Resource Allocation in the Intensive Care Unit

Published on 22/03/2015 by admin

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215 Resource Allocation in the Intensive Care Unit

Two truisms of economics are that the supply of goods and services is finite and that the supply will be insufficient to meet all demands. The tension between supply and demand for food, water, energy, education, and other goods and services creates economies. All societies must determine how goods and services will be allocated to individuals. Although the term rationing connotes a specific process of allocation during circumstances of severe resource limitation (rationing coupons to allocate gasoline during World War II, for example, or one’s daily ration of water on a life raft), rationing is just an emotionally laden synonym for resource allocation. In this chapter, the terms are used interchangeably.

Market-based economies allocate many resources on the basis of ability to pay, but other strategies exist (Table 215-1).1 In developed nations, some goods and services—for example, health care and education—are treated differently from luxury goods and are allocated by society using criteria other than an individual’s ability to pay. Regardless of the strategy ultimately used, decisions to allocate medical resources are fundamentally identical to decisions to allocate other resources. Because medical resources are finite, it is impossible to provide every effective treatment in every case in which it might offer benefit and the patient desires the care. This does not mean that clinicians are aware on a daily basis of the burden of this reality. Sometimes the decisions are explicit, with immediate repercussions—for example, the selection of one patient to receive a heart transplant when several might benefit from the sole available organ, or the decision to admit one patient to the last intensive care unit (ICU) bed when several critically ill patients could benefit from ICU admission. More frequently, the decisions are subtle and occur even when the supply of therapy is not absolutely limited—for example, the decision to use cheaper antibiotics, sedatives, imaging modalities, or operative procedures when more expensive options might be beneficial. Finally, allocation decisions can be completely implicit and almost hidden. For example, the decision to build an ambulatory care clinic instead of adding ICU beds has profound implications for the delivery of critical care services, but individual clinicians are largely unaware of this relationship.

TABLE 215-1 Strategies for Allocating Resources

Principle Definition
Autocracy To each according to the will of one
Democracy To each according to the will of the majority
Equality To each according to an equal share
Lottery To each according to an equal chance
Capitalism To each according to their ability to buy
Personal worth To each according to their contribution to the community
Utilitarianism To each so that the utility of the community is maximized

Although common and necessary, allocation decisions are stigmatized in medicine. Such decisions bring two major ethical principles into conflict: the principle of beneficence guides clinicians to act solely in their patients’ best interests, while the principle of justice directs clinicians to act fairly.2 This conflict may explain why euphemisms are frequently used to describe decisions that essentially involve the rationing of resources. For example, “triage,” “optimization,” “prioritization,” “cost-effective care,” and “basic health care” all indicate some form of allocation decision.3,4 The purpose of this chapter is to explore these decisions in their many guises as they occur in critical care and to offer some guidance to clinicians in constructing processes for allocating resources in their ICU.

image Allocation Versus Evidence-Based Medicine

Decisions based solely on evidence of the efficacy of medical care are not rationing decisions. There is no medical obligation to provide and no societal obligation to pay for care that is harmful or ineffective. In fact, clinicians use special terms to describe interventions that fall into these categories, including “futile,” “not standard of care,” “medically inappropriate,” “wasteful,” or “experimental.”5,6 For example, an intensivist who decides not to transfuse a critically ill patient with a hematocrit of 27 is not rationing blood, even though blood is an expensive and limited resource; in this case, there is evidence that a transfusion would be of no benefit and might even be harmful.7 Likewise, the decision not to use human growth hormone, an expensive medication, in a chronically critically ill patient is not a rationing decision, because this treatment has been shown to be ineffective and may be harmful.8

Unfortunately, assessments of benefit and harm are not as straightforward as the terms would suggest, and the line between effective, ineffective, and experimental treatment often is a personal decision for the individual clinician. Decision science has taught us that medical decision making is a complex process that frequently obscures the true rationale for the choice.9 In fact, judgments allegedly based solely on objective evidence of safety and benefit often incorporate a variety of subjective values and biases.10 These may include the value the clinician assigns to being wrong; the value assigned to trying to “rescue” a patient in imminent danger of death; the clinician’s tolerance for uncertainty; the impact of the decision on the clinician’s finances; biases about the patient’s race, gender, functional status, or age; and the cost or availability of the resource.11 The transition from statements that summarize the evidence of benefit to recommendations that incorporate cost and other values is often very subtle. For example, the authors of a recent systematic review of colloid resuscitation in critical care conclude that “there is no evidence from randomized controlled trials that resuscitation with colloids reduces the risk of death compared to crystalloids in patients with trauma, burns and following surgery.”12 This is a statement of their summary of the evidence of efficacy of colloid therapy. Like many treatments in critical care, the evidence neither supports nor completely refutes the use of colloids as resuscitation fluids in the critically ill. However, the authors conclude, “As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patient types can be justified outside the context of randomized controlled trials.” Whereas the first statement may be a fair summary of the evidence, the recommendation against using colloids in the second sentence is not based solely on the evidence. It incorporates an implicit rationing strategy that pays only for treatments that have demonstrated benefit in a certain way. Although one might conclude from the authors’ review that colloid resuscitation is experimental or that its benefit is likely to be small, the reasoning for recommending against its use is based on the cost of the treatment. Presumably, if colloid fluids were the same price as crystalloids, the authors might reach different conclusions, even though the cost does not change the evidence of efficacy.

