Studies raise questions on value of intensive care

Home Health Columnist / Guide · Oct 11, 2004

washington post, oct. 8, 2004

studies raise questions on value of intensive care

more intensive medical care -- even at some of the most reputable hospitals in the nation -- does not necessarily translate into longer life or better health and may in fact leave patients worse off, according to researchers. elderly patients with chronic illnesses who stay in the icu longer, receive more diagnostic tests or are treated by numerous specialists do not fare better than those who receive less intensive care, two studies conducted by dartmouth medical school have found.

CCU NRS · Oct 11, 2004

washington post, oct. 8, 2004
studies raise questions on value of intensive care
more intensive medical care -- even at some of the most reputable hospitals in the nation -- does not necessarily translate into longer life or better health and may in fact leave patients worse off, according to researchers. elderly patients with chronic illnesses who stay in the icu longer, receive more diagnostic tests or are treated by numerous specialists do not fare better than those who receive less intensive care, two studies conducted by dartmouth medical school have found.

well i didn't want to register for the paper to read the story, but it probably goes back to the old chicken vs egg question, do elderly sick people die because they are in the uit or are they in the unit because they are dying

CCU NRS · Oct 11, 2004

washington post, oct. 8, 2004
studies raise questions on value of intensive care
more intensive medical care -- even at some of the most reputable hospitals in the nation -- does not necessarily translate into longer life or better health and may in fact leave patients worse off, according to researchers. elderly patients with chronic illnesses who stay in the icu longer, receive more diagnostic tests or are treated by numerous specialists do not fare better than those who receive less intensive care, two studies conducted by dartmouth medical school have found.

well i didn't want to register for the paper to read the story, but it probably goes back to the old chicken vs egg question, do elderly sick people die because they are in the uit or are they in the unit because they are dying

talaxandra · Oct 11, 2004

The articles' title is quite misleading - the benefit of ICU in general is not in doubt. What it seems to be saying is that for elderly patients with chronic illnessest he costs of ICU admission and care outweigh the benefits. I, for one, would be comfortable with some restrictions on ICU admission. I'm not saying no elderly person should be admitted; I am saying that we should consider likely outcome before initiating some forms of treatment, including ICU, and we should consider this as soon as practcally possible, before the situation changes.

For example, I have a 90 year old patient from a nursing home on the ward even as I type. She's come in with aspiration pneumonia. I'm happy to have her admitted, to hydrate her, to give her antiiotics. What I would like is the unit to consider resus status before anything deteriorates. She's 90 - if she arrests there's no possibility of getting her back intact (well, as intact as she currently is). But the consultant says that she had a good quality of life before being admitted, and in his eyes that's good enough. I'm not her - I don't know what her subjective quality of life was/is. But I know without doubt that we have no chance of getting her back if she codes - even if we catch it immediately, intubate her in just moments, correct any electrolyte derangements, miraculously get a salvagable rhythm and manage not to fracture her osteoporotic ribs and spine, she hasn't got the cerebrovascular infrastructure to survive without hypoxic injury, so why put her thorough that? Aaargh!

Sorry, frustratingly bad night, but it's home time in just three hours!

talaxandra · Oct 11, 2004

The articles' title is quite misleading - the benefit of ICU in general is not in doubt. What it seems to be saying is that for elderly patients with chronic illnessest he costs of ICU admission and care outweigh the benefits. I, for one, would be comfortable with some restrictions on ICU admission. I'm not saying no elderly person should be admitted; I am saying that we should consider likely outcome before initiating some forms of treatment, including ICU, and we should consider this as soon as practcally possible, before the situation changes.

For example, I have a 90 year old patient from a nursing home on the ward even as I type. She's come in with aspiration pneumonia. I'm happy to have her admitted, to hydrate her, to give her antiiotics. What I would like is the unit to consider resus status before anything deteriorates. She's 90 - if she arrests there's no possibility of getting her back intact (well, as intact as she currently is). But the consultant says that she had a good quality of life before being admitted, and in his eyes that's good enough. I'm not her - I don't know what her subjective quality of life was/is. But I know without doubt that we have no chance of getting her back if she codes - even if we catch it immediately, intubate her in just moments, correct any electrolyte derangements, miraculously get a salvagable rhythm and manage not to fracture her osteoporotic ribs and spine, she hasn't got the cerebrovascular infrastructure to survive without hypoxic injury, so why put her thorough that? Aaargh!

Sorry, frustratingly bad night, but it's home time in just three hours!

Pediatric Critical Care Columnist · Oct 11, 2004

I agree totally with Talaxandra. There are patients whose underlying condition (at any time, not just at greatly advanced age) almost precludes ICU admission. It's so awful to work our tails off to resus someone who will never even know that they needed it. For those patients that would not benefit from an ICU stay, I think there should be criteria, and if there is clearly no likelihood of an intact, aware recovery, then our time and money are better spent elsewhere.

