Endocrine support Diabetes insipidus: hypovolaemia and hypernatraemia should be corrected w ith appropriate IV \202 uid administra- tion. Excessive polyuria should be managed with D DAVP which can be administered either as intermittent boluses or as an infusion. DDAVP is a ssociated with a lower inci- dence of acute tubular necrosis and graft failure than vaso- p ressin. Hyperglycaemia should be treated with an insulin infusion according to usual intens ive care protocols. 536 I THOMAS & AR MANARA Other hormone replacement should be considered in organ donors with cardiovascular instabil ity, escalating vasoactive drug requirements and a worsening acidosis. \200 performed, local policy may dictate that intravascular can- nulae, the ETT and urethral cat heter are left in place, oth- erwise they may be removed. Last of \201 ces are performed b y the nursing staff with help from the transplant coordina- tor, and the relatives should b e given the opportunity to view the body after surgery if they wish to do so. Meeting the w ishes of individuals and their relatives to donate organs after death is an important aspec t in bereavement care. The attitudes of medical staff in explain- ing the need for ongoing therapies despite the donor being declared dead will lead to greater understanding on the p art of the relatives, many of whom gain comfort from following their relative \200\231s wis hes after death and consola- tion in knowing that some good has come from their trag- edy. Psychological and pastoral support offered to relatives by the ICU team and the transplant coordinator may help alleviate feelings of guilt, anger or remorse. They should be invited to return and discuss any issues with ICU staff or the coordinator in the future. It is com mon practic for relatives to be informed of the patients that bene \201 ted from the donat ion of their loved one \200\231s organs. Some cardiothoracic transplant centers recommend using T3 to reduce inotrope requirements a nd help restore cardiovascular stability, hoping that this will improving the function of t he transplanted heart The administration of high dose methylprednisolone has been advocated to reduce vasoactive drug requirements, to attenuate the effects of proin \202 ammatory c ytokines, and to reduce the accumulation of lung water. It improves oxygenation in the dono r and is associated with increas- ing likehood of successful retrieval and transplantation of the lungs. On the basis of the failure of the hypothalamo-pituitary axis, others have suggested that \200\230hormonal resuscitation \200\231 with vasopressin, methylprednisolone and T3 should be more routine since its administration has been associated with an increase in the possib ility of the kidney, heart, liver, lung and pancreas being transplanted, along with an impr ovement in the short-term function of the donor heart. In practice whether it is used or no t is determined by the preferences of the Transplant Center involved. Further reading Barber K, Falvey S, Hamilton C, et al. Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 2006; 352: 1124 \200\2236. Renal support Renal perfusion pressure should be optimized by maintain- ing an adequate MAP with \202 uid resuscitation or vasoactive drugs as appropriate. Episodes of hypotension should be treated aggressively as they are associated with acute tubular necrosis and failu re of the transplanted kidneys. Pennefather SH, Bullock RE, Dark JH. Use of low dose arginine vasopressin to support brain dead organ donors. Transplantation 1995; 59: 58 \200\22362. Pennefather SH, Bullock RE, Dark JH. The effect of \202 uid therapy on alveolar arterial oxygen gradient in brain dead organ donors. Transplantation 1993; 56: 1418 \200\22322. Hematological support Any coagulopathy should be corrected with the adminis- tration of FFP and platelets. Four units of blood should be available prior to multi-organ procurement si nce the surgery may involve signi \201 cant blood loss. Rosendale JD, Kauffman MH, McBride MA, et al. Aggressive pharmacologic donor management res ults in more transplanted organs. Transplantation 2003; 75: 482 \200\2237. Shafer TJ, Ehrle RN, Davis KD, et al. Increasing organ recovery form level 1 trauma centers : the in-house coordinator intervention. Prog Transplant 2004; 14: 250 \200\22363. Temperature support Normothermia should be restored and maintained using forced air warming blankets, IV \202 uid warmers, heated and humidi \201 ed inspired gasses and, if necess ary, by increasing the ambient temperature Sque, M, Long, T. and Payne, S. Organ and tissue donation: exploring the needs of families. Final report of a three-year study commis- sioned by the British Organ Donor Society, fund ed by the National Lottery Community Fund. University of Southampton, 2003. http://eprints. soton.ac.uk/11140/ Other considerations Documentation should be continued as for any critically ill patient. T he time of death is recorded as the time that the \201 rst set of tests con \201 rming d eath according to neuro- logical criteria is completed. If a post-mortem is to be The Intensive