The delivery of futile care is harmful to other patients Michael S. Niederman, MD; Jeffrey T. Berger, MD I ntensive care units (ICUs) in dif- ferent parts of the world provide care to patients with advanced age and terminal illness at different rates and in different patterns. In the United States, ICU beds make up a dis- proportionate number of acute care beds. Nearly half of all patients who die in US hospitals have received ICU care, some of which may be futile. The use of ICU care for the elderly at the end of life The elderly comprise a large percent- age of patients treated in ICUs through- out the United States with patients 65 yrs accounting for 50% of all ICU care, although they constitute 15% of the population (1). In one study, those aged 60 yrs used the ICU in 60% of hospital admissions compared with 30% in those 60 yrs (1). The highest admission rate was in those aged 70 –79 yrs, but the elderly had a higher mortality rate, longer length of stay, and higher cost of care than younger patients. Thus, the el- derly consume a large amount of re- sources and present with some of the most challenging and complex illnesses. Currently, there is no clear consensus about how to best allocate critical care resources to this population. Practices vary widely in different countries, but the focus of this discussion is the premise that the use of resources for elderly indi- viduals can impact on the outcome and care of other populations. This becomes a particular problem when we provide fu- tile care, a prospect that often arises in the elderly, particularly with the use of antibiotic therapy for patients with no meaningful chance of recovery. The use of ICU resources for the el- derly is a practice that varies from coun- try to country. In comparing the use of ICU in western Europe with that in the United States, investigators observed that ICU admissions per 100,000 population were higher in the United States with the exception of Germany (2). However, un- like European countries, the number of ICU beds in the United States did not parallel the number of acute care beds. The United States had a disproportion- ately higher percent of acute care beds devoted to ICU care and spent more money than other countries per ICU bed. Another recent study compared practices in the United States with those in En- gland (3). Age-adjusted acute hospitaliza- tion rates were 110.5 per 1000 population in England vs. 105.3 in the United States with similar mortality rates. In England, 50.3% of deaths occurred in the hospital, but only 5.1% of deaths involved ICU care. In the United States, 36.6% of deaths occurred in the hospital, whereas 17.2% of deaths involved the ICU. Thus, overall, 47.1% of hospital deaths in the United States involved ICU care com- pared with 10.1% in England. In the United States, the elderly received ICU care far more often; in those aged 85 yrs, 31.5% of medical deaths and 61% of From the Department of Medicine (MSN, JTB), Division of Pulmonary and Critical Care Medicine (MSN), and the Division of Geriatrics and Palliative Medicine (JTB), Winthrop-University Hospital, Mineola, NY; and and Department of Medicine (MSN, JTB), SUNY at Stony Brook, Stony Brook, NY. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: mniederman@winthrop.org Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181f1cba5 Objective: Intensive care units (ICUs) in different parts of the world provide care to patients with advanced age and terminal illness at different rates and in different patterns. In the United States, ICU beds make up a disproportionate number of acute care beds. Nearly half of all patients who die in U.S. hospitals have received ICU, some of which may be futile. The objective of this study was to examine ways in which the delivery of futile care in the ICU can cause harm to patients other than those receiving the futile care. Design: Review of available studies of patient and family attitudes about cardiopulmonary resuscitation and other support- ive modalities, including antibiotic therapy, and the relation- ship of the delivery of such care to the outcomes of others treated in the ICU. Patients: Those treated in ICUs and those receiving futile care. Measurements and Main Results: Compared with younger pa- tients, the elderly in the United States use more ICU care, at higher cost, have more serious comorbidities, and have a higher mor- tality rate. Certain populations demand ICU care more than others and often with less benefit than less-demanding populations. In a situation of unlimited resources, the provision of ICU care, even when futile, has been viewed as an individual patient decision with no harm to others within the hospital. However, even with unlimited resources, the use of antibiotics for those who are receiving futile care can be considered unethical by egalitarian theory because it can lead to antibiotic resistance that may make the treatment of other patients impossible. In the setting of limited resources, like in pandemic influenza, or with the potential limiting of resources, in a pay-for-performance environment, the provision of futile care can also harm the hospital population as a whole. Conclusions: The delivery of futile care is not only an individual patient decision, but must be viewed in a broader context. Soci- etal awareness of this problem is necessary, and better scoring systems to identify when ICU care has limited benefit are needed to address these difficult and challenging realities. (Crit Care Med 2010; 38[Suppl.]:S518 –S522) KEY WORDS: futile care; antibiotic use; antimicrobial resistance; pay for performance; pandemic influenza; end-of-life care; el- derly; scoring systems; nonmaleficence; egalitarian theory S518 Crit Care Med 2010 Vol. 38, No. 10 (Suppl.)