Background: Non-beneficial treatment can be defined as medical interventions that are ineffective in achieving the desired goals or are “a disservice to patients who are subjected to ongoing and likely uncomfortable conditions with no benefit”. At times, critically ill patients are declined Intensive Care Unit (ICU) admission due to perceived lack of benefit from medical futility but continue to be medically managed on the general medical floor. At present, the demographics and hospital outcomes of patients declined ICU admission due to perceived lack of benefit (ICU non-benefit) is not well described.
Methods: We performed a retrospective chart review examining critically ill patients who had ICU consults at the time of admission or during the course of their hospitalization and determined not to benefit from further escalation of care to ICU. Patients with this triage determination received ongoing care on the medical wards. Chart review investigated underlying chronic conditions, functional status, treatments including vasopressors and mechanical ventilation, consultation with palliative care, in-hospital mortality, and disposition among survivors. This study to better understand the clinical characteristics of these patients was carried out as part of a QI initiative to better allocate necessary resources to care for these patients outside of an ICU.
Results: The medical records of 65 patients hospitalized between July 2020 and January 2021 were reviewed. Most common reason for ICU triage was hypotension (82%). Most common Karnofsky score indicating baseline functional status, on a scale of 0 (dead) to 100 (no evidence of disease), was 10 (54%). These patients had a high likelihood of requiring vasopressors (63%), mechanical ventilation (63%), and renal replacement therapy (13.6%) at time of triage request. 40% of all patients analyzed had metastatic cancer, 4.6% had end stage heart failure, and 4.6% had advanced liver disease. Among those included in analysis, 51% had died at 1 week after triage decision, 71% at 1 month, 83% at 6 months. 38% had a DNR/DNI order at time of triage which increased to 73% at time of final disposition (discharge/death). 18.5% had a medical code during hospitalization after triage decision. Among these patients whose care was not escalated to ICU, 20% were ultimately discharged from the hospital, with 3 (4.6%) patients discharged to home, 6 (9.2%) discharged to a long-term acute care hospital (LTACH), and 4 (6.2%) discharged to hospice. 12 out of 58 patients (20.7%) who received a palliative care consult survived to hospital discharge compared to 1 out of 7 patients (14.3%) who did not receive one.
Conclusions: Of the 65 patients included in the analysis, the most common reason for ICU triage request was hypotension. Almost two-thirds of these patients required vasopressors or mechanical ventilation. Of those who received a palliative care consult, more survived to hospital discharge. Though the vast majority of patients declined ICU admission had poor functional status or died during the index admission, 20% survived to hospital discharge. While these patients may not have benefitted from the advanced therapies offered in ICU, they remained critically ill on the medical wards. These data were used to add additional resources to the wards to continue the ongoing care of these patients such as enhanced respiratory therapy presence, improved nursing to patient ratios, and greater abundance of monitoring devices.