Care Society \200\231s Working Group on Organ and Tissue Donation. Guidelines for adult organ and tissue donation, 2004. http://www.ics.ac.uk/icmprof/downloads/Organ% 2 0&%20Tissue%20Donation.pdf This page intentionally left blank 538 I THOMAS & AR MANARA Non-heart-beating organ donation Background Organ transplantation offers patients with end-stage organ failure an improved q uality of life and increased life expect- ancy. In non-heart-beating organ donation (NHBD), organs are retrieved form a donor following cardiorespiratory arrest rather than after the con \201 rmation of death using neurological criteria. This is not a new concept. Prior t o recognition in 1968 by the Harvard Medical Committee that death resulted from irreversibl e damage to the brain- stem and the introduction in 1976 of clinical tests to con- firm dea ths using neurological criteria, organs for transplantation were routinely retrieved from N HBDs. After this declaration, transplant centers rapidly switched to transplanting organs f rom patients declared dead using neurological criteria, i.e. heart-beating donors, and the practice of NHBD declined rapidly. However, with the gap between organ supply and demand wi dening and the demonstration that kidneys retrieved from NHBDs have the same long-term outc ome as those from brainstem dead donors, transplant centers are re-introducing NHBD schemes . Table 32.4.1 The modi \201 ed Maastricht classi \201 cation of NHBDs Category I Category II Category III Category IV Category V Dead on arrival Unsuccessful resuscitation Anticipated cardiac arrest Cardiac arrest in a b rainstem dead donor Unexpected cardiac arrest in an ICU patient Potential NHBD Patients suitable for NHBD are typically, but not exclusively, those who hav e experienced a catastrophic brain injury but who do not ful \201 l the neurological crite ria for death. They are dependent on life-sustaining support, yet contin- ued medical inter vention is not considered to be in the patient \200\231s best interests. As a result, withd rawal of active treatment has been planned and it is anticipated that cardi- orespiratory a rrest will follow quickly and predictably. Patients with other diagnoses in whom treatment with- drawal is planned may also be suitable and should be dis- cussed with the donor trans plant coordinator to assess suitability. Absolute contraindications to NHBD are the same as those described for brainstem dead heart-beating donors. Rationale In the UK, demand for organs continues to outstrip supply, with a record 7234 peo ple listed as waiting for an organ transplant in March 2007. The disparity between the numb er of transplants performed and the number of patients on the waiting list continues to gro w. Factors con- tributing to this disparity include: \200 \200 \200 Organs suitable for donation The kidneys are relatively tolerant of warm ischaemia compared with other solid organs, and can achieve similar transplant outcomes to those retrieved fr om heart-beating donors. However, increasingly, other organs retrieved from NHBDs including the liver, pancreas and lungs are also being transplanted successfully with acceptable out comes. an ageing population an increase in the prevalence of renal failure advances in transplant technology Whilst the demand for organs increases, the actual number of heart-beating donors is declin ing. This pattern is likely to continue for two reasons: \200 Withdrawal of active treatment The decision to withdraw treatment should be made in consult ation with the patient \200\231s relatives, the referring med- ical team and the critical c are team in accordance with guidelines from the Intensive Care Society, British Medical Ass ociation and GMC, and must be made separate from any consideration of organ donation. To av oid a con \202 ict of interest, no member of the transplant team should be involved in any aspect of the decision to withdraw treatment. Agreement on the exact timing of treatment w ithdrawal is then reached between the critical care team, patient \200\231s relatives and r etrieval team. The dignity, well-being and comfort of the dying patient are paramount when with- drawing treatment, and the process itself should take place in line with local critic al care unit policy; there should be no difference because organ donation is being consider ed. This may involve stopping mechanical ventilation, vasoac- tive drug support or suppleme ntary oxygen and/or remov- ing the ETT. The process should ideally take place within the IC U. In circumstances where the ICU is too distant from theaters for NHBD to be possible, tre atment with- drawal may have to take place in the theater complex if the wishes of the pati ent and relatives are to be met. This should not, however, be done routinely simply to redu ce the warm ischaemic time. When treatment withdrawal does occur outside an ICU, the same d egree of critical care nursing expertise in the management of the dying patient should be p rovided. Alongside treatment withdrawal, seda- tive or opioid infusions may be started as a ppropriate. Fewer young people are