Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SATURDAY, March 3, 1990 TAG: 9003052220
SECTION: VIRGINIA PAGE: A4 EDITION: METRO
SOURCE: CHARLES HITE MEDICAL WRITER
DATELINE: LENGTH: Long
Dr. Jim Gardner has a desperate tone in his voice as he glances at the wall board listing the patients on the medical intensive care unit at the University of Virginia.
Gardner is on the phone with the hospital's chief resident, who is trying to find a bed for a critically ill patient on a regular medical floor.
The wall board says it all. Each of the 10 beds on the unit has an extremely ill patient. "We're locked," Gardner says. "We've got nine patients on ventilators."
Overcrowded intensive care units are common in the nation's hospitals. Temples of medical technology, they are seen as the last hope for the hopelessly ill, the staging area for a patient's final battle with death.
But an increasing demand for critical care beds has led to spiraling costs in treating the patients who fill them. More than 50,000 intensive care beds in the United States run up costs of nearly $40 billion each year. Put another way, nearly one-fourth of the nation's hospital costs are generated by intensive care units.
Despite the widespread use of critical care units, no studies have shown conclusively that they cut patient death rates. About a fifth of all patients admitted to intensive care units will die there. But the death rate for some groups of patients is much higher - sometimes approaching 98 percent.
"People come in here and see all this fancy stuff and think we must be able to fix anything," ICU nurse Kim Waldman says. "We can't."
For many patients, a visit to critical care means prolonging the act of dying, not prolonging life.
"A lot of our patients, we know from the outset that they aren't going to get better and yet we work so hard to save them," ICU nurse Deb Carpenter says. "Why do we do it? Why do we put them through it?"
The growing demand for intensive care beds and the high cost of keeping alive patients who are almost certain to die has led some doctors, nurses and other health professionals to a startling conclusion: The United States simply can't afford to give critical care treatment to every patient who wants it.
"The issue is not whether we are going to have rationing of intensive care," says John Fletcher, director of the Center for Biomedical Ethics at UVa. "The issue is what kind of approach is best."
"Some people should be allowed into the intensive care unit and some shouldn't," says Mary Faith Marshall, a former critical care nurse who now coordinates nursing education programs at UVa.
"ICU care needs to be looked at in terms of health care needs in general," she says. "It should receive a low priority, I think." She would rather see health care dollars go first to preventive care and basic medical treatment. "I would support critical care being at the bottom of the list."
ICUs try to manage the bed crunch by identifying one or two patients each day who could be "bumped" to a regular floor if space is needed for a more critically ill patient.
But sometimes patients on a unit are so sick that it's difficult to say who should go and who should stay.
"I remember one time last week that the patient we were admitting was better off than the patient we were sending out," says Rick Carpenter, a Medical ICU nurse at UVa.
"A lot of people we send out to the floor . . . because we simply need another bed," says Medical ICU nurse Dot Cage.
ICU doctors and nurses readily admit that too much money and too many valuable resources are spent maintaining patients who have virtually no hope of recovery. They feel uncomfortable being asked to decide which patients should get care, yet they don't want to relinquish the responsibility to some impartial panel of experts that sets arbitrary limits.
"I can't envision having some form of standard criteria for ICU admission because every patient is so individual," says Dr. Coleen McNamara, one of two chief medical residents at UVa.
McNamara was on the other end of the phone the day Jim Gardner was saying the medical intensive care unit was full and that all his patients were too sick to bump.
One of those patients was James Thompson, a 68-year-old man with a bad liver, cancer of the esophagus and a chronic bleeding in his gut.
Thompson, who had been in and out of the ICU three times in two months, had become a topic of conversation among doctors and nurses on the unit. The talks always seemed to boil down to this: Was it fair to keep giving such intensive treatment to someone who probably had less than a year to live?
