, patients, and families. We offer 4 suggestions for how clinicians in critical care units should conceptualize and respond to requests for treatment that they judge to be futile or wrong. First, we believe that clinicians should generally avoid using the term futile to describe such treatment and instead use the term potentially inappropriate. It is exceedingly rare for surrogates in ICUs to request treatments that are strictly futile (ie, stand no chance of achieving their intended goal). Instead, disputes generally arise from requests for treatments that stand at least some chance of accomplishing the patient’s goal but for which the clinician believes that there are competing ethical considerations thatmay justify treatment refusal, such as the low likelihood of benefit or the high cost. Second, from an ethical and legal standpoint, these disputes are often more complicated than they seem. Although in some cases cliniciansmay believe strongly that it would be wrong to administer the requested treatments, there is ongoing debate about the boundaries of acceptable practice near theendof life. Shortofbraindeath, therearenocriteriaor rules towhich clinicians canappeal to justifydecisions to refuse life support, at least when those treatments hold even a small chanceof achieving thepatient’s goals. Evenwithin themedical profession, clinicians vary substantially in their attitudes andpractices regardingwhat sortsof treatments shouldbeprovided near the end of life.4 An added ethical complexity in critical care is that incapacitated, critically ill patients arevulnerable indifferentways than patients in other settings. For example, many critically ill patients are unable to speak for themselves, haveno choice regarding who will treat them, and, because of their overwhelming illness, have limited ability to seek out alternative physicians. In contrast, inambulatorypracticeandmanyother Related article page 1887 Original Investigation Critical Care Treatment Perceived to Be Futile