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Critical care medicine has engendered much medical-legal scholarship over the past several years, almost all of it dealing with the termination of treatment for patients who are either terminally ill or irreversibly comatose. While this is an important subject, it pales in comparison to the legal question posed by the shifting reimbursement climate in health care: when must we withdraw or deny treatment to patients whose treatment would consume a disproportionate share of resources.[231]

Such decisions are complicated by financial incentives to care for patients who are well insured or have a favorable DRG. Likewise, there are pressures not to admit poorly insured patients to the CCU. Physicians who care for patients in the CCU must resist the pressure to make medical decisions on billing criteria. When financial considerations enter into these decisions, physicians are more susceptible to malpractice litigation and punitive damage awards for violating the fiduciary duty owed to their patients.

[231]Zoloth-Dorfman L; Carney B: The AIDS patient and the last ICU bed: Scarcity, medical futility, and ethics. QRB 1991; 17:175-81.

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