dying as a result of severe injury or catastrophic cerebrovascular e vents. Improvements in the ICU management and outcome of traumatic brain injuries means tha t fewer people ful \201 l neurological criteria for con \201 rming death. A 41% refusal rate amongst relatives approached with a request for organ donation, means th at not all potential donors are converted into actual donors. One strategy to increase the number of organs available for transplantation is the introduction of NHBD schemes. Apart f rom the obvious bene \201 t to transplant recipients, NHBDs also gives more families the o pportunity to honor the wishes of a relative who had expressed a wish to donate their organ s after death but who failed to ful \201 l the criteria for neuro- logical death. NHBD mee ts the need of families to be with the deceased and to witness the observable ending of lif e as represented by the cessation of the heart beat. Controlled non-heart beating organ donation Classi \201 cation Potential NHBDs can be clas si \201 ed into 5 categories accord- ing to the modi \201 ed Maastricht classi \201 cati on (Table 32.4.1). Categories I, II and V are described as \200\230uncontrolled \200\231 a nd categories III and IV as \200\230controlled \200\231, the main difference being that in controlled potential NHBD the patient \200\231s imminent death is expected and the donatio n process better planned. In the ICU setting NHBDs are usually controlled. 539 CHAPTER 32.4 Non-heart-beating organ donation In the ICU setting these observations should be supported by the continued use of current m onitoring including ECG and IAP monitoring. Any return of cardiac or respiratory activity d uring this period prompts a further 5min of observation from that point. After 5min, a lack of response to supraorbital pressure and the absence of papillary and corneal re \202 exe s are con \201 rmed. Once a decision to withdraw treatment has been made, the instigation of new therapies (e.g. the administration of heparin or vasoactive drugs) or the undertaking of invasive interven tions (e.g. vascular cannulation to allow cold per- fusion) that are of no bene \201 t to the dying patient but are introduced speci \201 cally to improve organ viability are not r ecommended in the UK. With agreement from the rela- tives, blood samples may be taken from an in-dwelling intra- vascular catheter for tissue typing and serology purposes. Once treat ment is withdrawn, the transplant team need to be kept informed of any prolonged periods of hypotension (SBP <50mm Hg), hypoxia (SaO2 <80%) or anuria, allowing them to decide whether organ donation remains a viable option. If cardiorespiratory arrest has not occurred withi n 2 \200\2233h following treatment withdrawal, organ donation is usually abandoned. Management of the NHBD after death Once death has been con \201 rmed, the opportunity to s pend a further period of time with the patient should be availa- ble to the relatives. This period should necessarily be brief, usually 5min, in order to minimize the warm ischaemic time of organs to be transplanted. Should relatives require a longer period of time with t he patient then the donation process should be reviewed and, if necessary, abandoned. Proce dures such as chest compressions and full cardiopul- monary bypass designed to reduce the w arm ischaemic time, but that may inadvertently restore CBF should not be instituted post-mo rtem. Cannulation of the femoral vessels to allow cold perfusion of the intra-abdominal org ans may take place in ICU whilst awaiting an operating theater to become available. Alterna tively the patient is transferred quickly to the operating theater for organ retrieval to b e undertaken. Once the retrieval process has been completed, relatives of the patient are g iven the opportunity to spend a further period of time with the deceased patient if require d. Communication Discussion as to the suitability of the patient as a potential NHBD should ta ke place with the transplant coordinator before approaching the relatives. This avoids the relatives agreeing to the patient becoming an organ donor only to then \201 nd that they are not suitable. Even if concerns exist about contraindications to the patient becoming an organ donor, all potential donors should be referred, leaving the decision about suitabili ty to the transplant team. Agreement from the coroner/procurator s \201 scal should also ideally be obtained where necessary before any approach to the family. The approach to the relatives offering NHBD should only be made once they have understood and accepted the futi lity of the clinical situation, the futility of continued treatment and the reasons for its withdrawal. The practi- calities of NHBD should be explained, including, when appropriate, the requirement for post-mortem cannula- tion and perfusion to maintain organ viability. I t is also important to explain that: \200 Care of relatives of the NHBD It is central to the principles of organ donation that dona- tion be carried out to meet the wishes of the deceased and also to bring comfort to the rel