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First Come, First Served in the Intensive Care Unit: Always?

Published online by Cambridge University Press:  07 December 2017

LEONARD M. FLECK  and
TIMOTHY F. MURPHY
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Abstract:

Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.

Keywords

democracyethicsintensive carerationing
Type
Special Section: Open Forum
Information
Cambridge Quarterly of Healthcare Ethics , Volume 27 , Issue 1 , January 2018 , pp. 52 - 61
Copyright
Copyright © Cambridge University Press 2017 

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References

Notes

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5. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1283.

6. Some may find this position ethically troubling or at least worth further analysis, but for purposes of this article, we will not discuss this particular issue here.

7. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1283.

8. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

9. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

10. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

11. Cardoso L, McGrion C, Matsuo T, Anami EH, Kauss IA, Seko L, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: A cohort study. Critical Care 2011;15:R28; available at http://ccforum.com/content/15/1/R28 (last accessed 18 June 2016).

12. These have acronyms such as APACHE IV, SOFA, and TISS. See Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system: Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619–36.

13. One publicized example of a bed-blocker was Scott Crawford, 41years old, who had a failing heart. He had received a heart transplant but shortly thereafter became septic. He experienced kidney and respiratory failure, and required a leg amputation, among other medical complications. He was maintained in the ICU for 11 months, even though his prospects after 6 months were described as “bleak.” His ICU care costs mounted to $2,700,000. See Adamy J, McGinty T. The crushing cost of care. Wall Street Journal, July 6, 2012; available at http://www.wsj.com/articles/SB10001424052702304441404577483050976766184 (last accessed 19 Apr 2016).

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15. This is the sort of argument that is often made in re-transplantation cases. See Ubel, PA, Arnold, RM, Caplan, AL. Rationing failure: The ethical lessons of the retransplantation of scarce vital organs. JAMA 1993;270:2469–74.CrossRefGoogle ScholarPubMed See in reply: Fleck LM. Re-transplantation of major organs: A critical assessment. Unpublished paper, 1994. Readers may request a copy.

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17. Fleck, LM. Just Caring: Health Care Rationing and Democratic Deliberation. New York: Oxford University Press; 2009, at chap. 5.Google ScholarPubMed