Bed rationing and allocation in the intensive care unit

That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. Allocation of funds for intensive care may be case-based, historically based, per diem, or capitation-based but is always heavily influenced by political and economic considerations. Attempts have been made to relate costs to severity or intervention scores, but all these techniques are limited by the high fixed costs of intensive care. Methods available to help the physician faced with patient-selection dilemmas include cost-effectiveness and cost-utility analysis. These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.