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Explicit Rules

Every intensive care unit should have written protocols for admitting and discharging patients. A patient should not be accepted just because there is a bed available. This leads to problems in quality of care and accusations that the physicians are more concerned about money than care. An example might be the terminal patient who has decided that she does not want invasive therapy to postpone the time of death. This patient should have been given the opportunity to sign a living will and to ask that CPR not be performed. It is hard to see what benefit such a patient would derive from intensive care. But if the patient is well insured and the floor nurses are unable or unwilling to provide good supportive care, this patient is likely to end up in the CCU. Unfortunately for the patient, being in the CCU may hasten her death and will certainly make the process of dying less pleasant. In many CCUs she will be surrounded by lights and noisy machines day and night and will have limited opportunities to see family and friends.

A corollary problem to rationing care is the necessity for triage. As the availability of properly staffed and equipped CCU beds declines, it will become imperative to ensure that these beds are reserved for persons who can best benefit from CCU care. This is problematic, however, because of the lack of scientific evidence as to the relative benefits of CCU care. Triage becomes especially difficult when it involves moving a patient out of the CCU when a patient with better prospects for recovery requires care. While displacing less ill patients was once a common procedure, it has fallen out of use in the last 20 to 30 years. This may have to be reinstated in CCU protocols as ever more patients, especially AIDS and elderly patients, compete for limited CCU resources.

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