Andrew Numa on Futility and Rationing

Futility, limitation & Futility, limitation & rationing in critical carerationing in critical care

Andrew NumaAndrew NumaDirector, ICUDirector, ICUSydney Children’s HospitalSydney Children’s Hospital

““Gently blow air or smoke Gently blow air or smoke into the lungs or the into the lungs or the

rectum”rectum”

1919thth century century

““Most Americans in 1800 had probably heard Most Americans in 1800 had probably heard that such things as hospitals existed but only a that 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 which 1873 - 120 hospitals in the USA, most of which were custodial institutions serving the were custodial institutions serving the “deserving poor”“deserving poor”

Middle class patients rarely entered hospitalsMiddle class patients rarely entered hospitals

Children’s Hospital Children’s Hospital Boston,1871 - goals:Boston,1871 - goals:

““removing sick children from abodes of removing sick children from abodes of drunkenness and vice....and allowing them to drunkenness and vice....and allowing them to spend their last days in a home of purity, spend their last days in a home of purity, comfort and peace”comfort and peace”

Children’s Hospital Boston, 3rd annual report, 1871Children’s Hospital Boston, 3rd annual report, 1871

Hartford Hospital 1874Hartford Hospital 1874

““Hopeless chronic cases are admitted without Hopeless chronic cases are admitted without any expectation of a recovery, because they can any expectation of a recovery, because they can be better cared for at the hospital and it is a be better cared for at the hospital and it is a good place to lie down and die in peace”good place to lie down and die in peace”

Hartford Hospital, 14th annual report, 1874Hartford Hospital, 14th annual report, 1874


Laboratory and radiology became more Laboratory and radiology became more complex and expensive, necessitating complex and expensive, necessitating economies of scaleeconomies of scale

Economic constraints forced adoption of Economic constraints forced adoption of business models that relied on fees generated business models that relied on fees generated by middle class patientsby middle class patients

Hospitals sought to attract patients with the Hospitals sought to attract patients with the prospect of recovery and survivalprospect of recovery and survival

120 US hospitals in 1873 → 4,359 in 1909120 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

TrustTrust

Structured interview of 50 AICU decision makers Structured interview of 50 AICU decision makers given a hypothetical scenario of 100% mortalitygiven a hypothetical scenario of 100% mortality

64% expressed unwillingness to believe 64% expressed unwillingness to believe physicians’ futility predictionsphysicians’ futility predictions

felt that predicting the future with certainty was felt that predicting the future with certainty was “beyond the ability of their physicians” (63%)“beyond the ability of their physicians” (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; Zier L et al. Surrogate decision makers’ responses to predictions of futility. Chest 2009; 136: 110-7136: 110-7

Scenario 2Scenario 2

Relative in ICU for 2 weeks with life threatening Relative 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 1 including tracheostomy, gastrostomy plus 1 month rehabilitation.month rehabilitation.

Even then the chance of survival is only Even then the chance of survival is only x x %%

1%1%

<1%<1%

0%0%

Luke 7:22Luke 7:22

““The blind see, the lame walk, the lepers are The blind see, the lame walk, the lepers are cleansed, the deaf hear, and the dead are cleansed, the deaf hear, and the dead are raised.”raised.”

20% of the text of New Testament gospels 20% of the text of New Testament gospels describe the healing of physical or mental illness describe 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

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

How good are we at How 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 asked Nurse, resident, fellow and attending asked each day:each day:

““do you think this patient is going to die in do 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

PredictionsPredictions

6,000 predictions obtained for 560 patients (43 6,000 predictions obtained for 560 patients (43 patients died before predictions could be patients died before predictions could be recorded)recorded)

433/560 survived to discharge433/560 survived to discharge

334/433 survivors (77%) had 100% prediction 334/433 survivors (77%) had 100% prediction of survival by all staff on all daysof survival by all staff on all days

SurvivorsSurvivors

99/433 = 23% survivors had at least one 99/433 = 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 15/433 = 3% survivors had ≥ 1 day on which all respondents predicted deathall respondents predicted death

Non-survivorsNon-survivors

72/127 (57%) non-survivors had unanimous 72/127 (57%) non-survivors had unanimous predictions of death by all respondents on all predictions of death by all respondents on all daysdays

But: 55/127 (43%) non-survivors had at least 1 But: 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 1 And: 35/127 (27%) non-survivors had at least 1 day of unanimous prediction of survivalday of unanimous prediction of survival

Predicting deathPredicting death

206 patients had ≥ 1 prediction of death206 patients had ≥ 1 prediction of death

107/206 died (53%)107/206 died (53%)

The predictive power of a single prediction of The 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 died prediction of death actually died

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

Neonatal predictionsNeonatal predictions

Probability of death in infants unanimously Probability of death in infants unanimously predicted to die on at least one day = 0.52predicted to die on at least one day = 0.52