Part of the frustration in treating bleeders like Thompson, the doctors and nurses acknowledge, is that their condition is a result of alcohol abuse. Years of drinking have destroyed their livers, leading to repeated episodes of bleeding and repeated admissions to the intensive care unit.
"These people soak up tremendous amounts of resources," says Priscilla Merrill, the head nurse on the unit. It's especially frustrating, she says, when the ICU staff works hard to get a bleeder stable, then sees him bounce back two days later because he's gone out and drunk a couple of six-packs.
But it's hard for the staff to turn these people away.
"Let's give Mr. Thompson the benefit of a doubt. He's no longer drinking and he's doing what he's supposed to do," Merrill says. "I don't want to be the person to say, `Mr. Thompson, we're only going to give you three more units of blood and then you're going to die.' "
Adding more intensive care beds isn't going to solve the problem, Merrill believes. UVa's medical intensive care was supposed to expand from 10 to 12 beds early this year, but a shortage of critical-care nurses has put those plans on hold indefinitely.
"I think even if we had 12 beds open for critically ill patients, there would still be patients out there who need to be here but can't get in," Merrill says.
Setting limits on critical care is one of the toughest issues facing health care today. "No one wants to touch this problem," Merrill says. "If I had to do it, there would be a panel of people to review cases and their decisions would be binding. Members of the panel would have to have some criteria to work by."
These would be tough to develop, she says. What would be considered? A person's value to society? Age? The manner in which a disease was acquired? Would someone with liver disease from alcohol abuse not be treated while someone with liver disease from hepatitis is? Would there be a limit on the amount of money spent on any single person?
One solution has been reduced by two well-known critical care policy analysts to a simple formula. According to this formula, or "entitlement index," admission to the ICU equals P times Q times L over C. In this equation, P is the probability of a successful outcome, Q is the quality of success, L is the length of life remaining to the patient and C is the costs required to treat the patient.
Such a formula, the authors say, is needed to create a common method for assigning monetary values to life. Without such common agreement, they argue, there will continue to be "widespread chaos" in the way medical care is allocated. Without a common way of determining who gets intensive care treatment and who doesn't, they say, healthy patients may die or suffer permanent disabilities because resources were spent on patients less likely to be restored to health.
Other critical-care experts propose a rationing system that relies largely on scientific studies of ICU treatment. Researchers at Georgetown University, for example, are analyzing the treatment of thousands of ICU patients nationwide. Such a study could allow hospitals to set up medical guidelines for admitting and discharging patients from the ICU.
Physicians already know that some patients have virtually no chance of surviving a stay in the ICU. For example, patients who have more than three organ systems fail after three days in an ICU have a death rate of 98 percent, according to one study.
The outlook for some patients on mechanical breathing machines also is grim. One recent study shows that more than half of ICU patients on ventilators for seven days or more died. These patients consumed 37 percent of the ICU resources in their hospitals. Put another way, after seven days on a breathing machine, the expected cost of the remaining hospital stay for these ICU patients is comparable to that for a heart transplant patient.
The notion that some patients would be denied admission to a critical care unit solely on the basis of guidelines established by a committee clearly bothers some physicians.
"I don't like the concept of denying people admission to the ICU," says Dr. Dudley Rochester, a pulmonary specialist who regularly sees patients on the medical ICU at UVa. "The person who serves as the gatekeeper can't possibly be well informed enough to make that decision."
Rochester would prefer to control critical care costs by being more willing to withdraw care from hopelessly ill patients once they have been evaluated in the ICU.
"I think the best situation is to admit patients to the ICU for a week and see if they respond to therapy," agrees Dr. Jonathon Truwit, the director of UVa's medical ICU. Like Rochester, he believes physicians, patients and families should be more willing to withdraw ICU care in situations where treatment seems futile.
A system that relies on withdrawing intensive therapy as a means of rationing won't work unless society understands the limits of modern medicine, says Kevin High, one of the two chief medical residents at UVa.
