By Gordon D. Rubenfeld, MD
The modern intensive care unit is defined by its technology: ventilators, monitors, dialysis machines, and catheters. Technologic innovation continues to drive the field through venous oximetry, continuous renal replacement therapy, percutaneous tracheostomy, and handheld information management systems. On the horizon are new modes of mechanical ventilation, continuous and, perhaps, noninvasive measures of blood chemistry, and the promise of immunomodulating therapies for sepsis and ARDS. Perhaps the future intensivist will manage patients by an audiovisual interface over the Internet? Or, perhaps, this technocentric view of the future is inaccurate.I believe that daily clinical practice in the ICU in the next decade will be altered minimally by technologic innovation. I am not a Luddite and fully acknowledge the important contributions technology has made to critical care in the past. Despite this conviction, I believe that the greatest changes in day-to-day critical care practice in the United States will occur in three non-technology areas: death and dying, health care reimbursement, and medical education. Furthermore, it is my prediction that these changes will move critical care in a direction that many practitioners have wanted.
Death and Dying
Death in the modern ICU no longer occurs with ritualistic CPR.1 Patients, by their own choice, through a loved one, or as a medical decision by the treating physicians, now die as a result of an explicit decision to limit life supporting technology. Society is facing the reality of death in America and is not quite pleased with what it sees.2 Several national initiatives focusing on death and dying indicate a growing awareness and willingness to discuss this taboo subject.3,4There is more than a little ambivalence in this discussion. On one hand, Americans seem to say that they want less technology when they die, more palliative care, and to remain out of the acute care hospital. On the other hand, it is the perception of critical care physicians that many families, when actually faced with the decision to forego life sustaining treatment, opt for intensive care.
Improvements will not come from better living wills, more explicit advanced directives, or legal reform. Education, both of patients and clinicians, better communication skills, and the slow forces of cultural change through the mass media will result in a different approach to end-of-life care. Clinicians must be better educated about the prognoses of critical illness. Better objective prognostic data will be made available, although this, alone, is insufficient to change care. While coercion is unacceptable, it is clear that there are skills involved in managing the family conference, and these should be identified and taught effectively. Clinicians need to realize the strong role their own feelings about death and disability play in their decisions, and learn techniques to separate these emotions from the clinical decision at hand. Irrational fears of malpractice litigation for withdrawing life support in futile cases and for using narcotics when discontinuing ventilatory support must be allayed.
Since providers do respond to the fear of the law, lawsuits against physicians for providing unwanted life support will provide an additional stimulus for clinicians to heed the requests of their patients.5 Patients, informed by mass media, will take a consumerist approach to avoiding unwanted care and make their wishes known strongly to family members and providers. Effective palliative care will help terminally ill and neurologically devastated patients avoid using acute care hospital resources just because it is the only outlet for relief of pain and suffering.
Critical care clinicians of the future armed with better prognostic data, a rich toolkit of communication skills for the family conference, and an open mind will find that fewer patients receive care inconsistent with the goals of the intensive care unit.
Health Care Financing
Trying to predict the future of health care financing is well beyond my crystal ball's power. I think it is safe to say that the small-business-owner physician is nearly extinct. The future of health care delivery lies in some combination of large corporate or government entities. They will exert control over ("manage") some aspects of clinical practice and reimbursement. What form this management will take: gatekeepers, guidelines, incentives, capitation, or budgets, is not at all clear. Practice will be guided by enhanced data on the outcomes and process of medical care.With the disappearance of fee-for-service reimbursement, many of the traditional, political, and economic barriers to the organization of health care delivery will vanish. Instead, decisions on who will carry which responsibilities for patient care will be based on competence, training, and outcomes. Most ICUs will become "closed" as the financial incentives for caring for one's own patients in the ICU wane. Intensivists learned long ago that the best care is delivered by a coordinated team including physicians, nurse, respiratory therapist, nutritionist, and pharmacist. These relationships will become formalized as the scope of practice for non-physician providers expands. Their role will be strengthened by growing evidence that, once a plan has been established, many common ICU practices (for example, weaning, anticoagulation, drug dosing) can be improved by removing the physician from the feedback loop.6
When the ICU is no longer a revenue generator, financial incentives to keep patients locally will disappear and regionalization of intensive care will occur. Large medical entities will not leave purchasing decisions to individual practitioners, so vendors of catheters, drugs, and ventilators will not "detail" individual physicians. Instead a committee will review the evidence and make purchasing decisions for several ICUs based on cost and documented efficacy. Intensivists, as some have already done, will form companies to "carve out" critical care services and provide it to hospitals. Finally, some hospitals will re-engineer acute care services. As less sick patients are shunted toward subacute care nursing homes, the entire hospital will have higher levels of acuity. The use of critical care providers outside of the geographic confines of the intensive care unit will be recognized. We will think in terms of a continuity of acute care that begins in the emergency room or operating theater and extends until discharge.
