Editorials
shows that the SMR does not point out which ICU is best for an individual patient. It merely shows what the performance (or outcome) of an ICU is, given its particular case-mix of patients in comparison to a reference population (8). Another major drawback of comparing SMRs is that discharge policies are ignored. ICUs that transfer their patients to other facilities have a good outcome (discharged alive), even when these patients die in the next hospital. Therefore, it preferred to focus on long-term outcome (e.g., 1-year survival) (9). If the process of benchmarking is difficult and the interpretation of SMRs is hampered by pitfalls, then the obvious question is: should we continue benchmarking? Let’s go back to Donabedian (1). Why did we start benchmarking in the first place? Because we wanted to learn which ICU processes are associated with a better outcome (so-called best practices) and should be implemented in all ICUs. This is the proper way to quality improvement. However, the unintelligent translation of SMRs to rank-order listings for ICUs should only be scored as “a negative quality indicator.”
REFERENCES
1. Donabedian A: Evaluating the quality of medical care. 1966. Milbank Q 2005; 83:691–729
2. de Vos M, Graafmans W, Keesman E, et al: Quality measurement at intensive care units: Which indicators should we use? J Crit Care 2007; 22:267–274 3. Flaatten H: The present use of quality indicators in the intensive care unit. Acta Anaesthesiol Scand 2012; 56:1078–1083 4. Kramer AA, Higgins TL, Zimmerman JE: Comparing Observed and Predicted Mortality Among ICUs Using Different Prognostic Systems: Why Do Performance Assessments Differ? Crit Care Med 2015; 43:261–269 5. Kramer AA, Higgins TL, Zimmerman JE: Comparison of the Mortality Probability Admission Model III, National Quality Forum, and Acute Physiology and Chronic Health Evaluation IV hospital mortality models: Implications for national benchmarking. Crit Care Med 2014;42:544–553 6. Zimmerman JE, Kramer AA, McNair DS, et al: Acute Physiology and Chronic Health Evaluation (APACHE) IV: Hospital mortality assessment for today’s critically ill patients. Crit Care Med 2006; 34:1297–1310 7. Bakhshi-Raiez F, Peek N, Bosman RJ, et al: The impact of different prognostic models and their customization on institutional comparison of intensive care units. Crit Care Med 2007; 35:2553–2560 8. Manktelow BN, Evans TA, Draper ES: Differences in case-mix can influence the comparison of standardised mortality ratios even with optimal risk adjustment: An analysis of data from paediatric intensive care. BMJ Qual Saf 2014; 23:782–788 9. Brinkman S, Abu-Hanna A, de Jonge E, et al: Prediction of long-term mortality in ICU patients: Model validation and assessing the effect of using in-hospital versus long-term mortality on benchmarking. Intensive Care Med 2013; 39:1925–1931
Nonbeneficial Care: We Have Got to Do Something?* Amaya D. George, DO Christopher J. Colombo, MD Critical Care Section Department of Medicine Dwight David Eisenhower Army Medical Center Fort Gordon, GA
C
oncerns regarding the effectiveness of communication and the provision of end-of-life care are apparent in the medical literature, beginning largely with the publication of the Support Trial in 1995 which demonstrated a
*See also p. 270. Key Words: communication; ethics; healthcare cost; medical futility; rationing Dr. George disclosed government work. Dr. Colombo is employed by the United States Army, received support for travel from Georgia Regents University for the 2012 and 2013 critical care symposium (lodging reimbursed during days lectures given for critical care conference and meeting registration fee waived), and disclosed government work. His institution received grant support from AMEDD Advanced Medical Technology Initiative (military research grant for collaborative research with industry and civilian academia on medical technology). The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. Government. Copyright © 2015 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000759
474
www.ccmjournal.org
chasm between patient autonomy and physician awareness and implementation of the same. At the time, the commonsense intervention of a communication specialist had no meaningful impact (1). The subsequent 2 decades of research, public policy, and physician education have been marked by multiple attempts to improve communication among the patient, the family, and a team of providers. In this issue of Critical Care Medicine, Downar et al (2) investigate an aspect of end-of-life care they term nonbeneficial treatment (NBT). Through a survey used at multiple facilities in Canada, they sought to arrive at a healthcare provider’s functional definition of NBT and explore perceptions of NBT as well as causes, impacts, and mitigation strategies for NBT. Strengths of the study include the exceptional agreement with the two NBT definitions that include quality of life and patient