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Distributive justice across generations. Epidemiology of ICU care for the very young and the very old
W Meadow1, J D Lantos, M Mokalla
1Department of Pediatrics, La Rabida Children's Hospital, University of Chicago, Illinois, USA.
Insights
Intensive care for extremely low birthweight infants is more cost-effective than for elderly adults. Elderly patients consume significantly more resources before death, suggesting resource allocation may be more justifiable for the young.
Area of Science:
- Medical Ethics
- Healthcare Economics
- Neonatal and Critical Care Medicine
Background:
- Both extremely low birthweight infants and elderly adults require significant healthcare resources and have poor prognoses in intensive care.
- Resource allocation and rationing decisions in intensive care units (ICUs) often consider these vulnerable populations.
Purpose of the Study:
- To compare the cost-effectiveness of neonatal intensive care unit (NICU) versus adult intensive care unit (ICU) care, focusing on resources consumed per survivor.
- To evaluate whether current resource allocation in ICUs is ethically justifiable regarding the very young and very old.
Main Methods:
- Retrospective analysis of mortality patterns and resource consumption in a NICU and adult medical ICUs.
- Comparison of ICU resource utilization between deceased neonates and deceased adult ICU patients.
Main Results:
- Adult ICU patients who died consumed substantially more ICU resources than deceased NICU patients, irrespective of illness severity or mortality risk.
- Neonatal intensive care, despite higher mortality rates, appears more resource-efficient when measured by resources directed toward survivors.
Conclusions:
- The expenditure of societal resources on prolonging the dying process of extremely low birthweight infants in the NICU is not an undue burden.
- Rationing intensive care for the very old, rather than the very young, may be more justifiable from a distributive justice perspective.
Abstract:
Babies of extremely low birthweight and elderly adults both require expensive and scarce resources, and both have a relatively poor prognosis for survival if they require intensive care. Thus, proposals for rationing often target one or both of these groups. We suspected that although mortality rates might be higher in the neonatal intensive care unit (NICU) than in the adult intensive care unit (ICU), NICU care might nevertheless be more cost effective, where cost efficiency is measured along the dimension of resources targeted to survivors. We examined mortality patterns in our NICU and for adults admitted to our medical intensive care units. We found that adult ICU patients who died consumed many times more ICU resources before their death than did their NICU confreres, independent of the severity of illness or likelihood of dying. Although there may be many legitimate concerns about justice and ethics in the NICU, undue expenditure of society's resources prolonging the dying of extremely low birthweight infants is not among them. To the extent that concerns about distributive justice drive allocation decisions in ICU care, it would seem more justifiable to ration intensive care for the very old, not the very young.
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