Medical Workforce and Training
Predictions about workforce requirements are fraught with uncertainty. New technology, unpredictable changes in health care financing, and an aging population all must be incorporated into attempts to guess at the future requirement for clinicians of various types. Nevertheless, all of the workforce prediction models agree on one issue: we are significantly oversupplied with specialists, and, unless changes are made in training, this oversupply will continue to grow.7Medical educators responded to these predictions by making major changes. Generalist residency programs were revised to decrease the number of hospital ward and ICU months and increase the amount of ambulatory care time. The marketplace has caused its own changes. Responding to changes in job availability, fewer medical students and residents are choosing subspecialty training programs.8 Restrictions on foreign medical graduate training have been proposed. As these students move through the education pipeline, there will be several effects on critical care. Fewer residents will select critical care fellowships, and the graduates from generalist programs will have significantly less experience caring for the critically ill. Given the workforce predictions, these are actually adaptive responses to the new marketplace and, hopefully, will result in no net future unemployment for physicians who practice in ICUs.
The picture for academic critical care is less encouraging. Increasing the level of documentation and supervision for housestaff while simultaneously shrinking the number of fellowship slots, competing in the medical marketplace, and continuing to generate the research essential to medical care will pose a significant challenge. Regionalization of critical care services and specific funding for academic overhead through a health care tax may alleviate some of this burden by directing more patients and resources to centers of excellence.
Conclusion
Change is always scary because it brings the unknown. It is also inevitable in a modern economy. While some aspects of future medical practice will no doubt be disagreeable to some providers, many changes that are likely to occur in response to trends in dying, health care financing, and medical education will actually lead to outcomes many critical care providers have written about for 15 years.9 Fewer patients will receive unwanted and ineffective care prior to death, patients in ICUs will only be cared for by providers with expertise, technology will be evaluated and purchased based on evidence, ICU care will be regionalized on the basis of cost and quality, and care will be delivered by a coordinated team. Change is always scary but sometimes it's for the best.References
1. Prendergast TJ, Luce JM. Am J Respir Crit Care Med 1997;155(1):15-20.2. Fein EB. New York Times. New York, 1997; Sec B P 5.
3. Last Acts. http://www.lastacts.org/.
4. Project on Death in America. http://www.soros.org/ death.html.
5. Anderson vs. St.Francis-St.George Hospital. N.E. 2d ; 671:225.
6. Kollef MH, et al. Crit Care Med 1997;25(4):567-574.
7. Weiner JP. JAMA 1994;272(3):222-230.
8. Seifer SD, et al. JAMA 1996;276(9):695-699.
9. NIH consensus development conference on critical care medicine. Crit Care Med 1983;11(6):466-469.
Administration of inhaled NO in this study:
a. correlated with improved survival in a dose-dependent fashion.
b. demonstrated improvement in PaO2 during the initial four-hour study period.
c. was toxic, and patients had unsafe levels of methemoglobinemia and NO2.
d. correlated with clinically significant reductions in ventilator support.
e. demonstrated clinically significant reductions in PA pressure.
Which of the following predicts a mortality of approximately 30%?
a. Age 20, no inhalation injury, 30% burn
b. Age 40, inhalation injury, 30% burn
c. Age 40, no inhalation injury, 50% burn
d. Age 70, inhalation injury, 50% burn
e. Age 70, no inhalation injury, 50% burn
Use of an outcomes-managed approach in long-term mechanical ventilation:
a. significantly decreased days of mechanical ventilation.
b. had no significant effect on outcomes.
c. significantly decreased hospital length-of-stay.
d. significantly decreased mortality.
e. none of the above.
Cisatracurium:
a. is the only available safe relaxant for the neurologically injured patient.
b. is more toxic than atracurium.
c. raises ICP less than atracurium in some patients.
d. is less expensive than atracurium for continuous infusion.
e. is contraindicated for seizure-prone patients.
Family members responded to a structured communication program by:
a. expressing less satisfaction with care.
b. contacting the medical staff more often.
c. increasing incoming phone calls.
d. decreasing incoming phone calls.
e. none of the above.
Which of the following is the least likely to occur in health care financing?
a. Capitated payment to specialists
b. Bonus payments for quality of care
c. Return to fee-for-service reimbursement without oversight
d. Carve outs for subspecialty care including oncology, dialysis, and critical care
e. Elimination of gatekeeper incentives to reduce referrals to specialists
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