ICU Variability in Decisions to Limit Life Sustaining Therapies

Yesterday, at the ATS, Caroline M. Quill, MD, a fellow in Penn's department of Pulmonary, Allergy, and Critical Care at Penn Medicine, presented (and here) "Variation Among ICUs In Decisions To Limit Life Sustaining Therapies."

Quill's team found substantial variation in decisions to forgo life-sustaining therapies rates among 153 ICUs in the United States.  This suggests that many factors unrelated to the patient or family may be affecting such decisions.  Patient factors such as severity of illness, age, race, and functional status explain a significant amount of the variability in decisions.  But ICU culture and physician practices also play a major role.  

Quill's study revealed a six-fold variation among ICUs in the probability of a decision to forgo life-sustaining therapy. This suggests that the ICU to which a given patient is admitted influences his or her odds of having a decision for stop life-sustaining treatment, regardless of personal or clinical characteristics. 

Hospice and the Triple Crown

Orb won the Kentucky Derby earlier this month.  But on Saturday, while heavily favored, Orb was handily defeated at the Preakness Stakes.  Again this year, there is no Triple Crown winner.


While horse racing has not seen a Triple Crown in 35 years, hospice regularly achieve its own triple crown.  Indeed, it is almost too good to be true.  But it is true.  Hospice helps patients (1) live longer, (2) experience a better quality of life, (3) and save Medicare and family dollars.

Is there Room for Conscientious Objection in Critical Care Medicine?

Tomorrow morning from 8:15 to 10:45 a.m., at the Philadelphia Convention Center, I will be participating on an ATS panel titled "Is there Room for Conscientious Objection in Critical Care Medicine?" 

8:15 AM - Welcome and Symposium Overview
M. Lewis-Newby, MD, MPH 

8:25 AM - Reasons for and against Accommodating Conscience-Based Objections in the ICU
M. Wicclair, PhD  

8:50 AM - How the Law Applies to Conscience-Based Objections in the ICU
T.M. Pope, JD, PhD  

9:10 AM - Are Clinicians at Risk of Moral Harm in the Provision of Critical Care Medicine?
C. Rushton, PhD, RN 

9:35 AM - Special Case: When ICU Clinicians Morally Object to “Futile” Care
D.B. White, MD  

10:00 AM - ATS Recommendations for Managing Conscience-Based Objections in The Intensive Care Unit
M. Lewis-Newby, MD, MPH  

10:20 AM - Panel Discussion: Summarizing Reasons for and against Accomodating CBOs

Catholic Medical Association White Paper on POLST

The Catholic Medical Association (CMA) has just published a 35-page White Paper on POLST in the May issue of the Linacre Quarterly.

The CMA White Paper is titled “The POLST Paradigm and Form: Facts and Analysis.”  It reviews the origin and stated goals of the POLST program, and analyzes a wide range of arguments favoring or opposing POLST.  The White Paper also examines whether the POLST paradigm will provide real solutions to challenges faced by patients and families trying to make good decisions regarding end-of-life care.

Most notably, the CMA White Paper identifies some significant problems posed by POLST, and makes practical recommendations about how to promote decision-making for vulnerable patients that is medically and ethically sound, and consistent with the Catholic Church’s teachings on respect for human life.

Choosing Wisely - Top 7 List in Critical Care Medicine

This morning, at the ATS conference in Philadelphia, Scott Halpern, MD, PhD, MBE, presented "Top Ways to Reduce Low Value Care in Pulmonary and Critical Care Medicine."  Halpern leads the ATS's Choosing Wisely Task Force. 

"Choosing Wisely is designed to have physicians take the high ground in reining in the costs of their practices versus leaving that in the hands of external policymakers. . . .  There are a lot of diagnostic tests and therapies for which available evidence suggests a lack of effectiveness, and physicians are in the best position to determine exactly which practices in their own specialties fit that bill." 

Choosing Wisely Top 7 List in Critical Care Medicine:

1. Don't order diagnostic tests at regular intervals (e.g., daily), but rather in response to specific clinical questions.
2. Don't transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.
3. Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4. Don't deeply sedate mechanically ventilated patients without specific indications, and do attempt to lighten sedation daily.
5. Don't continue life support for patients at high risk for death or impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
6. Do not initiate or continue antimicrobial agents without specifying an evidence-based duration or endpoint and reassessing daily whether to narrow the spectrum of coverage based on cultures and clinical response.
7. Do not place or maintain arterial and central venous catheters in critically ill patients without specific indications.

Texas Medical Futility - No Change Again

For the past four legislative sessions in Texas (2007, 209, 2011, and now 2013), a broad group of stakeholders has sought to revise Texas Health & Safety Code 166.046.  

Some want to make the law more fair (.e.g. longer notice periods).  That is what S.B. 303 would have done.  Others, like Texas Right to Life want to completely repeal provisions allowing clinician to unilaterally refuse life-sustaining treatment.  

Unfortunately, it looks like these two opposing forces have again canceled out.  It looks like no bills to amend TADA will advance.  

Oklahoma Requires Provision of Futile Treatment

Many states are working to find ways to permit or encourage clinicians to avoid providing non-beneficial treatment.  In contrast, Oklahoma has specifically mandated that clinicians provide non-beneficial treatment, if that is what the patient's surrogate wants.  

I blogged about the Oklahoma law here.  I posted a copy of the law here.  Elsewhere, I have explained that Oklahoma's Nondiscrimination in Treatment Act makes Oklahoma a "red light" state as far as medical futility disputes.  I am pleased to see some more press coverage, indeed informed quality coverage, of this new law.