Andrew Numa on Futility and Rationing

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Andrew Numa's fantastic presentation on futility and resource allocation in ICU. Goes with this talk: http://www.intensivecarenetwork.com/index.php/icn-activities/smacc-2013/podcasts/621-smacc-numa-on-when-enough-is-enough

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  • In case you thought it was an isolated case, there are others
  • Andrew Numa on Futility and Rationing

    1. 1. Futility, limitation &Futility, limitation &rationing in critical carerationing in critical careAndrew NumaAndrew NumaDirector, ICUDirector, ICUSydney Children’s HospitalSydney Children’s Hospital
    2. 2. ““Gently blow air or smoke intoGently blow air or smoke intothe lungs or the rectum”the lungs or the rectum”
    3. 3. 1919ththcenturycentury““Most Americans in 1800 had probably heardMost Americans in 1800 had probably heardthat such things as hospitals existed but only athat such things as hospitals existed but only aminority would ever had occasion to see one”minority would ever had occasion to see one”Rosenberg CE. Care of StrangersRosenberg CE. Care of Strangers1873 - 120 hospitals in the USA, most of which1873 - 120 hospitals in the USA, most of whichwere custodial institutions serving thewere custodial institutions serving the“deserving poor”“deserving poor”Middle class patients rarely entered hospitalsMiddle class patients rarely entered hospitals
    4. 4. Children’s HospitalChildren’s HospitalBoston,1871 - goals:Boston,1871 - goals:““removing sick children from abodes ofremoving sick children from abodes ofdrunkenness and vice....and allowing them todrunkenness and vice....and allowing them tospend their last days in a home of purity, comfortspend their last days in a home of purity, comfortand peace”and peace”Children’s Hospital Boston, 3rd annual report, 1871Children’s Hospital Boston, 3rd annual report, 1871
    5. 5. Hartford Hospital 1874Hartford Hospital 1874““Hopeless chronic cases are admitted withoutHopeless chronic cases are admitted withoutany expectation of a recovery, because they canany expectation of a recovery, because they canbe better cared for at the hospital and it is a goodbe better cared for at the hospital and it is a goodplace 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. 6. 2020ththcenturycentury
    7. 7. 2020ththcenturycenturyLaboratory and radiology became moreLaboratory and radiology became morecomplex and expensive, necessitatingcomplex and expensive, necessitatingeconomies of scaleeconomies of scaleEconomic constraints forced adoption ofEconomic constraints forced adoption ofbusiness models that relied on fees generatedbusiness models that relied on fees generatedby middle class patientsby middle class patientsHospitals sought to attract patients with theHospitals sought to attract patients with theprospect of recovery and survivalprospect of recovery and survival120 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
    8. 8. TrustTrustStructured interview of 50 AICU decisionStructured interview of 50 AICU decisionmakers given a hypothetical scenario of 100%makers given a hypothetical scenario of 100%mortalitymortality64% expressed unwillingness to believe64% expressed unwillingness to believephysicians’ futility predictionsphysicians’ futility predictionsfelt that predicting the future with certaintyfelt that predicting the future with certaintywas “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
    9. 9. Scenario 2Scenario 2Relative in ICU for 2 weeks with life threateningRelative in ICU for 2 weeks with life threateningillness, ventilated and sedatedillness, ventilated and sedatedAdvised 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 1month rehabilitation.month rehabilitation.Even then the chance of survival is onlyEven then the chance of survival is only xx %%
    10. 10. 1%1%<1%<1%0%0%
    11. 11. Luke 7:22Luke 7:22““The blind see, the lame walk, the lepers areThe blind see, the lame walk, the lepers arecleansed, the deaf hear, and the dead arecleansed, the deaf hear, and the dead areraised.”raised.”
