Intersection of Outcomes, Ethics, and Economics in Critical Care

In 2011, health policy makers forecast that Medicare will be insolvent by 2024.[1] An ever-increasing proportion of Medicare expenditures (27.9% in 1999 amounting to $24,856/beneficiary) are spent in the last year of life.[2] Although some have argued that limiting end-of-life critical care will not necessarily reduce expenditures (perhaps instead shifting costs to hospice or other expensive modalities),[3] more than 11% of elderly patients spend a week or more in intensive care units (ICUs) in the months prior to death. If critical care accounts for 20% of hospital costs,[3] well over $100 billion was spent on critical care in the United States in 2010.[4] Accordingly, critical care accounts for a relatively large national expenditure for end-of-life care that often neither prolongs life, nor—as will be argued in this issue—promotes recovery that would be acceptable to patients. The United States cannot sustain its current course of critical care by default, and although it may be rational to consider rationing low-yield, expensive, end-of-life care, demagoguery has quashed even simple efforts to promote patients' autonomy through advanced decision making.[5] This issue of Seminars explores—in the political safety of the academic vacuum—this critical intersection of critical care outcomes, economics, and ethics.

In this issue of Seminars in Respiratory and Critical Care Medicine, we've invited some of the world's most creative critical care thinkers to review this conundrum from various angles. More important, we've invited them to forecast what they think the future might hold. It has made for an innovative, thought-provoking volume that examines some of the seminal issues facing us as clinicians and citizens.

• References

• 1 Social Security and Medicare Board of Trustees. Status of Social Security and Medicare Programs (2011). http://www.ssa.gov/oact/trsum/index.html . Accessed May 19, 2011
• 2 Calfo S, Smith J, Zezza M. Centers for Medicare and Medicaid Services, Office of the Actuary. Last year of life study. http://www.cms.gov/actuarialstudies/downloads/Last_Year_of_Life.pdf . Accessed September 23, 2011
• 3 Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life?. Am J Respir Crit Care Med 2002; 165 (6) 750-754
• 4 Centers for Medicare and Medicaid Services. Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2010. http://www.cms.gov/nationalhealthexpenddata/ . Accessed September 23, 2011
• 5 Pear R. False 'death panel' rumor has some familiar roots. New York Times, August 13, 2009. http://www.nytimes.com/2009/08/14/health/policy/14panel.html . Accessed September 23, 2011