"We need to tell the public that there are times when no matter what we do, the patient is going to die and that further treatment is futile," High says.
Some health care policymakers are proposing that patients fill out "advance directives" that authorize physicians to do the potentially risky lifesaving therapies that are common in the intensive care units.
Such directives, they argue, would educate patients about the risks of such care before emergency situations arise. All too often, they say, intensive care decisions are made in crisis situations in which the bias is to go ahead and treat and evaluate the benefits later.
Even when there is a realization that a patient wants intensive treatment limited, powerful emotional forces often cause that treatment to continue. For example, one study showed that ICU patients who were designated as "no code" or "Do Not Resuscitate" continued to get more intense levels of treatment than a control group of seriously ill patients.
Part of the reason, Rochester says, is that physicians have become trapped by the vast armament of treatments available to keep patients alive. "We are victims of our own ability to invent newer and newer technologies," he says. "Technology is out of control and everybody wants it. It's hard to stop intensivists from using these new technologies."
Another factor making it difficult to limit treatment is the deeply rooted tradition in America of focusing on the individual and the immediate, life-threatening situation rather than the good of society at large.
It can be seen at work when hundreds of people devote thousands of hours and spend thousands of dollars on rescuing a single miner trapped in a cave-in. Yet nowhere near the same resources are spent on enforcing regulations that could have prevented the cave-in in the first place.
When Americans discovered the practice of hospital committees' choosing among patients for renal dialysis, the result was a federal program that paid for everyone to get treatment. That program now costs more than $2 billion a year, nearly twice the amount spent on a program providing basic nutrition to pregnant women and their young children.
The best approach to rationing health care is one that puts limits on medical treatment in the last year of life, says Fletcher, the UVa ethics specialist. Under his scheme, age would not be the major factor in limiting care. Rather, he would rely on scientific studies that show a patient is not likely to live another year no matter what kind of treatment is given.
Such a policy, he says, would have to be implemented nationally in order to work. But the actual review of the medical factors governing each patient's treatment would have to be made by physicians.
To be successful, a program limiting care in the last year of life must come with the understanding that the savings will be used to prolong life for other groups, Fletcher says. He believes the savings should be devoted to providing care at the beginning of life: free prenatal care for all women who need it.
To do this, he acknowledges, would require a national system that assures the money saved in limiting care to people in their last year of life would be directed to pregnant women and children.
It also would require a change in attitudes. In Great Britain, for instance, there are one-fifth as many intensive care beds relative to the population as there are in U.S. hospitals. While physicians in Great Britain report that they could use more ICU beds, they also say this would pull resources from other programs that assure basic medical care to the public.
Until a crisis erupts that cannot be ignored, federal health care policy-makers aren't likely to push for any system that limits care on the basis of well-thought-out criteria, says Martin Strosberg, a professor of health management at Union College in Schenectady, N.Y.
"Policymakers in Washington don't want to touch this issue," says Strosberg, who spent a year touring intensive care units in the Northeastern U.S. and Canada. "It's too hot to handle."
The political mind-set in America right now is cost containment, Strosberg says. As long as tax increases can be avoided, politicians don't care how health care is limited.
A prime example, he says, is the decision by Congress to disband a program designed to improve catastrophic medical services for the elderly by expanding Medicare. The program was scrapped after a severe backlash from many elderly Americans who resented helping to pay for the improved coverage with modest increases in Medicare payments.
Even though ICU directors around the country say their units are filled and even though critical care costs are contributing to what some see as a health care system with runaway costs, "it isn't a political problem right now," Strosberg says. "There's no blood on the streets."
One thing that could change the political atmosphere, he says, is AIDS. As physicians find more and more AIDS patients can benefit from treatment in the ICU, there could be a tremendous influx of patients nationwide. If those patients start getting turned away from ICUs, Strosberg says, they might have enough political clout to get the nation's attention.
Memo: Life and Death in Intensive Care