    12. 12. 20% of the text of New Testament gospels20% of the text of New Testament gospelsdescribe the healing of physical or mental illnessdescribe the healing of physical or mental illnessand/or the resurrection of the deadand/or the resurrection of the deadPost 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
    13. 13. just hours before he was slated to be killed and hisorgans given to other patients
    14. 14. How good are we atHow good are we atpredicting death?predicting death?Single centreSingle centre603 consecutively admitted patients / 7 mo603 consecutively admitted patients / 7 moNurse, resident, fellow and attending askedNurse, resident, fellow and attending askedeach day:each day:““do you think this patient is going to die indo you think this patient is going to die inhospital 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
    15. 15. PredictionsPredictions6,000 predictions obtained for 560 patients (436,000 predictions obtained for 560 patients (43patients died before predictions could bepatients died before predictions could berecorded)recorded)433/560 survived to discharge433/560 survived to discharge334/433 survivors (77%) had 100% prediction334/433 survivors (77%) had 100% predictionof survival by all staff on all daysof survival by all staff on all days
    16. 16. SurvivorsSurvivors99/433 = 23% survivors had at least one99/433 = 23% survivors had at least oneprediction of death on 1 or more daysprediction of death on 1 or more days15/433 = 3% survivors had 1 day on which all≥15/433 = 3% survivors had 1 day on which all≥respondents predicted deathrespondents predicted death
    17. 17. Non-survivorsNon-survivors72/127 (57%) non-survivors had unanimous72/127 (57%) non-survivors had unanimouspredictions of death by all respondents on allpredictions of death by all respondents on alldaysdaysBut: 55/127 (43%) non-survivors had at least 1But: 55/127 (43%) non-survivors had at least 1prediction of survival on at least 1 dayprediction of survival on at least 1 dayAnd: 35/127 (27%) non-survivors had at least 1And: 35/127 (27%) non-survivors had at least 1day of unanimous prediction of survivalday of unanimous prediction of survival
    18. 18. Predicting deathPredicting death206 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 ofdeath 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
    19. 19. 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
    20. 20. Neonatal predictionsNeonatal predictionsProbability of death in infants unanimouslyProbability of death in infants unanimouslypredicted to die on at least one day = 0.52predicted to die on at least one day = 0.52Meadow 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
    21. 21. A man is legally dead when he has undergoneA man is legally dead when he has undergoneirreversible changes of a type that make itirreversible changes of a type that make itimpossible for him to seek to litigateimpossible for him to seek to litigateSir Peter MedawarSir Peter MedawarBeecher H. After the “definition of irreversible coma” NEJM 1969; 289: 1070-1Beecher H. After the “definition of irreversible coma” NEJM 1969; 289: 1070-1
    22. 22. The black swanThe black swanIt only takes one exception to disprove a ruleIt only takes one exception to disprove a ruleDo we need to be 100% certain?Do we need to be 100% certain?criminal convictions rely on “reasonablecriminal convictions rely on “reasonabledoubt”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)
    23. 23. Defining futilityDefining futility““When a physician concludes (either throughWhen a physician concludes (either throughpersonal experience, experiences shared withpersonal experience, experiences shared withcolleagues or consideration of reported empiriccolleagues or consideration of reported empiricdata) that in the last 100 cases medicaldata) that in the last 100 cases medicaltreatment has been useless, they shouldtreatment has been useless, they shouldregard 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 abenefitbenefitSchneiderman 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
    24. 24. Defining futilityDefining futilityTreatment has no value if the patient isTreatment has no value if the patient isincapable of appreciating the benefit or remainsincapable of appreciating the benefit or remainsunable to leave the ICUunable to leave the ICUNeed to avoid an outcome where “pre-Need to avoid an outcome where “pre-occupation with illness precludes the carryingoccupation with illness precludes the carryingout 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 futiletherapies we are obligated to resist demandstherapies we are obligated to resist demandsfor such therapiesfor such therapiesSchneiderman 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
    25. 25. Why worry?Why worry?Futile care may prolong a painful existenceFutile care may prolong a painful existenceFutile care impacts on family and carersFutile care impacts on family and carersFutile care impacts on the community at largeFutile care impacts on the community at large
    26. 26. Demographics is destinyDemographics is destiny
    27. 27. Age > 65Age > 65Tax baseTax baseAge 45-65Age 45-65
    28. 28. Intensive CareIntensive Care10% of hospital beds10% of hospital beds30% of hospital resources30% of hospital resources40% of MICU costs are spent on patients who40% of MICU costs are spent on patients whodie before dischargedie before discharge
    29. 29. Demographics is destinyDemographics is destinyPatients aged > 65 account for 15% of thePatients aged > 65 account for 15% of thepopulation and 50% of ICU patientspopulation and 50% of ICU patientsIncreasing age is associated with increasedIncreasing age is associated with increasedLOS and higher mortality in the ICULOS and higher mortality in the ICU47.7% of all patients who die in US hospitals47.7% of all patients who die in US hospitalshave 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 admittedto ICU during the last 6 months of their lifeto ICU during the last 6 months of their lifeNiederman 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
    30. 30. Demographics is destinyDemographics is destinyFor patients aged > 85 years intensive careFor patients aged > 85 years intensive careinvolved ininvolved in31.5% of medical deaths and 61% of surgical31.5% of medical deaths and 61% of surgicaldeathsdeaths(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
    31. 31. NeonatesNeonatesELBW < 500 gramsELBW < 500 grams29% 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 neurologicaloutcomeoutcomeMeadow 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. 32. 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, orthat effective therapies are denied to thosethat effective therapies are denied to thosethat can benefit.that can benefit.