self-determination as well as demonstrating providers comfort with being able to differentiate NBT from beneficial treatment with fairly high certainty. Not surprisingly, unrealistic expectations on the part of the patients and their surrogates were felt to be a driving force behind continuing NBT, and there were several variables that demonstrate different perceptions on the part of physicians and nurses; themes that were present 20 years ago (1) and still evident in recent literature (3–5). Lastly, the proposed solutions are to have better communication, training, and strategies and increased use of advanced care planning. Lack of advanced care planning as a perception by providers is congruent with current literature, showing only February 2015 • Volume 43 • Number 2
Editorials
18–30% of patients have an advance directive at the onset of their illness (6). One might conclude that this survey demonstrates that “nothing has changed” in the last 20 years and sound the alarm that as a society “we gotta do something!” There are many calls in the literature for governmental, legal, and regulatory reforms (7–9). Historically, when physicians fail to adequately address issues that are perceived by the populous as suboptimal, outside regulation is often sought and attained (10). In the recent past, these sometimes faulty perceptions have resulted in legal approaches to graduate medical education work hours (11), financial incentives for adoption of electronic health records (12), and a multigenerational tragicomedy of healthcare cost containment strategies (13), all with questionable results and unintended negative consequences. As much as this history of externally applied medical reforms in the recent past leaves me more cautious about substituting external judgment for physician-led intervention, the aforementioned study leaves me more hopeful about our state of affairs as a profession. Earlier this year, the critical care Choosing Wisely Campaign included the need to question the continuation of life-sustaining treatment in those whom it might not benefit without offering comfort and palliation as an alternative (14). The literature in the meantime shows multiple areas of improvement in communication, education, and outcome regarding end-of-life and palliative care led by providers. A recent study demonstrated that the addition of a palliative care team to an urban ICU led to earlier hospital discharge and an increased number of hospice admissions and transitions to palliative care (6). Including palliative care as an option leads to an improvement in surrogate and patient perception of end-of-life care (3, 6, 15). The study by Downar et al (2) and recent literature do not demonstrate that all is perfect, but that fact does not equate to immediate failure. Concern over central regulation of healthcare was wrought with political hysteria on the one hand with the coining of the phrase “death panels,” but the historical evidence indicates that even the best intended external “solutions” are often anything but. Additionally, discussions of rationing and scarcity are omnipresent in the medical and lay literature. Ignoring this scarcity as we take care of the individual patient paradoxically leads to lamenting the effect of those repeated heroic efforts on the medicine profession as a whole (16). Investigating NBT could have the dual benefit of reducing care that is individually and societally unethical and costly as it has been estimated that approximately 40% of lifetime healthcare costs accrue in the last month of life (5). Some believe that we will not get a handle on systematic healthcare costs without rationing medical care (13). The emotional and morally difficult choices raised by the rationing of lifesaving medical therapies may prove resistant to rational debate (16), but it is imperative that the medical profession uses a bottom-up approach in order to avoid outside regulatory bodies from removing agency from the patient-provider team.
Critical Care Medicine
A one size fits all, inflexible solution to the issue of scarcity in medicine is less desirable than the art of medicine, because the consequences of systematically and uniformly denying lifesustaining treatments to individual patients may be intolerable (16). To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measures may be needed (1). This is a complex process that revolves improvement on patientphysician communication and collaborative decision making as well as professional responsibility toward society by aiming to maximize efficient utilization of scarce resources without diminishing both patient self-determination and physician autonomy. It is intuitively obvious that only healthcare professionals and their patients together can determine how best to maintain this balance (10). The composition of “we” in the “we have got to do something” is vital: it must remain healthcare providers and patients. If “we” don’t, “they” will.
