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
EGD Esophagogastroduodenoscopy
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:
·
Coma
·
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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