    33. 33. OregonOregon1987 - Coby Howard - a 7 y/o awaiting BMT1987 - Coby Howard - a 7 y/o awaiting BMTdied while his family were trying to raise fundsdied while his family were trying to raise fundsProposal to reinstate Medicaid funding for BMTProposal to reinstate Medicaid funding for BMTJohn Kitzhaber argued that while Oregon couldJohn Kitzhaber argued that while Oregon couldnot afford to pay for every medical care servicenot afford to pay for every medical care servicefor every person it could expand insurance tofor every person it could expand insurance tocover all the uninsured if it wascover all the uninsured if it was willing to rationwilling to rationcarecare
    34. 34. OregonOregonIntroduction of “universal” health coverage, viaIntroduction of “universal” health coverage, viaMedicaid and subsidised HMOs for residents upMedicaid and subsidised HMOs for residents upto 100% of the poverty line ($16,500 pa forto 100% of the poverty line ($16,500 pa forfamily of 4)family of 4)Cover included pre-existing ailmentsCover included pre-existing ailmentsNot all illnesses insuredNot all illnesses insured10,000 diseases reduced to 69610,000 diseases reduced to 696condition/treatment pairs, ranked in order ofcondition/treatment pairs, ranked in order ofbenefit, top 574 coveredbenefit, top 574 covered
    35. 35. 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
    36. 36. OregonOregonWithin 4 years, the list had grown to 743Within 4 years, the list had grown to 743conditionsconditionsCosts higher than expected (backlog)Costs higher than expected (backlog)Co-contributions sought from families at theCo-contributions sought from families at thehigher endhigher endCollege students excludedCollege students excludedConsideration given to reducing the number ofConsideration given to reducing the number ofconditions insured (505)conditions insured (505)Tobacco tax introducedTobacco tax introduced
    37. 37. Blurring the lineBlurring the linePhysician visits are covered, even if treatmentsPhysician visits are covered, even if treatmentsaren’taren’tCo-morbidities are coveredCo-morbidities are coveredFormulaic analysis of cost-benefit has beenFormulaic analysis of cost-benefit has been“modified” by politicians responding to“modified” by politicians responding tocommunity pressurescommunity pressuresCosts have not been reduced, althoughCosts have not been reduced, althoughcoverage has been expandedcoverage has been expandedNo other State has followed a similar programNo other State has followed a similar program(yet)(yet)
    38. 38. RationingRationingIs already happening in an ad hoc fashion inIs already happening in an ad hoc fashion inmost centres and in slightly more organisedmost centres and in slightly more organisedway in someway in someIs going to increase as the population agesIs going to increase as the population agesBest place to start is with futile casesBest place to start is with futile cases
    39. 39. What to do?What to do?Avoid confusing:Avoid confusing:Means and endsMeans and endsEffects and benefitsEffects and benefitsAvailable technologies and obligatoryAvailable technologies and obligatorytherapiestherapiesAccept a degree of uncertaintyAccept a degree of uncertaintySchneiderman 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. 40. 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 thesufferings of the sick, to lessen the violence ofsufferings of the sick, to lessen the violence oftheir diseases and totheir diseases and to refuse to treat those who arerefuse to treat those who areovermastered by their disease, realising that inovermastered by their disease, realising that insuch cases medicine is powerlesssuch cases medicine is powerless..Hippocratic corpusHippocratic corpus
    41. 41. January 5-10, 2014January 5-10, 2014www.colloquium.com.auwww.colloquium.com.au4th

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