Thursday, June 30, 2005

The View from The ICU

I've noticed that different medical centers, even in the same city, may have significantly different procedures for admitting patients to the intensive care unit. In some institutions, everyone is admitted, regardless of how sick they are or how likely they are to recover. As a result, the majority of patients in these ICUs eventually die, and many physicians caring for them develop pessimistic attitudes, like in this well-written but grim assessment of ICU care in Slate. In other institutions, before patients can be admitted to the ICU, they receive an "ICU consult." This consulting physician may make the determination that the patient is extremely unlikely to recover -- for example, if they have end-stage cancer and end-stage congestive heart failure. These patients, who "would not benefit from the ICU," may be intubated and receive aggressive medical care (if their families wish), but they receive it on a general medical floor. As a result, patients in the ICUs in these institutions seem far more likely to survive, physicians seem less likely to develop pessimistic attitudes, and (I presume) fewer resources are spent on patients who have no chance of surviving. From Slate:

Located deep in the bowels of every big hospital, often behind locked doors that open only to the swipe of a key card, is the medical intensive care unit. Known as the MICU, this is where the hospital's sickest patients are brought for the most aggressive possible care. By the time patients need to be in the MICU, several organ systems are usually failing, and there is little chance of a good outcome. Some MICU patients have fixable problems, such as bleeding from the stomach or a sudden blood clot in the lungs. But many have relentless diseases that make decline irreversible and a decent quality of life irretrievable.

Doctors typically ask the person least able to make a clearheaded decision—the closest relative—about the most important choices regarding a desperately ill patient's care. Here is what happens when that relative tells us to "do everything" to save the life of an ailing loved one...

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