This document discusses the history of futility, limitation and rationing in critical care. It traces the evolution of hospitals and ICUs from the 19th century when most hospitals were custodial institutions for the poor, to the 20th century when advances in technology led to specialization and the need for economies of scale. The ability to predict death is limited, even with unanimous agreement, and definitions of futility are challenging. Considering demographics, aging populations and limited resources require difficult decisions around pursuing ineffective treatments versus denying effective care to others. The example of Oregon introducing rationing to expand health insurance coverage for all residents is provided.

1. Futility, limitation &Futility, limitation &
rationing in critical carerationing in critical care
Andrew NumaAndrew Numa
Director, ICUDirector, ICU
Sydney Children’s HospitalSydney Children’s Hospital

2. ““Gently blow air or smoke intoGently blow air or smoke into
the lungs or the rectum”the lungs or the rectum”

3. 1919thth
centurycentury
““Most Americans in 1800 had probably heardMost Americans in 1800 had probably heard
that such things as hospitals existed but only athat such things as hospitals existed but only a
minority would ever had occasion to see one”minority would ever had occasion to see one”
Rosenberg CE. Care of StrangersRosenberg CE. Care of Strangers
1873 - 120 hospitals in the USA, most of which1873 - 120 hospitals in the USA, most of which
were custodial institutions serving thewere custodial institutions serving the
“deserving poor”“deserving poor”
Middle class patients rarely entered hospitalsMiddle class patients rarely entered hospitals

4. Children’s HospitalChildren’s Hospital
Boston,1871 - goals:Boston,1871 - goals:
““removing sick children from abodes ofremoving sick children from abodes of
drunkenness and vice....and allowing them todrunkenness and vice....and allowing them to
spend their last days in a home of purity, comfortspend their last days in a home of purity, comfort
and peace”and peace”
Children’s Hospital Boston, 3rd annual report, 1871Children’s Hospital Boston, 3rd annual report, 1871

5. Hartford Hospital 1874Hartford Hospital 1874
““Hopeless chronic cases are admitted withoutHopeless chronic cases are admitted without
any expectation of a recovery, because they canany expectation of a recovery, because they can
be better cared for at the hospital and it is a goodbe better cared for at the hospital and it is a good
place to lie down and die in peace”place to lie down and die in peace”
Hartford Hospital, 14th annual report, 1874Hartford Hospital, 14th annual report, 1874

6. 2020thth
centurycentury

7. 2020thth
centurycentury
Laboratory and radiology became moreLaboratory and radiology became more
complex and expensive, necessitatingcomplex and expensive, necessitating
economies of scaleeconomies of scale
Economic constraints forced adoption ofEconomic constraints forced adoption of
business models that relied on fees generatedbusiness models that relied on fees generated
by middle class patientsby middle class patients
Hospitals sought to attract patients with theHospitals sought to attract patients with the
prospect of recovery and survivalprospect of recovery and survival
120 US hospitals in 1873 4,359 in 1909→120 US hospitals in 1873 4,359 in 1909→
Abel K. In the last stages of irremediable disease. Bull Hist Med 2011; 85: 29-56Abel K. In the last stages of irremediable disease. Bull Hist Med 2011; 85: 29-56

16. TrustTrust
Structured interview of 50 AICU decisionStructured interview of 50 AICU decision
makers given a hypothetical scenario of 100%makers given a hypothetical scenario of 100%
mortalitymortality
64% expressed unwillingness to believe64% expressed unwillingness to believe
physicians’ futility predictionsphysicians’ futility predictions
felt that predicting the future with certaintyfelt that predicting the future with certainty
was “beyond the ability of their physicians”was “beyond the ability of their physicians”
(63%)(63%)
““need to see for themselves” (38%)need to see for themselves” (38%)
belief that “God may intervene” (56%)belief that “God may intervene” (56%)Zier L et al. Surrogate decision makers’ responses to predictions of futility. Chest 2009; 136:Zier L et al. Surrogate decision makers’ responses to predictions of futility. Chest 2009; 136:
110-7110-7

