Making Care Decisions for ICU Patients

While a study has found that unrealistic family expectations resulted in the increased use of healthcare resources without noticeable improvement in gravely ill patients in the intensive care unit (ICU), limiting aggressive care to such patients upon arrival might shorten potentially productive lives.

The researchers described this dilemma in the February 2005 issue of the Mayo Clinic Proceedings (Mayo Clinic, Rochester, MN, USA). In the study, they used a computerized system (APACHE III) designed to predict mortality rates in real-time for ICU patients, in order to identify those patients with a very low likelihood of survival. They compared a group of these patients, in which families had unrealistic expectations of survival, with a group in which family expectations were judged appropriate. Although the first group spent four days in the ICU compared to 11 days for the latter group, survival at one year did not differ much in the two groups. Nearly all survivors were severely disabled at discharge and at one year.

"Perhaps the best way to avoid vast expenditures of resources on patients very unlikely to survive is by improving communications between patients, their families, and their caregivers,” said Keith Berge, M.D., a Mayo Clinic anesthesiologist who led the study.

Dr. Berge suggested that increased utilization of advanced directives by patients (offered by only 19% in the study), formal patient-care reviews, and assistance from ethicists and family counselors might better align patient or family expectations with reasonable therapeutic goals. The researchers noted that APACHE III was more than five times more pessimistic than what they themselves observed in their extremely ill subset of patients. They also noted the value of physician insights in interpretations in making care decisions.




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