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Effectiveness of CCUs

All rational approaches to rationing CCU care stumble over the problem that CCU care has not been proved to improve patient survival for many classes of patients. This makes it difficult to calculate the cost-benefit ratios that are necessary to make rationing decisions. The one class of patients for whom CCU care is clearly effective are those who are fundamentally healthy but have an acute, curable condition that requires life support. While these patients are easy to identify, they are a small percentage of CCU patients. Other than accident victims, persons who have overdosed on drugs, and the victims of certain rare illnesses, many persons who have traditionally been treated in the CCU suffer conditions from which there is little probability of recovery.

There are three classes of patients who may benefit from treatment in an intensive care unit but for whom the benefits are marginal: (1) those with chronic conditions who may survive the acute exacerbation of their underlying illness but have no prospect of returning to health; (2) those with acute illnesses or injuries who require extensive treatment and have a low probability of recovery; and (3) those with nonserious conditions who are admitted to the CCU for monitoring because they have a small probability of developing a more severe problem. These patients mask the benefits of CCU care and provide the greatest argument for limiting the availability of CCU care.

The lack of litigation over CCU care has created a false sense of security about the robustness of the therapeutic imperative. Rather than leading to ever more effective care, the complexity of high-technology medicine has created a therapeutic parallel to Heisenburg's uncertainty principle: the more you do to the patient, the greater is the chance of iatrogenic injury. The increased risk of infection, stress, and equipment-related problems becomes a significant limit on the effectiveness of CCU care.

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