Pediatric Critical Care Columnist · Oct 11, 2004

I agree totally with Talaxandra. There are patients whose underlying condition (at any time, not just at greatly advanced age) almost precludes ICU admission. It's so awful to work our tails off to resus someone who will never even know that they needed it. For those patients that would not benefit from an ICU stay, I think there should be criteria, and if there is clearly no likelihood of an intact, aware recovery, then our time and money are better spent elsewhere.

Ross1 · Oct 11, 2004

This is a very important discussion with very valid points raised. My two cents would be that it is not the opinion of RN or MD regarding whether or not this patient should be resuscitated. It is her choice. We can have all the sound arguments in the world regarding the probability of a successful resuscitation as well as the anticipated complications (mentioned above).....but all we can do as professionals is ensure that the patient is given this information in an objective way and in a manner that she or he can understand....and the decision is the patient's. Obviously, if the patient's decision making ability is compromised, this would have to go to the next of kin or legally appointed decision maker.

From my observations, some facilities are better then others at ensuring that patients receive adequate education and counseling regarding DNR orders.

Ross1 · Oct 11, 2004

This is a very important discussion with very valid points raised. My two cents would be that it is not the opinion of RN or MD regarding whether or not this patient should be resuscitated. It is her choice. We can have all the sound arguments in the world regarding the probability of a successful resuscitation as well as the anticipated complications (mentioned above).....but all we can do as professionals is ensure that the patient is given this information in an objective way and in a manner that she or he can understand....and the decision is the patient's. Obviously, if the patient's decision making ability is compromised, this would have to go to the next of kin or legally appointed decision maker.

From my observations, some facilities are better then others at ensuring that patients receive adequate education and counseling regarding DNR orders.

CCU NRS · Oct 12, 2004

In the first report, Wennberg examined the Medicare records of 90,600 patients during the last six months of life in 77 well-regarded teaching hospitals. He compared frequency of doctor visits and hospitalizations and time in the intensive care unit for people with solid tumor cancers, congestive heart failure and chronic lung disease.

My first problem is that the study used, too varied a sample, why would you lump solid tumor CA in with Heart failure & COPD?

My facility has a CA floor and we NEVER recieve the CA Pt's because the Oncologists want them on the Onc. floor with nurses that do Onc. care and meds. So if they had used my facility they would have little to no CA Pt's with intensive care "per'se"

"In the current system, poor quality pays," he said. "Physicians are reimbursed for both incorrect treatment and effective therapy."

So with this statement I can only assume that in the (Bush) future only medical treatment that shows results will be billable, so wouldn't it just be better to do nothing and send anyone that is terminally ill home with Hospice Day One? I mean why try to treat or diagnose if only treatment that "shows" improvemnet will be covered, how many treatments do you know of that response can be easily measured? Digoxin nurses will have to begin to document specific rate changes after digioxin is administered what about contractility , lasix exact output in the 6 hours that lasix works not by shift, Amiodorone if no rate or rhythm changes in the initial 6 hours do we stop the 18 hour regimen at 0.5mg? Treatment regimens are different and work differently for each individual that is why it is not an exact science if we were all machines and just get an oil change then perhaps things would be simpler.

CCU NRS · Oct 12, 2004

In the first report, Wennberg examined the Medicare records of 90,600 patients during the last six months of life in 77 well-regarded teaching hospitals. He compared frequency of doctor visits and hospitalizations and time in the intensive care unit for people with solid tumor cancers, congestive heart failure and chronic lung disease.

My first problem is that the study used, too varied a sample, why would you lump solid tumor CA in with Heart failure & COPD?

My facility has a CA floor and we NEVER recieve the CA Pt's because the Oncologists want them on the Onc. floor with nurses that do Onc. care and meds. So if they had used my facility they would have little to no CA Pt's with intensive care "per'se"

"In the current system, poor quality pays," he said. "Physicians are reimbursed for both incorrect treatment and effective therapy."

So with this statement I can only assume that in the (Bush) future only medical treatment that shows results will be billable, so wouldn't it just be better to do nothing and send anyone that is terminally ill home with Hospice Day One? I mean why try to treat or diagnose if only treatment that "shows" improvemnet will be covered, how many treatments do you know of that response can be easily measured? Digoxin nurses will have to begin to document specific rate changes after digioxin is administered what about contractility , lasix exact output in the 6 hours that lasix works not by shift, Amiodorone if no rate or rhythm changes in the initial 6 hours do we stop the 18 hour regimen at 0.5mg? Treatment regimens are different and work differently for each individual that is why it is not an exact science if we were all machines and just get an oil change then perhaps things would be simpler.