17. Scenario 2Scenario 2
Relative in ICU for 2 weeks with life threateningRelative in ICU for 2 weeks with life threatening
illness, ventilated and sedatedillness, ventilated and sedated
Advised that to have any chance of survival,Advised that to have any chance of survival,
patient will need 1 further month of ICU care,patient will need 1 further month of ICU care,
including tracheostomy, gastrostomy plus 1including tracheostomy, gastrostomy plus 1
month rehabilitation.month rehabilitation.
Even then the chance of survival is onlyEven then the chance of survival is only xx %%

18. 1%1%
<1%<1%
0%0%

21. Luke 7:22Luke 7:22
““The blind see, the lame walk, the lepers areThe blind see, the lame walk, the lepers are
cleansed, the deaf hear, and the dead arecleansed, the deaf hear, and the dead are
raised.”raised.”

22. 20% of the text of New Testament gospels20% of the text of New Testament gospels
describe the healing of physical or mental illnessdescribe the healing of physical or mental illness
and/or the resurrection of the deadand/or the resurrection of the dead
Post SGl. Medical futility and the free exercise of religion. J Law Med Ethics 1995; 23: 20-6Post SGl. Medical futility and the free exercise of religion. J Law Med Ethics 1995; 23: 20-6

25. just hours before he was slated to be killed and his
organs given to other patients

26. How good are we atHow good are we at
predicting death?predicting death?
Single centreSingle centre
603 consecutively admitted patients / 7 mo603 consecutively admitted patients / 7 mo
Nurse, resident, fellow and attending askedNurse, resident, fellow and attending asked
each day:each day:
““do you think this patient is going to die indo you think this patient is going to die in
hospital or survive to discharge?”hospital or survive to discharge?”
Meadow WM et al. Power and limitations of daily prognostications of death in the MICU. Crit Care Med 2011; 39:Meadow WM et al. Power and limitations of daily prognostications of death in the MICU. Crit Care Med 2011; 39:
474-9474-9

27. PredictionsPredictions
6,000 predictions obtained for 560 patients (436,000 predictions obtained for 560 patients (43
patients died before predictions could bepatients died before predictions could be
recorded)recorded)
433/560 survived to discharge433/560 survived to discharge
334/433 survivors (77%) had 100% prediction334/433 survivors (77%) had 100% prediction
of survival by all staff on all daysof survival by all staff on all days

28. SurvivorsSurvivors
99/433 = 23% survivors had at least one99/433 = 23% survivors had at least one
prediction of death on 1 or more daysprediction of death on 1 or more days
15/433 = 3% survivors had 1 day on which all≥15/433 = 3% survivors had 1 day on which all≥
respondents predicted deathrespondents predicted death

29. Non-survivorsNon-survivors
72/127 (57%) non-survivors had unanimous72/127 (57%) non-survivors had unanimous
predictions of death by all respondents on allpredictions of death by all respondents on all
daysdays
But: 55/127 (43%) non-survivors had at least 1But: 55/127 (43%) non-survivors had at least 1
prediction of survival on at least 1 dayprediction of survival on at least 1 day
And: 35/127 (27%) non-survivors had at least 1And: 35/127 (27%) non-survivors had at least 1
day of unanimous prediction of survivalday of unanimous prediction of survival

30. Predicting deathPredicting death
206 patients had 1 prediction of death≥206 patients had 1 prediction of death≥
107/206 died (53%)107/206 died (53%)
The predictive power of a single prediction ofThe predictive power of a single prediction of
death was approximately the same as chance.death was approximately the same as chance.
Only 79/94 (84%) of patients with 1 day of≥Only 79/94 (84%) of patients with 1 day of≥
unanimousunanimous prediction of death actually diedprediction of death actually died

31. Meadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in pressMeadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in press

32. Neonatal predictionsNeonatal predictions
Probability of death in infants unanimouslyProbability of death in infants unanimously
predicted to die on at least one day = 0.52predicted to die on at least one day = 0.52
Meadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in pressMeadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in press

37. A man is legally dead when he has undergoneA man is legally dead when he has undergone
irreversible changes of a type that make itirreversible changes of a type that make it
impossible for him to seek to litigateimpossible for him to seek to litigate
Sir Peter MedawarSir Peter Medawar
Beecher H. After the “definition of irreversible coma” NEJM 1969; 289: 1070-1Beecher H. After the “definition of irreversible coma” NEJM 1969; 289: 1070-1

