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“Futile” Care in the Intensive Care Unit–Reply–I

      Dr Persaud has raised some interesting points about the pertinence of our findings to the broader debate about futility in the ICU. Given that consensus on defining medical futility has not been achieved,
      • Helft PR
      • Siegler M
      • Lantos J
      The rise and fall of the futility movement.
      we did not determine the proportion of end-of-life ICU care provided to Olmsted County residents that was “futile.” Discussions among caregivers regarding the futility of providing care to some critically ill patients in the study cohort certainly occurred, as they often do in large ICUs. Because patient autonomy usually determines what life-sustaining treatments are ultimately administered or withheld, discussions with patients and families should include not only prognosis and treatment goals but also the potential benefits and limitations of ICU therapies.
      • Curtis JR
      • Patrick DL
      • Shannon SE
      • Treece PD
      • Engelberg RA
      • Rubenfeld GD
      The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement.
      This process may be more challenging during a time when perceptions of the benefits of medical therapies can be formed from information delivered through the mass media, which often misrepresents the limitations of medical treatments.
      • Diem SJ
      • Lantos JD
      • Tulsky JA
      Cardiopulmonary resuscitation on television: miracles and misinformation.
      Moreover, these beliefs may sometimes lead to unrealistic family expectations even in the most gravely ill patients in the ICU.
      • Berge KH
      • Maiers DR
      • Schreiner DP
      • et al.
      Resource utilization and outcome in gravely ill intensive care unit patients with predicted in-hospital mortality rates of 95% or higher by APACHE III scores: the relationship with physician and family expectations.
      Much still needs to be done to improve end-of-life care in the ICU. Recently, our institution began initiating discussions about advanced directives and end-of-life care issues at every inpatient encounter. Perhaps as importantly, previous discussions about end-of-life treatment preferences between primary care physicians and patients, particularly those with serious or chronic illness, can be helpful when these issues are confronted during critical illness. These discussions may also lead to the establishment of a greater number of living wills and advanced directives. Until such time, the ICU will likely continue to be the site of care for a substantial number of patients at the end of life.

      REFERENCES

        • Helft PR
        • Siegler M
        • Lantos J
        The rise and fall of the futility movement.
        N Engl J Med. 2000; 343: 293-296
        • Curtis JR
        • Patrick DL
        • Shannon SE
        • Treece PD
        • Engelberg RA
        • Rubenfeld GD
        The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement.
        Crit Care Med. 2001; 29: N26-N33
        • Diem SJ
        • Lantos JD
        • Tulsky JA
        Cardiopulmonary resuscitation on television: miracles and misinformation.
        N Engl J Med. 1996; 334: 1578-1582
        • Berge KH
        • Maiers DR
        • Schreiner DP
        • et al.
        Resource utilization and outcome in gravely ill intensive care unit patients with predicted in-hospital mortality rates of 95% or higher by APACHE III scores: the relationship with physician and family expectations.
        Mayo Clin Proc. 2005; 80: 166-173

      Linked Article

      • “Futile” Care in the Intensive Care Unit
        Mayo Clinic ProceedingsVol. 81Issue 11
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          To the Editor: In their article on intensive care unit (ICU) use at the end of life, which was published in the July 2006 issue of Mayo Clinic Proceedings, Seferian and Afessa1 concluded that the rate of ICU use increases with patient age and with the number of coexisting chronic illnesses. They supplied many other statistics that contribute to the debate that a large proportion of ICU patients receive what could best be described as “futile” care. For example, they found that residents of Olmsted County, Minnesota, who were 85 years and older in the last year of life used nearly three quarters of ICU days while accounting for less than 40% of admissions for that age group.
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