Balancing care decisions for gravely ill patients

ROCHESTER, Minn. -- Mayo Clinic researchers studying gravely ill intensive care unit (ICU) patients found that unrealistic family expectations resulted in the increased use of health care resources without a significant improvement in survival rate among these patients.

The February Mayo Clinic Proceedings study is important for patients who have a high likelihood of death in a hospital. Early, accurate identification of these patients when they arrive at the hospital might limit potentially futile, aggressive ICU care to such patients. However, limiting such aggressive care based on inaccurate tools might shorten potentially productive lives, says Keith Berge, M.D., a Mayo Clinic anesthesiologist who was the lead researcher.

In this study, researchers used the Acute Physiology and Chronic Health Evaluation III (APACHE III), a computerized system that is designed to prospectively predict mortality rates in "real time" for ICU patients, to identify a group of patients with a very low predicted likelihood of survival. This group of extremely ill patients was then looked at in more detail.

The researchers compared a group of these patients in which the families had unrealistic expectations of survival with a group of patients whose families' expectations were deemed appropriate. They found that patients whose families had unrealistic expectations used substantially more ICU resources. The median number of days in ICU for all patients was four, while the median number of days in ICU for patients whose families had unrealistic expectations was 11 days. While these patients survived to hospital discharge at a higher rate than others (33 percent versus 17 percent), their survival one year later did not differ much from those without documentation of unrealistic expectations (11 percent versus 6 percent). Nearly all survivors were severely disabled at discharge and at one year.

"Perhaps the best way to avoid vast expenditures of resources on


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