Blood Products Provided to Patients Receiving Futile Critical Care
The number of hospitalized patients receiving treatment perceived to be futile is not insignificant. Blood products are valuable resources that are donated to help others in need. We aimed to quantify the amount of blood transfused into patients who were receiving treatment that the critical care physician treating them perceived to be futile. During a 3-month period, critical care physicians in 5 adult intensive care units completed a daily questionnaire to identify patients perceived as receiving futile treatment. Of 1136 critically ill patients, physicians assessed 123 patients (11%) as receiving futile treatment. Fifty-nine (48%) of the 123 patients received blood products after they were assessed to be receiving futile treatment: 242 units of packed red blood cells (PRBCs) (7.6% of all PRBC units transfused into critical care patients during the 3-month study period); 161 (9.9%) units of plasma, 137 (12.1%) units of platelets, and 21 (10.5%) units of cryoprecipitate. Explicit guidelines on the use of blood products should be developed to ensure that the use of this precious resource achieves meaningful goals.
© 2017 Society of Hospital Medicine
Critical care physicians frequently find themselves providing care that they find to be futile or inappropriate for hospitalized critically ill patients. A survey of physicians found that 87% felt that “futile” treatment was provided in their intensive care unit (ICU) in the past year.1 In a single-day cross-sectional study, 27% of ICU clinicians reported providing inappropriate care to at least 1 patient, most of which was excessive.2 In a 3-month study, 11% of all ICU patients were perceived by their physician as receiving futile treatment at some point during their ICU hospitalization.3 Given that more than 1 in 5 decedents die after an ICU stay during a terminal admission, there is increasing scrutiny of the ICU as a setting where potentially inappropriate resource-intensive treatment is provided.4-6 Blood is an especially valuable resource, not only because it exists in finite supply (and is sometimes in shortage) but also because it is donated in ways that arguably create special stewardship expectations and responsibilities for those trusted to make decisions about its use. The amount of blood products used for patients who are perceived to be receiving inappropriate critical care has not been quantified.
Blood transfusion is the most frequently performed inpatient procedure, occurring in more than 10% of hospital admissions that involve a procedure.7 When used appropriately, the transfusion of blood products can be lifesaving; however, studies show that some transfused blood might not be needed and efforts are afoot to improve the match between transfusion and transfusion need.8,9 These efforts largely focus on generating guidelines based on physiologic benefit and aim mainly at promoting a restrictive transfusion protocol by avoiding blood product use for patients who will likely do well even without transfusion.8,10-12 The guiding principle behind efforts to improve the stewardship of scarce blood products is that they should only be used if they will make a difference in patient outcomes. Unlike prior studies, the goal of this study is to quantify the amount of blood products administered to patients who would do poorly with or without receipt of blood products, that is, patients perceived by their physicians as receiving futile critical care.
MATERIALS AND METHODS
Based on a focus group discussion with physicians who cared for critically ill patients, a questionnaire was developed to identify patients perceived as receiving futile critical care. Details of the definition of futile treatment and the core data collection are described in detail elsewhere.3
For each ICU patient under the physician’s care, the attending physician completed a daily questionnaire asking whether the patient was receiving futile treatment, probably futile treatment, or nonfutile treatment. These surveys were administered every day from December 15, 2011, through March 15, 2012, to each critical care specialist providing care in 5 ICUs (medical ICU, neurocritical care ICU, cardiac care unit, cardiothoracic ICU, and a mixed medical-surgical ICU) in 1 academic health system. All clinicians provided informed consent.
Patients were categorized into the following 3 groups: patients for whom treatment was never perceived as futile; patients with at least 1 assessment that treatment was probably futile, but no futile treatment assessments; and patients who had at least 1 assessment of futile treatment. Hospital and 6-month mortality was abstracted for all patients.
The Division of Transfusion Medicine provided a database of all adult patients during the 3-month study period who received a transfusion of packed red blood cells (PRBCs), apheresis platelets, plasma, or cryoprecipitate (5 unit prepooled units). This database was merged with the daily assessments of the appropriateness of critical care. To determine the proportion of blood products that was utilized for patients receiving inappropriate treatment, we tallied the blood products infused to these patients after the day the patient was assessed as receiving probably inappropriate or inappropriate treatment. The denominator was the total amount of blood products used by all assessed patients during the 3-month study period.
This study was approved by the University of California Los Angeles Institutional Review Board.