REFERENCES
1. Connors AF, Dawson NV, Desbiens NA, et al: A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA 1995; 274:22–29 2. Downar J, You JJ, Bagshaw SM; on behalf of the Canadian Critical Care Trials Group: Nonbeneficial Treatment Canada: Definitions, Causes, and Potential Solutions From the Perspective of Healthcare Practitioners. Crit Care Med 2015; 43:270–281 3. Burge F, Lawson B, Johnston G, et al: Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: Does location matter? BMC Palliat Care 2014; 13:25 4. Rivera S, Kim D, Garone S, et al: Motivating factors in futile clinical interventions. Chest 2001; 119:1944–1947 5. Wood KA, Marik PE: ICU care at the end of life. Chest 2004; 126:1403–1406 6. O’Mahony S, McHenry J, Blank AE, et al: Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24:154–165 7. Vierra M: Death panels. Ann Intern Med 2012; 156:394–395 8. Kettl P: One vote for death panels. JAMA 2010; 303:1234–1235 9. Yuen JK, Reid MC, Fetters MD: Hospital do-not-resuscitate orders: Why they have failed and how to fix them. J Gen Intern Med 2011; 26:791–797 10. Prendergast TJ: Futility and the common cold. How requests for antibiotics can illuminate care at the end of life. Chest 1995; 107:836–844 11. Spritz N: Oversight of physicians’ conduct by state licensing agencies. Lessons from New York’s Libby Zion case. Ann Intern Med 1991; 115:219–222 12. Hoffman S, Podgurski A: The use and misuse of biomedical data: Is bigger really better? Am J Law Med 2013; 39:497–538 13. Altman DE, Levitt L: The sad history of health care cost containment as told in one chart. Health Aff (Millwood) 2002; Suppl Web Exclusives:W83–W844 14. Halpern SD, Becker D, Curtis JR, et al: Choosing Wisely Campaign Document. Available at: http://www.sccm.org/SiteCollectionDocuments/ Choosing-Wisely.pdf. Accessed September 23, 2014 15. Sulmasy DP, McIlvane JM: Patients’ ratings of quality and satisfaction with care at the end of life. Arch Intern Med 2002; 162:2098–2104 16. Scheunemann LP, White DB: The ethics and reality of rationing in medicine. Chest 2011; 140:1625–1632
www.ccmjournal.org
475
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
shows that the SMR does not point out which ICU is best for an individual patient. It merely shows what the performance (or outcome) of an ICU is, given its particular case-mix of patients in comparison to a reference population (8). Another major drawback of comparing SMRs is that discharge policies are ignored. ICUs that transfer their patients to other facilities have a good outcome (discharged alive), even when these patients die in the next hospital. Therefore, it preferred to focus on long-term outcome (e.g., 1-year survival) (9). If the process of benchmarking is difficult and the interpretation of SMRs is hampered by pitfalls, then the obvious question is: should we continue benchmarking? Let’s go back to Donabedian (1). Why did we start benchmarking in the first place? Because we wanted to learn which ICU processes are associated with a better outcome (so-called best practices) and should be implemented in all ICUs. This is the proper way to quality improvement. However, the unintelligent translation of SMRs to rank-order listings for ICUs should only be scored as “a negative quality indicator.”
