Rule of rescue or the good of the many? An analysis of physicians’ and nurses’ preferences for allocating ICU beds
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To examine intensive care unit (ICU) clinicians’ willingness to trade off societal benefits in favor of a small chance of rescuing an identifiable critically ill patient.
We sent mixed-methods questionnaires to national samples of US ICU clinicians, soliciting their preferences for allocating their last bed to a gravely ill patient with little chance to survive, versus a deceased or dying patient for whom aggressive management could help others through organ donation.
Complete responses were obtained from 684 of 2,206 physicians (31.0%) and 438 of 988 nurses (44.3%); there was no evidence of non-response bias. Physicians were more likely than nurses to adhere to the “rule of rescue” by allocating the last bed to the gravely ill patient (45.9 vs. 32.6%, difference = 13.2%; 95% CI 9.1–17.3%). The magnitude of the social benefit to be obtained through organ donor management (5 or 30 life-years added for transplant recipients) had small and inconsistent effects on clinicians’ willingness to prioritize the donor. In qualitative analyses, the most common reason for allocating the last bed to an identifiable patient (identified by 65% of physicians and 75% of nurses) was that clinicians perceived strong obligations to identifiable living patients.
More than one-third of ICU clinicians forewent substantial social benefits so as to devote resources to an individual patient unlikely to benefit from them. Such allegiance to the rule of rescue suggests challenges for efforts to reform ICU triage practices.
KeywordsResource allocation Intensive care unit Ethics Rationing Organ donation Cost containment
- 6.Garrouste-Orgeas M, Montuclard L, Timsit JF, Reignier J, Desmettre T, Karoubi P, Moreau D, Montesino L, Duguet A, Boussat S, Ede C, Monseau Y, Paule T, Misset B, Carlet J, French ADMISSIONREA Study Group (2005) Predictors of intensive care unit refusal in French intensive care units: a multiple-center study. Crit Care Med 33:750–755PubMedCrossRefGoogle Scholar
- 8.Truog RD, Brock DW, Cook DJ, Danis M, Luce JM, Rubenfeld GD, Levy MM; for the Task Force on Values, Ethics, and Rationing in Critical Care (VERICC) (2006) Rationing in the intensive care unit. Cri Care Med 34:958–963Google Scholar
- 11.Lanken PN, Terry PB, Adler DC et al (1997) Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 156:1282–1301Google Scholar
- 12.Society of Critical Care Medicine Ethics (1994) Consensus statement on the triage of critically iII patients. JAMA 271:1200–1203Google Scholar
- 15.The Society of Critical Care Medicine Ethics Committee (1994) Attitudes of critical care medicine professionals concerning distribution of intensive care resources. Crit Care Med 22:358–362Google Scholar
- 20.D’Alessandro AM, Peltier JW, Phelps JE (2008) An empirical examination of the antecedants of the acceptance of donation after cardiac death by health care professionals. Am J Transplant 7:1–8Google Scholar
- 22.American Association for Public Opinion Research (2008) Standard definitions: final dispositions of case codes and outcome rates for surveys, 5th edn. http://www.aapor.org/uploads/Standard_Definitions_07_08_Final.pdf. Accessed 11 August 2009
- 24.Halpern SD, Kohn R, Metkus T, Asch DA, Volpp KG (2011) Lottery-based versus fixed incentives to increase response to clinician surveys. Health Serv Res. doi:10.1111/j.1475-6773.2011.01264.x