38. The black swanThe black swan
It only takes one exception to disprove a ruleIt only takes one exception to disprove a rule
Do we need to be 100% certain?Do we need to be 100% certain?
criminal convictions rely on “reasonablecriminal convictions rely on “reasonable
doubt”doubt”
so does the scientific literature: usually 5% (pso does the scientific literature: usually 5% (p
= 0.05) or 1% (p = 0.01)= 0.05) or 1% (p = 0.01)

39. Defining futilityDefining futility
““When a physician concludes (either throughWhen a physician concludes (either through
personal experience, experiences shared withpersonal experience, experiences shared with
colleagues or consideration of reported empiriccolleagues or consideration of reported empiric
data) that in the last 100 cases medicaldata) that in the last 100 cases medical
treatment has been useless, they shouldtreatment has been useless, they should
regard that treatment as futile.”regard that treatment as futile.”
95% CI of 0/100 is 3%95% CI of 0/100 is 3%
Need to differentiate between an effect and aNeed to differentiate between an effect and a
benefitbenefit
Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54

40. Defining futilityDefining futility
Treatment has no value if the patient isTreatment has no value if the patient is
incapable of appreciating the benefit or remainsincapable of appreciating the benefit or remains
unable to leave the ICUunable to leave the ICU
Need to avoid an outcome where “pre-Need to avoid an outcome where “pre-
occupation with illness precludes the carryingoccupation with illness precludes the carrying
out of life goals” (Plato)out of life goals” (Plato)
Not only are we not obligated to carry out futileNot only are we not obligated to carry out futile
therapies we are obligated to resist demandstherapies we are obligated to resist demands
for such therapiesfor such therapies
Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54

41. Why worry?Why worry?
Futile care may prolong a painful existenceFutile care may prolong a painful existence
Futile care impacts on family and carersFutile care impacts on family and carers
Futile care impacts on the community at largeFutile care impacts on the community at large

43. Demographics is destinyDemographics is destiny

44. Age > 65Age > 65
Tax baseTax base
Age 45-65Age 45-65

47. Intensive CareIntensive Care
10% of hospital beds10% of hospital beds
30% of hospital resources30% of hospital resources
40% of MICU costs are spent on patients who40% of MICU costs are spent on patients who
die before dischargedie before discharge

48. Demographics is destinyDemographics is destiny
Patients aged > 65 account for 15% of thePatients aged > 65 account for 15% of the
population and 50% of ICU patientspopulation and 50% of ICU patients
Increasing age is associated with increasedIncreasing age is associated with increased
LOS and higher mortality in the ICULOS and higher mortality in the ICU
47.7% of all patients who die in US hospitals47.7% of all patients who die in US hospitals
have received intensive care (10.1% in UK)have received intensive care (10.1% in UK)
30% of all people who die in USA are admitted30% of all people who die in USA are admitted
to ICU during the last 6 months of their lifeto ICU during the last 6 months of their life
Niederman MS et al. The delivery of futile care is harmful to other patients. Crit Care Med 2010: 38 (Suppl): S518-Niederman MS et al. The delivery of futile care is harmful to other patients. Crit Care Med 2010: 38 (Suppl): S518-
2222

49. Demographics is destinyDemographics is destiny
For patients aged > 85 years intensive careFor patients aged > 85 years intensive care
involved ininvolved in
31.5% of medical deaths and 61% of surgical31.5% of medical deaths and 61% of surgical
deathsdeaths
(UK: 1.9% medical and 8.5% surgical)(UK: 1.9% medical and 8.5% surgical)
Seferain EG, Afessa B. Adult intensive care use at end of life. Mayo Clin Proc 2006: 81: 896-901Seferain EG, Afessa B. Adult intensive care use at end of life. Mayo Clin Proc 2006: 81: 896-901

50. NeonatesNeonates
ELBW < 500 gramsELBW < 500 grams
29% of NICU bed days assessed as futile (i.e.29% of NICU bed days assessed as futile (i.e.
utilised for MV of patients who ultimately died)utilised for MV of patients who ultimately died)
Estimate does not include poor neurologicalEstimate does not include poor neurological
outcomeoutcome
Meadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in pressMeadow W et al. The prediction and cost of futility in the NICU. Acta Paediatrica 2011 in press

51. Given an inevitable cap on health expenditure,Given an inevitable cap on health expenditure,
the only two alternatives are:the only two alternatives are:
ineffective treatments are not pursued, orineffective treatments are not pursued, or
that effective therapies are denied to thosethat effective therapies are denied to those
that can benefit.that can benefit.

