Those of us working daily in intensive care medicine are familiar with the dilemmas that face medical and other staff involved in the care of patients who, by definition, are the sickest patients in the hospital. Intensive care is a low-volume high-cost speciality which is stressful for staff, patients and particularly relatives. Unnecessary intensive care is therefore both costly and inhumane.
I always teach medical students that the first criterion for admission to intensive care is the knowledge that the natural history of the disease is recovery, as the treatments that we employ are mostly directed at supporting vital organs until such time as they can recover spontaneously. If the underlying disease is fatal, for example, irreversible respiratory failure, there is nothing to be gained for that patient by prolonged support of the lungs by mechanical ventilation.
The nature of intensive care is such that often the history, examination and results of relevant investigations are not known at the time of admission. As the diagnosis becomes obvious, we are therefore sometimes bound to be faced with a situation in which treatment has to be withdrawn, since the patient cannot benefit from lengthy intensive care, and the relatives are subjected to enormous stress.
The harm done by offering false hope to dying patients and their relatives is immeasurable. The fact that money may be saved by limiting treatment is incidental; the overriding concern must be the well-being of the patient.
Anyone specialising in intensive care medicine therefore has to decide to limit treatment. Dr Bihari's perhaps clumsily expressed view that he would allow a computer to determine the outcome is, on the face of it,
a considerable departure from accepted intensive care practice.
We all, however, frequently have to make decisions to terminate hopeless high-technology treatment when it becomes obvious that the disease processes are irreversible. The fact that one's clinical judgement can be augmented by a knowledge of the results in former patients, with similar diagnoses and disease severity scores, is likely to be helpful in the long term.
What the computer cannot replace is many years of clinical experience in dealing with very ill patients. Dr Bihari no doubt has his reasons for expressing his views in such an alarmist manner, but his true aim is, I hope, humanitarian and compassionate, not financial.
J. H. COAKLEY
The writer is a consultant physician in intensive therapy.Reuse content