atives. All medical staff have a role in offering support to the relatives of the donor bef ore, during and after the process. Some relatives may wish to be present at the time of dea th following treat- ment withdrawal, and this option should be incorporated into NHBD proto cols. Pastoral care and bereavement counseling should be made available to relatives if req uired. Death may occur quickly after treatment withdrawal and that if organ donation is to be poss ible the time relatives can have with their loved one at this stage is limited. The dying p rocess may be prolonged and therefore organ donation may not be possible due to an unaccept - ably long warm ischaemic time Retrieved organs may not always be suitable for trans- plan tation if perfusion has failed or they are damaged during the retrieval process The relativ es will have a further opportunity to spend time with their loved one after organ retrieval has taken place The relatives can stop the donation process at any stage. The transplant c oordinator has a central role in facilitating effective communication between the critical care team, retrieval team, operating theater staff and the relatives. They are responsible for ensuring a smooth transition from withdrawal of active treatment to con \201 rmation o f death and organ retrieval. Controversies Despite the endorsement of the practice of NHBD by professional and regulator y bodies on both sides of the Atlantic, some intensive care practitioners remain concerned about the ethics and legality of NHBD. The areas of concern revolve around reaching a decis ion that continued treatment is futile, the associated potential for con \202 ict of inter est in the context of NHBD, uncertainties over the time at which death can be con \201 rme d using cardiorespiratory criteria and the possibility of the sponta- neous return of cardi ac function after asystole (the Lazarus phenomenon). Further reading A de \201 nition of irreversible coma. Report of the Ad Hoc Committee of t he Havard Medical School to Examine the De \201 nition of Brain Stem Death. JAMA 1968; 205 : 337 \200\22340. American College of Critical Care Medicine. Position Paper by the Ethics Committee, Recomme ndations for non-heart beating organ donation. Crit Care Med 2001; 29: 1826. Con \201 rming death using cardiorespiratory criteria Once cardiorespiratory arrest has oc curred after the withdrawal of treatment, a member of the critical care team con \201 rms death after observing a 5min period of continuous asystole, apnoea and unconsciousness as r ecommended by the ethics committee of the Society of Critical Care Medicine and adopted by the Intensive Care Society \200\231s Working Group on Organ and Tissue Donation. Barber K, Falvey S, Hamilton C, et al. Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 2006; 352: 1124 \200\2236. Clayton TJ, Nelson RJ, Manara AR. Reduction in mortality from severe heads injury following introduction of a protocol for intensive care management. Br J Anaesth 2004; 93: 761 \200 \2237. 540 I THOMAS & AR MANARA Patel HC, Menon DK, Tebbs S, et al. Specialist neurocritical care and outcome from head inj ury. Intensive Care Med 2002; 28: 547 \200\22353. Conference of the Medical Royal Colleges and their Faculties in the United Kingdom. Diagnos is of Brainstem Death. Lancet 1976; ii: 1069 \200\22370. Death rate trends for RTA \200\231s and CVA \200\231s, WHO European Health for Ridley S, Bonner S, Bray K, et al. UK guidance for non-heart beating All Database http://www.euro.who.int/hfadb organ donation. Br J Anaesth 2005; 95: 592-5. Dobson R. Number on UK transplant waiting list reaches new high. Sque M, Long T, Payne S. Organ donation: key factors in \202 uencing BMJ 2007, 334; 920 \200\2231. families \200\231 decision making. Transplant Proc 2005: 37: 543. Gardiner D, Riley B. Non-heart-beating organ donation \200\224solution Weber M, Dindo D, Demartines N, et al. Kidney transplantation from donors without a heartbe at. N Engl J Med 2002; 347: 248 \200\22355. or a step too far. Anesthesia 2007; 62: 431 1 \200\2233. Kootstra G, Daemen JH, Oomen AP. Categories of non-heart beating organ donors. Transplant Proc 1995; 27: 2893 \200\2234. 541 Chapter 33 ICU organization and management Chapter contents Consent on the ICU 542 Rationing in critical care 544 ICU layout 546 Medic al staf \201 ng in critical care 548 ICU staf \201 ng: nursing 550 ICU staf \201 ng: sup porting professions 554 Fire safety 556 Legal issues and the Coroner 560 Patient safety 564 Severity of illness scoring systems 568 Comparison of ICUs 570 Critical care disaster plan ning 572 Health technology assessment 574 Transfer of the critically ill patient 576 Aerome dical evacuation 580 Outreach 582 Medical emergency teams 584 Critical care follow-up 586 M anaging antibiotic resistance 588 542 C DANBURY Consent on the ICU De \201 nition Consent is the giving of permission of a person for another individual, or group, to touch them. Although, the Law Commission has said that, \200\230if seriously dis abling injury results, we will take the view that a person, who consents to it