Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Aug 2012
ReviewEconomics at the end of life: hospital and ICU perspectives.
Not all feasible care is desirable care. At the end of life, aggressive interventions may not only be futile but also inappropriate because they may impair the quality of the remaining life for both the patient and the caregiver. Although it is challenging to identify patients with a poor prognosis, certain terminal conditions among the elderly, such as end-stage dementia, heart failure, and metastatic cancer, demand a more measured use of aggressive care. Frank discussions with patients and family about their desires in the context of the prognosis, as well as symptom support, can yield both economic savings and better quality of life.
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Semin Respir Crit Care Med · Aug 2012
ReviewIntensivist time allocation: economic and ethical issues surrounding how intensivists use their time.
Intensivists' time is a fundamentally constrained resource. Many factors can put intensivists under conditions in which demands for their time outstrip the amount of time available. ⋯ In deciding how to allocate their time, intensivists face many challenges. This article highlights two of these challenges: (1) How should intensivists approach two common scheduling-related issues (24/7 intensive care unit coverage and long blocks of service time that promote continuity but sacrifice weekends off) and balance these issues with the very real workforce concern of accelerated professional burnout? (2) What are the hidden financial impacts of intensivist participation in quality improvement programs, given current reimbursement systems?
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Medical care offered to the critically ill often occurs by default, unfolding automatically unless concerted effort is made to do otherwise. In their scope, defaults include traditional approaches to treatment and decision making, as well as policies deliberately set to promote specific health outcomes. ⋯ Unfortunately in practice, some defaults lead to ineffective, unwanted, and expensive care. This article reviews the ethical and economic impact of defaults, paying special attention to their influence on the practice of cardiopulmonary resuscitation and admission to the intensive care unit.
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Semin Respir Crit Care Med · Aug 2012
EditorialThe brave new world revealed: wrestling with reality, rationing, and rationality.
When Dr. Joseph Lynch, editor of Seminars in Respiratory and Critical Care Medicine, invited us to organize and edit this topic we-and our contributors-were initially baffled about how we could marry outcomes, ethics, and economics. His perspective as an elder-statesman, who has observed the evolution of critical care medicine over 4 decades, provided perspective as to how these three areas are intimately related and that their synthesis is essential if the US medical system is to best serve our populace as resources become increasingly limited.
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Semin Respir Crit Care Med · Aug 2012
The physician as rationer: uncertainty about the physician's role obligations.
Although the need to ration health care is increasingly accepted, the need for bedside physicians to participate in it is not. There are three common perspectives on physicians' roles in rationing: one is that bedside physicians should advocate fully for their patients and eschew rationing; another is that some rationing is permissible but should be imposed from outside the patient-physician relationship; the third is that bedside physicians should simultaneously advocate for their individual patients and make bedside rationing decisions that incorporate societal interests. The first two conceptualizations are at odds with empirical evidence that physicians do ration at the bedside and the idea that doing so may be a necessary part of efforts to control costs, whereas the third raises difficult ethical questions about the extent of physicians' obligations to advocate maximally for their individual patients.