52. OregonOregon
1987 - Coby Howard - a 7 y/o awaiting BMT1987 - Coby Howard - a 7 y/o awaiting BMT
died while his family were trying to raise fundsdied while his family were trying to raise funds
Proposal to reinstate Medicaid funding for BMTProposal to reinstate Medicaid funding for BMT
John Kitzhaber argued that while Oregon couldJohn Kitzhaber argued that while Oregon could
not afford to pay for every medical care servicenot afford to pay for every medical care service
for every person it could expand insurance tofor every person it could expand insurance to
cover all the uninsured if it wascover all the uninsured if it was willing to rationwilling to ration
carecare

53. OregonOregon
Introduction of “universal” health coverage, viaIntroduction of “universal” health coverage, via
Medicaid and subsidised HMOs for residents upMedicaid and subsidised HMOs for residents up
to 100% of the poverty line ($16,500 pa forto 100% of the poverty line ($16,500 pa for
family of 4)family of 4)
Cover included pre-existing ailmentsCover included pre-existing ailments
Not all illnesses insuredNot all illnesses insured
10,000 diseases reduced to 69610,000 diseases reduced to 696
condition/treatment pairs, ranked in order ofcondition/treatment pairs, ranked in order of
benefit, top 574 coveredbenefit, top 574 covered

55. Orlander J et al. Rationing medical care - rhetoric and reality in the Oregon health plan. CMAJ 2001; 164: 1583-7Orlander J et al. Rationing medical care - rhetoric and reality in the Oregon health plan. CMAJ 2001; 164: 1583-7

56. OregonOregon
Within 4 years, the list had grown to 743Within 4 years, the list had grown to 743
conditionsconditions
Costs higher than expected (backlog)Costs higher than expected (backlog)
Co-contributions sought from families at theCo-contributions sought from families at the
higher endhigher end
College students excludedCollege students excluded
Consideration given to reducing the number ofConsideration given to reducing the number of
conditions insured (505)conditions insured (505)
Tobacco tax introducedTobacco tax introduced

57. Blurring the lineBlurring the line
Physician visits are covered, even if treatmentsPhysician visits are covered, even if treatments
aren’taren’t
Co-morbidities are coveredCo-morbidities are covered
Formulaic analysis of cost-benefit has beenFormulaic analysis of cost-benefit has been
“modified” by politicians responding to“modified” by politicians responding to
community pressurescommunity pressures
Costs have not been reduced, althoughCosts have not been reduced, although
coverage has been expandedcoverage has been expanded
No other State has followed a similar programNo other State has followed a similar program
(yet)(yet)

58. RationingRationing
Is already happening in an ad hoc fashion inIs already happening in an ad hoc fashion in
most centres and in slightly more organisedmost centres and in slightly more organised
way in someway in some
Is going to increase as the population agesIs going to increase as the population ages
Best place to start is with futile casesBest place to start is with futile cases

59. What to do?What to do?
Avoid confusing:Avoid confusing:
Means and endsMeans and ends
Effects and benefitsEffects and benefits
Available technologies and obligatoryAvailable technologies and obligatory
therapiestherapies
Accept a degree of uncertaintyAccept a degree of uncertainty
Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990: 112: 949-54

60. First I will define what I conceive medicine to be.First I will define what I conceive medicine to be.
In general terms it is to do away with theIn general terms it is to do away with the
sufferings of the sick, to lessen the violence ofsufferings of the sick, to lessen the violence of
their diseases and totheir diseases and to refuse to treat those who arerefuse to treat those who are
overmastered by their disease, realising that inovermastered by their disease, realising that in
such cases medicine is powerlesssuch cases medicine is powerless..
Hippocratic corpusHippocratic corpus

61. January 5-10, 2014January 5-10, 2014
www.colloquium.com.auwww.colloquium.com.au
4th