has made a m istake and that to be really disabled is against his or her interests \200\231. Within the con \201 nes of a doc- tor/patient relationship, consent provides a \200\230Legal \202 ak- jacket \200\231 protecting the doctor and the rest of the medical team from the charge of assault. Consent for treatment can be withdrawn at any stage for any reason. Consent doe s not have to be written. It can be verbal or implicit. The presence of a signed consent fo rm indicates that the process of consent may have taken place, but does not imply that it h as de \201 nitely taken place. in the best interests of the patient. This standard, of \200\230best interests \200\231, w ill be discussed later. The commonly held view that the next-of-kin has an intrinsic right to grant or withhold consent is wrong. If the incapacitated adult does not have any family or friends available to participate in discussions, NHS bodies are required to provide an I ndependent Mental Capacity Advocate. This person is mandated to participate in the decision -making process in such circumstances. In this situation, the doctor is not obliged to adhe re to the opinions of the Advocate, although it would be wise to document the reasons for n ot doing so. When considering treating the incapacitated adult, it must be remembered that a major focus of that treat- ment must be to restore the capacity of the individual, so tha t they can make autonomous decisions. However, psy- chiatric pathologies may co-exist, or b e precipitated by the physical illness. In the case of Ms B, mentioned above, it was succes sfully argued that she lacked capacity for some months, due to a depressive illness brought on by her physical illness. Therefore, if a patient on ICU who otherwise appears to have c apacity expresses unex- pected wishes, it is sensible to seek psychiatric review. Who can consent on behalf of a patient? Competent adults All adults are presumed to be able to consent or refuse consent for themselves. \200 No one else can consent or refuse consent on behalf of a competent adult. As Dame Butler-Sl oss said, \200\230A compe- tent woman who has the capacity to decide may, for reli- gious reasons, other reasons, for rational or irrational reasons or for no reason at all, choose not to have med- ical intervention, even though the consequence may be her own death \200 \231. Further, if the woman is pregnant, then the unborn child has no rights in law until i t is born. An example of what can happen occurred to Ms B whilst she was treated on an ICU for 10 months in 2001. Ms B repeatedly expressed a wish to be allowed to die, i.e. she refu sed continued treatment. The treating team did not respect her wishes and she brought a cas e against the hospital. The hospital was held to be treating her unlawfully. The trial judg e said, \200\230The treating clinicians and the hospital should always have in mind that a seriously physically disabled patient who is mentally competent has the same right to pers onal autonomy and to make decisions as any other person with mental capacity. \200\231 Ment al Health Legislation only applies to the treatment of mental health. Speci \201 cally, a person held under the terms of the Mental Health Act, may not be treated for a physical ail ment without their consent Children \200 \200 \200 A \200\230Gillick \200\231 competent child A person or local authority with parental respo nsibility The Court of Protection \200 In treating children, consent from one valid source is all that is legally required to trea t the child. A child \200\231s and/or parents \200\231 refusal can be over-ridden by anothe r valid source. However, it is good practice to discuss the treatment decision with all con cerned. There have been cases where the Courts have insisted on the treatment of minors aga inst their own and their parents wishes. These are few and far between, but the absence of a child \200\231s and parents \200\231 consent does not obviate a doctor against treating t hat child in what the doctor perceives to be their best interests. In these circumstances i t is advisable to seek a second opinion and consult with the legal services department. Thi s illustrates the point that \200\230Gillick \200\231 competent children have the right to consent, but not to refuse consent. Capacity A person must be assumed to have capacity unless it is established that he lacks c apacity. She is not to be treated as unable to make a decision unless all practicable steps to help her to do so have been taken without success. She is not to be treated as unable t o make a decision merely because she makes an unwise decision. To test to see if a patient has the capacity to consent, the following tests must be applied and should be documented i n the medical notes. The patient should, \200 Incompetent adults A person with a Lasting Power of Attorney (LPA), or Welfare Attorney (WA ) in Scotland, may consent or refuse consent on behalf of the individual to whom the LPA/WA applies. The Courts may grant or withhold consent \200 The majority of patients presenting in an emergency to ICU fall into this group of temporar y incompetence. Studies have shown that <5% of patients on ICU have the capacity to determi ne their own best interests. Unless an LPA or court deputy is available, no-one can grant o r withhold consent on behalf of an incapacitated adult. Medical treatment can be undertaken in an emer- gency even if, through a lack of capacity, no consent had been competently giv en, provided the treatment was a necessity and did no more than was reasonably required Understand the information relevant to the decision. (The fact that a person is able to ret ain the information relevant to a decision for a short period only does not prevent him fro m being regarded as able to make the decision.) Retain that information. 