Tuesday, July 28, 2009

Reform, rationing, swine flu, and futile intensive care

Nobody knows how bad Pandemic H1N1 2009 will be when it returns to the northern hemisphere at the end of the year, but it's reasonable to prepare for the worst, especially when the experience in the southern hemisphere has been somewhat difficult:


(I am not endorsing either the Torygraph or the Daily Terror with these links)

See http://www3.interscience.wiley.com/journal/122520541/abstract for the actual article.
The United States has one of the highest number of intensive care beds per capita in the industrialised world. This may be partly definitional: most intensive care units elsewhere are 1:1, with 1:2 units being described as "high dependency", and partly due to the proliferation of subspecialised ICUs. Current bed usage is about 65%, so there is room for a 50% rise in the number of ICU beds needed without going into bed debt, although of course not all those beds are ventilator beds, and ventilators seem to be what is needed right now.

However, there is the possibility that there will not be enough ICU beds for everyone. Daniel Sokol addresses this here.

In a country with a large amount of government control and payment of healthcare, like the UK or even Australia, the decisions are hard enough to make. When money comes into the equation, it may become even harder.

If a hospital is running out of ICU beds, should it be forced to give charity care through EMTALA for the people presenting with novel H1N1 pneumonia requiring ventilation?

Will a well-insured futile-care ICU patient take priority over a young and previously healthy uninsured H1N1 pneumonia patient?

Will hospitals be able to stay afloat if, instead of filling a cardiothoracic ICU with well-insured and high-paying CABG and MVR patients, it is filled with uninsured and never-planning-to-pay H1N1 pneumonias, each consuming a course of Xigris as per the SSC guidelines, and then staying on the vents forever?

How many patients will be bankrupted by a stay in the ICU, a course of Xigris, whatever fancy new antibiotic they decide to administer, etc?

Even ignoring money/insurance issues, is H1N1 going to be the tipping point, where hospitals decide that they will not take futile care patients into the ICU anymore?

I wonder if these relatives, gung-ho to go full-code, will regret the decision -- or even put down granny -- when they need a vent and cannot get one.

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