REFERENCES
1. Donabedian A: Evaluating the quality of medical care. 1966. Milbank Q 2005; 83:691–729
2. de Vos M, Graafmans W, Keesman E, et al: Quality measurement at intensive care units: Which indicators should we use? J Crit Care 2007; 22:267–274 3. Flaatten H: The present use of quality indicators in the intensive care unit. Acta Anaesthesiol Scand 2012; 56:1078–1083 4. Kramer AA, Higgins TL, Zimmerman JE: Comparing Observed and Predicted Mortality Among ICUs Using Different Prognostic Systems: Why Do Performance Assessments Differ? Crit Care Med 2015; 43:261–269 5. Kramer AA, Higgins TL, Zimmerman JE: Comparison of the Mortality Probability Admission Model III, National Quality Forum, and Acute Physiology and Chronic Health Evaluation IV hospital mortality models: Implications for national benchmarking. Crit Care Med 2014;42:544–553 6. Zimmerman JE, Kramer AA, McNair DS, et al: Acute Physiology and Chronic Health Evaluation (APACHE) IV: Hospital mortality assessment for today’s critically ill patients. Crit Care Med 2006; 34:1297–1310 7. Bakhshi-Raiez F, Peek N, Bosman RJ, et al: The impact of different prognostic models and their customization on institutional comparison of intensive care units. Crit Care Med 2007; 35:2553–2560 8. Manktelow BN, Evans TA, Draper ES: Differences in case-mix can influence the comparison of standardised mortality ratios even with optimal risk adjustment: An analysis of data from paediatric intensive care. BMJ Qual Saf 2014; 23:782–788 9. Brinkman S, Abu-Hanna A, de Jonge E, et al: Prediction of long-term mortality in ICU patients: Model validation and assessing the effect of using in-hospital versus long-term mortality on benchmarking. Intensive Care Med 2013; 39:1925–1931
Nonbeneficial Care: We Have Got to Do Something?* Amaya D. George, DO Christopher J. Colombo, MD Critical Care Section Department of Medicine Dwight David Eisenhower Army Medical Center Fort Gordon, GA
C
oncerns regarding the effectiveness of communication and the provision of end-of-life care are apparent in the medical literature, beginning largely with the publication of the Support Trial in 1995 which demonstrated a
*See also p. 270. Key Words: communication; ethics; healthcare cost; medical futility; rationing Dr. George disclosed government work. Dr. Colombo is employed by the United States Army, received support for travel from Georgia Regents University for the 2012 and 2013 critical care symposium (lodging reimbursed during days lectures given for critical care conference and meeting registration fee waived), and disclosed government work. His institution received grant support from AMEDD Advanced Medical Technology Initiative (military research grant for collaborative research with industry and civilian academia on medical technology). The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. Government. Copyright © 2015 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000759
474
www.ccmjournal.org
chasm between patient autonomy and physician awareness and implementation of the same. At the time, the commonsense intervention of a communication specialist had no meaningful impact (1). The subsequent 2 decades of research, public policy, and physician education have been marked by multiple attempts to improve communication among the patient, the family, and a team of providers. In this issue of Critical Care Medicine, Downar et al (2) investigate an aspect of end-of-life care they term nonbeneficial treatment (NBT). Through a survey used at multiple facilities in Canada, they sought to arrive at a healthcare provider’s functional definition of NBT and explore perceptions of NBT as well as causes, impacts, and mitigation strategies for NBT. Strengths of the study include the exceptional agreement with the two NBT definitions that include quality of life and patient self-determination as well as demonstrating providers comfort with being able to differentiate NBT from beneficial treatment with fairly high certainty. Not surprisingly, unrealistic expectations on the part of the patients and their surrogates were felt to be a driving force behind continuing NBT, and there were several variables that demonstrate different perceptions on the part of physicians and nurses; themes that were present 20 years ago (1) and still evident in recent literature (3–5). Lastly, the proposed solutions are to have better communication, training, and strategies and increased use of advanced care planning. Lack of advanced care planning as a perception by providers is congruent with current literature, showing only February 2015 • Volume 43 • Number 2
Editorials
18–30% of patients have an advance directive at the onset of their illness (6). One might conclude that this survey demonstrates that “nothing has changed” in the last 20 years and sound the alarm that as a society “we gotta do something!” There are many calls in the literature for governmental, legal, and regulatory reforms (7–9). Historically, when physicians fail to adequately address issues that are perceived by the populous as suboptimal, outside regulation is often sought and attained (10). In the recent past, these sometimes faulty perceptions have resulted in legal approaches to graduate medical education work hours (11), financial incentives for adoption of electronic health records (12), and a multigenerational tragicomedy of healthcare cost containment strategies (13), all with questionable results and unintended negative consequences. As much as this history of externally applied medical reforms in the recent past leaves me more cautious about substituting external judgment for physician-led intervention, the aforementioned study leaves me more hopeful about our state of affairs as a profession. Earlier this year, the critical care Choosing Wisely Campaign included the need to question the continuation of life-sustaining treatment in those whom it might not benefit without offering comfort and palliation as an alternative (14). The literature in the meantime shows multiple areas of improvement in communication, education, and outcome regarding end-of-life and palliative care led by providers. A recent study demonstrated that the addition of a palliative care team to an urban ICU led to earlier hospital discharge and an increased number of hospice admissions and transitions to palliative care (6). Including palliative care as an option leads to an improvement in surrogate and patient perception of end-of-life care (3, 6, 15). The study by Downar et al (2) and recent literature do not demonstrate that all is perfect, but that fact does not equate to immediate failure. Concern over central regulation of healthcare was wrought with political hysteria on the one hand with the coining of the phrase “death panels,” but the historical evidence indicates that even the best intended external “solutions” are often anything but. Additionally, discussions of rationing and scarcity are omnipresent in the medical and lay literature. Ignoring this scarcity as we take care of the individual patient paradoxically leads to lamenting the effect of those repeated heroic efforts on the medicine profession as a whole (16). Investigating NBT could have the dual benefit of reducing care that is individually and societally unethical and costly as it has been estimated that approximately 40% of lifetime healthcare costs accrue in the last month of life (5). Some believe that we will not get a handle on systematic healthcare costs without rationing medical care (13). The emotional and morally difficult choices raised by the rationing of lifesaving medical therapies may prove resistant to rational debate (16), but it is imperative that the medical profession uses a bottom-up approach in order to avoid outside regulatory bodies from removing agency from the patient-provider team.
