ICU Resource Allocation in the New Millennium: Will We Say "No"?

351 Pages·2013·2.41 MB·English

by  Ian M. Seppelt M.B.B.S.

ICU Resource Allocation in the New Millennium

David W. Crippen
Editor
ICU Resource Allocation
in the New Millennium
Will We Say “No”?
Editor
David W. Crippen, M.D., F.C.C.M
Departments of Critical Care Medicine and Neurological Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA, USA
ISBN 978-1-4614-3865-6 ISBN 978-1-4614-3866-3 (eBook)
DOI 10.1007/978-1-4614-3866-3
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2012939429
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This book is dedicated to my clinical colleagues in the
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of Pittsburgh Medical Center, all of whom have
dedicated their formidable talents to caring for the
critically ill.

Foreword
Health care is expensive, and spending had increased to cope with growing demand
and new, costly technology and treatments. In the USA, health expenditure
increased from 15.7% of GDP in 2004 to 17.4% in 2009. 1 With the global reces-
sion over the last few years, the rate of increase in health care allocated funds has
slowed worldwide, and in health care, as elsewhere, belts are tightening. But,
demand for health care is still increasing, new treatments are increasingly expen-
sive, and patient expectations are rising, so how can these aspects be balanced
against the decreased funding? At some point, the seemingly endless pot of gold is
going to run dry, and if we are to avoid a catastrophe, hard decisions regarding
resource allocation need to be made now. Numerous approaches to curtailing costs
or reducing expenditure have been proposed. Different countries have adopted
various strategies, but health care remains a burden on fi nancing authorities world-
wide. More restrictions are likely to be necessary if we continue to be able to provide
adequate health care for all.
Intensive care medicine is one of the fastest growing and arguably one of the
most expensive areas of medicine. Aging populations, the ability to treat conditions
that would previously have been considered fatal, more widespread use of immuno-
suppressive therapies, and improved organ support techniques all contribute to an
ever-increasing demand for ICU services. The percentage of GDP allocated to
intensive care is increasing in most developed countries as ICUs continue to expand.
Moreover, it is not always a very cost-effective therapeutic option. Many patients
treated in ICUs will have large amounts of expensive drugs, interventions, equip-
ment, and nursing hours used on them only to die from multiple organ failure.
Finances are limited and health care expenditure cannot continue to expand without
boundaries, so how are we to tackle this problem, how best to reduce costs while
maintaining the best possible service for all who need it?
1 D ata from OECD.
vii
viii Foreword
This is the topic of this book, the third in a series of volumes that confronts
diffi cult and thought-provoking topics within the ICU environment from a global
perspective. The fi r st in the series2 discussed how the so-called global village does
or should deal with the clinical treatment of ICU patients at the end of life. The
second volume3 focused on how doctors communicate with patients and families
about end-of-life issues across international, cultural, and religious boundaries. The
present volume covers perhaps the most challenging topic of the three—how can we
manage resource allocation, including end-of-life care, in the current era of fi nancial
constraints and resource rationing; and, equally, faced with increasing demands by
patients and society that “all be done” and the refusal by many to accept that inten-
sive care does not always (or even often) equate to successful care in terms of lives
saved, but rather to expensive care. Is it acceptable to ration care in the ICU, refuse
ICU admission, speed ICU discharge for patients in whom ongoing treatment is
considered futile, in whom there is no longer any hope of recovery, or recovery with
a meaningful quality of life? If so, who should make such decisions? Who should
de fi ne “futile,” “meaningful,” and “no hope,”…: The patient (in advance?), the doc-
tor, relatives, politicians, the courts, the payer, or some combination of several or all
of these? Do we view rationing differently in different areas of the globe? Is it pos-
sible to develop a global approach to ICU resource allocation and spending, or is
this simply not going to be achievable? What are the ethical implications of such
decisions? Rationing is surely supported by the key ethical principles of bene fi cence,
non-male fi cence, and distributive justice, but what of the right to patient autonomy?
Should individual patients be allowed to use or abuse the system to the potential
detriment of others?
These are sensitive issues and many are reluctant to discuss them. But, while it is
all too easy to put this debate on the back burner—after all, keeping patients alive is
surely our priority as intensivists, and we are busy enough without taking time to
debate who should not be treated or who should be left/“allowed” to die—this atti-
tude is no longer acceptable. We need to refl ect now on how we can best conserve
resources, so that appropriate protocols can be put into place, and that in the future
there will be suf fi cient funds for those patients who will actually bene fi t. We are,
after all, the frontline, and we must be involved in decisions about resource alloca-
tion to our units, our patients. This is a highly emotive issue, but we cannot afford
to be emotional—only with an objective eye can we truly make fair, equitable
decisions.
In this book, leading health care experts take us through the current setup around
the developed world in terms of resource allocation before discussing what health
care reforms are underway or in the pipeline across the globe. A hypothetical health
care act, the so-called Fair & Equitable Healthcare Act, is then presented in which
2 Crippen D, Kilcullen J, Kelly D. Three patients: international perspectives on intensive care at the
end of life. New York: Kluwer; 2002.
3 C rippen D. End-of-life communication: a global perspective. New York: Springer; 2008.
Foreword ix
what many would see as extreme proposals are put forward to improve ICU
ef fi ciency and reduce ICU spending. Ethicists and analysts are invited to explore the
acceptability of these suggestions in today’s climate and to draw their conclusions
on whether we need or will ever be able to say “no” to certain aspects of therapy or,
perhaps more controversially, to certain (types of) patients. This book is an impera-
tive and impelling read for all involved in health care and particularly intensive care.
By exploring differences in attitudes and approaches among countries and the rea-
sons behind these differences, this volume helps us understand why intensive care
is all too often inef fi cient care and challenges us to critically re fl ect on how we can
face current and future resource restrictions in our ICU, our country, our continent,
and our world in the context of ever-spiralling demand and costs.
Ixelles, Belgium Jean-Louis Vincent