Economic, Ethical, & Legal Issues in Critical Care
High-quality critical care is very expensive; poor-quality critical care is even more expensive. Inten-sive care unit (ICU) beds constitute only 10% of all beds in most hospitals yet account for a large frac-tion of hospital expenditures. If this cost is justified, clear reductions in morbidity or mortality should be readily demonstrable. Unfortunately, confirma-tory studies are few and typically flawed by the use of historical controls. A method of reliably identi-fying those patients who will benefit most from intensive care is needed. Several scoring systems based on the severity of physiological derangements and preexisting health have been used, such as the Acute Physiology and Chronic Health Evaluation (APACHE) and Therapeutic Intervention Scoring System (TISS), but while all reliably identify “sicker” patients none reliably identifies the very sick but recoverable patients for whom intensive care is intended. Survival is generally inversely related to the severity of illness and number of organ systems affected. The Society of Critical Care Medicine has established Project Impact, a system that allows ICUs to compare their outcomes and the care they provide against a national and international network of ICUs.
AC Assist-control (ventilation)
AKI Acute kidney injury
AMI Acute myocardial infarction
APACHE Acute Physiology and Chronic Health Evaluation
APRV Airway pressure release ventilation
ARDS Acute respiratory distress syndrome
CMV Continuous mandatory ventilation
CPAP Continuous positive airway pressure
CRRT Continuous renal replacement therapy
FENa+ Fractional excretion of filtered sodium
FIO2 Fraction of inspired oxygen
FRC Functional residual capacity
HFJV High-frequency jet ventilation
HFV High-frequency ventilation
I:E Inspiratory:expiratory (ratio)
ILV Independent lung ventilation
IMV Intermittent mandatory ventilation
IPAP Inspiratory positive airway pressure
MMV Mandatory minute ventilation
MODS Multiple organ dysfunction syndrome
Pplt Plateau pressure
PCV Pressure control ventilation
PEEP Positive end-expiratory pressure
PSV Pressure support ventilation
ROP Retinopathy of prematurity
RSBI Rapid shallow breathing index
SIMV Synchronized intermittent mandatory ventilation
SIRS Systemic inflammatory response syndrome
TISS Therapeutic Intervention Scoring System
VD Volume of distribution
VT Tidal volume
The high cost of critical care medicine has led to economic constraints being applied by govern-ments and third-party payers. At the same time an increased awareness of ethical and legal issues has changed the practice of critical care medicine.
Decisions about when to initiate or terminate treatment can be difficult. Generally, any treatment that can reasonably be expected to reverse illness or restore health is justified, whereas withholding that treatment requires specific ethical justifica-tion. Conversely, if treatment will definitely not reverse a disease process or restore health, then the decision to initiate such treatment may not be justi-fied and may be unethical. Until recently, nearly all patients in the United States—even those who were clearly about to die—received maximal treatment (sometimes contrary to the patient’s or family’s wishes) for fear of the possible legal repercussions of withholding treatment. “Heroic” measures such as chest compressions, drug resuscitation, and mechanical ventilation were continued until the patient died. These complex decisions must involve the patient (or guardian) and the family and must be consistent with hospital policies and state and federal law.
Fortunately, legal guidelines for arriving at these decisions are available in nearly all states. Although laws vary from state to state, they tend to be simi-lar. The greatest conundrums relate to withholding treatment and discontinuing artificial life-support systems. Competent patients (ie, individuals who have the capacity to understand and make medical decisions) have the right to refuse treatment and the right to have life-support machines or devices turned off (or not initiated) if and when they so request. Most states allow competent individuals to prepare an advance directive, usually either a liv-ing will or a durable power of attorney for health care, to prevent needless prolongation of life if they become incompetent (eg, severe mental disability, vegetative state, or irreversible coma). Withhold-ing treatment or discontinuing life support from patients who do not have advance directives or cannot provide their own consent requires per-mission of the spouse, guardian, next of kin, or an individual to whom the patient has given power of attorney for health care. In some cases, clarification from the courts may be necessary. “Do Not Resus-citate” (DNR) or “Allow Natural Death” (AND) orders have been upheld by the courts for patients in whom resuscitation offers no hope of curing or reversing the disease process responsible for immi-nent death.
Artificial support of ventilation and circula-tion complicates legal definitions of death. Until recently, most states required only a determination by a physician that irreversible cessation of venti-latory and circulatory function had occurred. All states have added the concept of brain death to that definition, while some states recognize religious exemptions. In New Jersey, for example, physi-cians cannot declare brain death “if it would violate the personal religious beliefs of the individual.” In addition, although brain death can be established in a pregnant woman, the issue of whether life sup-port can be withdrawn remains subject to both ethical and legal debate. There have been a num-ber of cases of women giving birth to a viable baby weeks or months after having been declared brain dead. These cases involve issues of maternal rights, “fetal rights,” and paternal rights and have yet to be resolved.
Brain death is defined as irreversible cessation of allbrain function. Spinal cord function below C1 may still be present. Establishing brain death relieves the burden on families of unjustifiable hope and pro-longed anxiety; it also prevents waste of medical resources, and potentially allows the retrieval of organs for transplantation.Brain death criteria can be applied only in the absence of hypothermia, hypotension, metabolic or endocrine abnormalities, neuromuscular blockers, and drugs known to depress brain func-tion. A toxicology screen is required if sufficient time since admission (at least 3 days) has not elapsed to exclude a drug effect. Moreover, the patient should be observed long enough to establish with reason-able certainty the irreversible nature of the injury.
Generally accepted clinical criteria for brain death include the following:
· Absent motor activity, including no decerebrate or decorticate posturing; spinal cord reflexes may be preserved in some patients
· Absent brainstem reflexes, including no pupillary, corneal, vestibuloocular (caloric), or gag (or cough) reflexes
· Absence of ventilatory effort, with the arterial CO2 tension at least 60 mm Hg or 20 mm Hg above the pretest level.
Repeating the examination (not less than 2 h apart) is optional. In the United States the required number of physician observers varies by state (Florida requires two), as does the level of expertise (Virginia requires a neurologist or neu-rosurgeon to make the determination). The apnea test should be reserved for last because of its det-rimental effects on intracranial pressure. Confir-matory test findings that may be helpful but are not required include an isoelectric electroenceph-alogram, absence of brainstem auditory evoked potentials, and absence of cerebral perfusion as documented by angiographic, transcranial Dop-pler, or radioisotopic studies.
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