Critical Care Medicine
A one size fits all, inflexible solution to the issue of scarcity in medicine is less desirable than the art of medicine, because the consequences of systematically and uniformly denying lifesustaining treatments to individual patients may be intolerable (16). To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measures may be needed (1). This is a complex process that revolves improvement on patientphysician communication and collaborative decision making as well as professional responsibility toward society by aiming to maximize efficient utilization of scarce resources without diminishing both patient self-determination and physician autonomy. It is intuitively obvious that only healthcare professionals and their patients together can determine how best to maintain this balance (10). The composition of “we” in the “we have got to do something” is vital: it must remain healthcare providers and patients. If “we” don’t, “they” will.
REFERENCES
1. Connors AF, Dawson NV, Desbiens NA, et al: A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA 1995; 274:22–29 2. Downar J, You JJ, Bagshaw SM; on behalf of the Canadian Critical Care Trials Group: Nonbeneficial Treatment Canada: Definitions, Causes, and Potential Solutions From the Perspective of Healthcare Practitioners. Crit Care Med 2015; 43:270–281 3. Burge F, Lawson B, Johnston G, et al: Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: Does location matter? BMC Palliat Care 2014; 13:25 4. Rivera S, Kim D, Garone S, et al: Motivating factors in futile clinical interventions. Chest 2001; 119:1944–1947 5. Wood KA, Marik PE: ICU care at the end of life. Chest 2004; 126:1403–1406 6. O’Mahony S, McHenry J, Blank AE, et al: Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24:154–165 7. Vierra M: Death panels. Ann Intern Med 2012; 156:394–395 8. Kettl P: One vote for death panels. JAMA 2010; 303:1234–1235 9. Yuen JK, Reid MC, Fetters MD: Hospital do-not-resuscitate orders: Why they have failed and how to fix them. J Gen Intern Med 2011; 26:791–797 10. Prendergast TJ: Futility and the common cold. How requests for antibiotics can illuminate care at the end of life. Chest 1995; 107:836–844 11. Spritz N: Oversight of physicians’ conduct by state licensing agencies. Lessons from New York’s Libby Zion case. Ann Intern Med 1991; 115:219–222 12. Hoffman S, Podgurski A: The use and misuse of biomedical data: Is bigger really better? Am J Law Med 2013; 39:497–538 13. Altman DE, Levitt L: The sad history of health care cost containment as told in one chart. Health Aff (Millwood) 2002; Suppl Web Exclusives:W83–W844 14. Halpern SD, Becker D, Curtis JR, et al: Choosing Wisely Campaign Document. Available at: http://www.sccm.org/SiteCollectionDocuments/ Choosing-Wisely.pdf. Accessed September 23, 2014 15. Sulmasy DP, McIlvane JM: Patients’ ratings of quality and satisfaction with care at the end of life. Arch Intern Med 2002; 162:2098–2104 16. Scheunemann LP, White DB: The ethics and reality of rationing in medicine. Chest 2011; 140:1625–1632
www.ccmjournal.org
475
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
