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March 4, 1998

Potentially Ineffective Care in Intensive Care

Author Affiliations

Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor

JAMA. 1998;279(9):651-654. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-9-jbk0304

To the Editor.—Prognosis-based futility guidelines have been proposed as the "solution" to solve the problem of the quality of care for dying patients and their families. The allure is that such guidelines are a simple and neat fix to the "high cost of dying." Drs Cher and Lenert1 report that HMOs achieved a 25% reduction in PIC. Yet, I would caution that proposed definitions of futility are value laden and in need of careful public scrutiny. Using data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments,2 we simulated a prognosis-based futility guideline that would withdraw life-sustaining treatment in all persons with a predicted 2-month survival of 1%. Such a guideline would reduce total hospital days by 11%, with an estimated savings of $1.2 million. However, a key question for consideration is whether society would accept achieving these savings given that the patient's religious preferences were an important influence on treatment decisions in 5 of the 12 persons who accounted for 75% of the savings.3