A man is legally dead when he has undergone A man is legally dead when he has undergone irreversible changes of a type that make it irreversible 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

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 “reasonable criminal convictions rely on “reasonable doubt”doubt”

so does the scientific literature: usually 5% so does the scientific literature: usually 5% (p = 0.05) or 1% (p = 0.01)(p = 0.05) or 1% (p = 0.01)

Defining futilityDefining futility

““When a physician concludes (either through When a physician concludes (either through personal experience, experiences shared with personal experience, experiences shared with colleagues or consideration of reported empiric colleagues or consideration of reported empiric data) that in the last 100 cases medical data) that in the last 100 cases medical treatment has been useless, they should treatment 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 a Need 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

Defining futilityDefining futility

Treatment has no value if the patient is Treatment has no value if the patient is incapable of appreciating the benefit or incapable of appreciating the benefit or remains unable to leave the ICUremains unable to leave the ICU

Need to avoid an outcome where “pre-Need to avoid an outcome where “pre-occupation with illness precludes the carrying occupation with illness precludes the carrying out of life goals” (Plato)out of life goals” (Plato)

Not only are we not obligated to carry out futile Not only are we not obligated to carry out futile therapies we are obligated to resist demands therapies we are obligated to resist demands for such therapiesfor such therapies


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

Demographics is destinyDemographics is destiny

Age > 65Age > 65

Tax baseTax base

Age 45-65Age 45-65

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 who 40% of MICU costs are spent on patients who die before dischargedie before discharge


Patients aged > 65 account for 15% of the Patients aged > 65 account for 15% of the population and 50% of ICU patientspopulation and 50% of ICU patients

Increasing age is associated with increased Increasing 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 hospitals 47.7% 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 admitted 30% 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): Niederman MS et al. The delivery of futile care is harmful to other patients. Crit Care Med 2010: 38 (Suppl): S518-22S518-22


For patients aged > 85 years intensive care For patients aged > 85 years intensive care involved ininvolved in

31.5% of medical deaths and 61% of surgical 31.5% 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

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 neurological Estimate does not include poor neurological outcomeoutcome


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 those that effective therapies are denied to those that can benefit.that can benefit.

OregonOregon

1987 - Coby Howard - a 7 y/o awaiting BMT 1987 - 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 could John Kitzhaber argued that while Oregon could not afford to pay for every medical care service not afford to pay for every medical care service for every person it could expand insurance to for every person it could expand insurance to cover all the uninsured if it was cover all the uninsured if it was willing to ration willing to ration carecare

OregonOregon

Introduction of “universal” health coverage, via Introduction of “universal” health coverage, via Medicaid and subsidised HMOs for residents up Medicaid and subsidised HMOs for residents up to 100% of the poverty line ($16,500 pa for to 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 696 10,000 diseases reduced to 696 condition/treatment pairs, ranked in order of condition/treatment pairs, ranked in order of benefit, top 574 coveredbenefit, top 574 covered

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

OregonOregon

Within 4 years, the list had grown to 743 conditionsWithin 4 years, the list had grown to 743 conditions

Costs higher than expected (backlog)Costs higher than expected (backlog)

Co-contributions sought from families at the higher Co-contributions sought from families at the higher endend

College students excludedCollege students excluded

Consideration given to reducing the number of Consideration given to reducing the number of conditions insured (505)conditions insured (505)

Tobacco tax introducedTobacco tax introduced

Blurring the lineBlurring the line

Physician visits are covered, even if treatments Physician visits are covered, even if treatments aren’taren’t

Co-morbidities are coveredCo-morbidities are covered

Formulaic analysis of cost-benefit has been Formulaic analysis of cost-benefit has been “modified” by politicians responding to community “modified” by politicians responding to community pressurespressures

Costs have not been reduced, although coverage Costs have not been reduced, although coverage has been expandedhas been expanded

No other State has followed a similar program (yet)No other State has followed a similar program (yet)

RationingRationing

Is already happening in an ad hoc fashion in Is already happening in an ad hoc fashion in most centres and in slightly more organised most 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

What to do?What to do?

Avoid confusing:Avoid confusing:

Means and endsMeans and ends

Effects and benefitsEffects and benefits

Available technologies and obligatory Available technologies and obligatory therapiestherapies

Accept a degree of uncertaintyAccept a degree of uncertainty


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 the In general terms it is to do away with the sufferings of the sick, to lessen the violence of sufferings of the sick, to lessen the violence of their diseases and to their diseases and to refuse to treat those refuse to treat those who are overmastered by their disease, who are overmastered by their disease, realising that in such cases medicine is realising that in such cases medicine is powerlesspowerless..

Hippocratic corpusHippocratic corpus

January 5-10, 2014January 5-10, 2014

www.colloquium.com.au

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Andrew Numa on Futility and Rationing

Health & Medicine

Transcript of Andrew Numa on Futility and Rationing