Expensive care? Resource-based thresholds for potentially inappropriate treatment in intensive care

Modelling futility in the setting of fertility treatment

When is a fertility treatment futile? This question has great practical importance, given the role futility plays in ethical, legal and clinical discussions. Here, we outline a novel method of determining futility for IVF treatments. Our approach is distinctive for considering the economic value attached to the intended aim of IVF treatments, i.e. the birth of a child, rather than just the effects on prospective parents and the health system in general. We draw on the commonly used metric, quality-adjusted life years (QALYs), to attach a monetary value to new lives created through IVF. We then define futility as treatments in which the chance of achieving a live birth is so low that IVF is no longer a cost-effective intervention given the economic value of new births. This model indicates that IVF treatments in which the chance of a live birth are <0.3% are futile. This suggests IVF becomes futile when women are aged between 47 and 49 years of age. This is notable older than ages currently considered as futile in an Australian context (∼45). In the UK, government subsidized treatment with the couple's own gametes stops at the age of 42, while privately funded treatments are self-regulated by individual providers. In most European countries and the USA, the 'age of futility' is likewise managed by clinical consensus.

Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

Considering Futility of Care Decisions in Neurosurgical Practice

Neurosurgeons commonly encounter futility of care decisions in their practice. Are these decisions being made with adequate consideration? What is the preparation of neurosurgical trainees for making these decisions? The advent of the COVID-19 pandemic with its extreme pressure on resources and, in particular, intensive care unit beds, has prompted many health care providers including neurosurgeons to consider more fully the potentially futile nature of some treatments and how we might better manage limited resources for the future. We review the concept of futility in neurosurgery and suggest potential solutions to the multiple challenges that arise.

Queue questions: Ethics of COVID-19 vaccine prioritization

The rapid development of vaccines against COVID-19 represents a huge achievement, and offers hope of ending the global pandemic. At least three COVID-19 vaccines have been approved or are about to be approved for distribution in many countries. However, with very limited initial availability, only a minority of the population will be able to receive vaccines this winter. Urgent decisions will have to be made about who should receive priority for access. Current policy in the UK appears to take the view that those who are most vulnerable to COVID-19 should get the vaccine first. While this is intuitively attractive, we argue that there are other possible values and criteria that need to be considered. These include both intrinsic and instrumental values. The former are numbers of lives saved, years of life saved, quality of the lives saved, quality-adjusted life-years (QALYs), and possibly others including age. Instrumental values include protecting healthcare systems and other broader societal interests, which might require prioritizing key worker status and having dependants. The challenge from an ethical point of view is to strike the right balance among these values. It also depends on effectiveness of different vaccines on different population groups and on modelling around cost-effectiveness of different strategies. It is a mistake to simply assume that prioritizing the most vulnerable is the best strategy. Although that could end up being the best approach, whether it is or not requires careful ethical and empirical analysis.

Periviable birth: A review of ethical considerations

BACKGROUND

Advances in perinatology and medical technology have pushed the limits of viability to unprecedented extremes, leading to a growing population of NICU "graduates" with a wide range of health issues. Although survival rates from 22 weeks of gestation onwards have improved over the last 30 years, the incidence of disabilities remains the same. Providing intensive care to a high-risk population with significant mortality and morbidity raises the fundamental conflict between sanctity and quality of life. Potential severe handicap and need for frequent tertiary care inevitably impact the whole family unit and may outweigh the benefit of survival. The aim of this study is to explore and summarize the ethical considerations in neonatal care concerning perivable birth.

METHODS

Eligible studies published on PubMed were included after a systematic search using the PICO methodology.

RESULTS

Forty-eight studies were systematically reviewed regarding guidelines, withholding or withdrawing treatment, parental involvement, and principles applied in marginal viability. As periviable birth raises an array of complex ethical and legal concerns, strict guidelines are challenging to implement.

CONCLUSIONS

Active life-sustaining interventions in neonatology should be balanced against the risk of putting infants through painful and futile procedures and survival with severe sequelae. More evidence is needed on better prediction of long-term outcomes in situations of imminent preterm delivery, while good collaboration between the therapeutic team and the parents for life-and-death decision-making is of utmost importance. HIPPOKRATIA 2021, 25 (1):1-7.

Deciding Under Uncertainty: The Case of Refractory Intracranial Hypertension

A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.

Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty

BACKGROUND

Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty.

METHOD

This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached.

CONCLUSION

In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.

Rapid Challenges: Ethics and Genomic Neonatal Intensive Care

NICUs are a priority implementation area for genomic medicine. Rapid genomic testing in the NICU is expected to be genomic medicine's "critical application," providing such clear benefits that it drives the adoption of genomics more broadly. Studies from multiple centers worldwide have now demonstrated the clinical utility and cost-effectiveness of rapid genomic sequencing in this setting, paving the way for widespread implementation. However, the introduction of this potentially powerful tool for predicting future impairment in the NICU also raises profound ethical challenges. Developing models of good practice that incorporate the identification, exploration, and analysis of ethical issues will be critical for successful implementation. In this article, we analyze 3 such issues: (1) the value and meaning of gaining consent to a complex test in a stressful, emotionally charged environment; (2) the effect of rapid diagnosis on parent-child bonding and its implications for medical and family decisions, particularly in relation to treatment limitation; and (3) distributive justice (ie, whether the substantial cost and diversion of resources to deliver rapid genomic testing in the NICU can be justified).