The preceding example shows how assessments of cost can creep into recommendations for therapy even without a formal discussion of allocation. Because clinicians and payers may be reluctant to admit they are incorporating cost or availability into the rationale for a decision, they may find decisions based on futility or appropriateness less ethically problematic than those based on rationing. In fact, these judgments may implicitly contain assessments of cost by incorporating cost into the definition. When is there sufficient evidence to move a treatment or diagnostic device from experimental care to standard care? When is there sufficient evidence, absent evidence of outright harm, that a treatment is ineffective as opposed to not yet of proven efficacy? These decisions are frequently made by consensus bodies using subjective or poorly characterized criteria. The evidence threshold tends to be higher for treatments that are risky or expensive or for which there is no alternative. Conversely, the threshold for accepting a treatment as “standard” is lower if that treatment is inexpensive and safe and offers the potential of rescuing a patient in imminent danger of dying. For example, consider the decision to elevate the head of the bed of mechanically ventilated patients to prevent ventilator-associated pneumonia. This is an inexpensive and safe treatment to offer patients. It might take less evidence to convince clinicians to use this treatment than to use kinetic beds or topical prophylactic antibiotics, which are more expensive and may raise safety issues. Therefore, the cost of an intervention may be incorporated into the assessment of whether it is a standard of care.

These judgments are further complicated by the motivation of the decision maker. It would be difficult for an insurance company that is assessing whether a specific therapy is experimental or standard of care to be unbiased, because its decision will affect its profits. Alternatively, surgeons who developed a procedure may be committed to its benefits in a way that compromises an objective evaluation. The complexity of the assessment of efficacy and cost highlights the importance of making allocation decisions as objective, explicit, and public as possible. Because medical decisions are so complex, and because decisions in the ICU are further complicated by their immediacy and the severity of patients’ illnesses, it is essential that clinicians understand their own motivations and the evidence supporting their decisions and have a process in place for allocating resources.

image Allocation Strategies

Allocation decisions are usually separated into macro-allocation decisions (involving groups of people and usually made at a managerial or health policy level) and micro-allocation decisions (made at the bedside and involving specific cases). A hospital’s decision not to hire additional ICU nurses is a macro-allocation decision; a nurse-manager’s decision to allocate a specific patient to share a nurse in the ICU rather than to receive 1 : 1 nursing is a micro-allocation decision. This chapter is concerned primarily with bedside, or micro-allocation, decisions that clinicians make on a routine basis. There is an important interaction between micro- and macro-allocation decisions, because macro-allocation decisions ultimately affect individuals, and macro-allocation regulations are an effective rationing strategy (Table 215-2). There are a number of approaches to allocating resources (see Table 215-1). Although they are all feasible, they are not all equally ethical.

TABLE 215-2 Allocation Decisions at Different Levels

Decision Maker Decision Rationale
Nonallocation Decision
Physician Not to use human growth hormone in chronically critically ill patients Evidence of harm in critically ill patients
President of insurance company Not to offer routine chest computed tomography screening for lung cancer Lack of sufficient evidence of benefit
Healthcare official Not to offer basic medical coverage to all people in the country Endorses goals other than equal access to health care—for example, the importance of choice or the value of free market
Macro-allocation Decision
Physician Not to admit routine post–coronary artery bypass patients to ICU Limited ICU beds better used for patients with more severe illness
President of insurance company Not to increase reimbursement for septic shock when new, expensive drug is approved Hopes to limit cost of care for patients to increase profitability of insurance company
Healthcare official To capitate reimbursement for hospital care By providing single fee for all care, hopes to limit costs so increased outpatient services can be provided
Micro-allocation Decision
Physician Not to admit a debilitated, elderly man with urosepsis to the ICU, despite a request by the patient’s primary care physician The patient is moribund, and the intensivist believes the ICU’s resources can be used to better effect on other patients.
President of insurance company Denial of claim to pay for prostacyclin infusion for pulmonary hypertension Treatment specifically not covered by contractual arrangement with insured patient
Healthcare official Not applicable Not applicable

The principles of equality, fairness, justice, and due process make some strategies less acceptable. The principle of utilitarianism directs resource allocation to maximize the “utility” or benefit to the greatest number of people for any given amount of resources. To the extent that utility can be determined by measuring patient outcomes such as health-related quality of life, and to the extent that we can theoretically estimate the effects of medical treatments on utility, we can calculate exactly which set of medical treatments to pay for to maximize the benefit to the population. These studies are called cost-effectiveness analyses and are the quantitative embodiment of utilitarianism.

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