543 CHAPTER 33.1 Consent on the ICU developed over the last few years. Scotland passed the Adults with Incapacity Act (Sc) in 2 001 which makes similar provisions. With respect to intensive care medicine, it has enabled \200 Use or weigh that information as part of the process of making the decision. Communicate hi s decision (whether by talking, using sign language or any other means). Adults to appoint another individual as LPA. The LPA can make decisions on their behalf if they become incapaci- tated. The LPA document has to be signed in advance of the time the p atient becomes incapacitated and has to state specifically that the LPA has powers to make healthcare decisions. The courts to appoint a deputy with similar powers to an LPA A requir ement for NHS bodies to appoint an inde- pendent Mental Capacity Advocate to represent thei r interests, when there is no-one appropriate to represent their interests Statutory rules and safeguards on advance directives New criteria and safeguards for research involving inc a- pacitated adults A new criminal offense of neglect The Court of Protection What matters is that the doctors should consider, whether at the time of the decision, the patient had a capacity which was commensurate with the gravity of the decision which he pur ported to make. The more serious the decision, the greater the capacity required. Best interests With regards to the incompetent patient, who lacks the requisite surrogate, the principal that applies is that of \200\230best interests \200\231. Best interests are not limited to best medical interests. The doctor must consider, so far as is reasonably as certainable \200 \200 the person \200\231s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity), the beliefs and values that would be likely to in \202 uence his decision if he had capacity and any other factors that he woul d be likely to consider if he were able to do so. \200 Further reading Mental Capacity Act 2005, http://www.opsi.gov.uk/acts/ Further, in addition to the views of an LPA or the Court, the doctor must take into account , if it is practicable and appropriate to consult them, the views of \200 acts2005/20050009.htm Mental Health Act 1983. Law Commission Consultation Paper No. 139 anyone named by the person as someone to be con- sulted on the matter in question or on mat ters of that kind, anyone engaged in caring for the person or interested in his welfare. Re MB (Medical Treatment). [1997] 2 FLR 426 In re C (Adult: Refusal of Treatment). [1994] 1 WLR 290 In re T (Adult: Refusal of Treatment). [1993] Fam. 95 St George \200\231s Healthca re NHS Trust v S. [1998] 3 All ER 673 Ms B v An NHS Hospital Trust. [2002] WL 347038 Mental Capacity Act 2005 The Act creates a statutory framework in England and Wales based i n large part on the common law that has 544 A LAWSON Rationing in critical care year \200\224with which to compare different healthcare inter- ventions. In such an approac h, the health needs of individu- als do not determine bene \201 t, merely the outcome of t reatment. If we accept that expenditure is limited, CEA and QALY analysis may give us a mea ns of deciding where to allocate resources and when it would be appropriate to stop. A much quoted example is the cost of increasing the number of fecal occult blood tests per patien t in screen- ing for colon cancer in the USA; extending the screening to six from \201 ve tests saves a year of life but at the cost of $26m, compared with $810 for mammography for women >50yrs. In the USA, 40% of health expenditure is spent in the last month of the patient \200\231s l ife, which amounts to 1.5% of the GDP of the USA. At the pinnacle of high tech medicine is the critical care unit. It is hardly news that a limitation of healthcare expenditure coup led with temporary or permanent demand excess leads to an imbalance between available resou rces and expenditure. This imbalance has led to providers seeking to \200\230contain costs \200\231 in a wide variety of disciplines in medicine. In the UK, the use of the R word (R ationing) in conjunction with healthcare is politically and sociologically problematical, c onjuring up images of the post-war period of austerity and con \202 icting with the concep t of free access from cradle to the grave healthcare. It is, however, self-evident that tho se resources are not in \201 nite. Coupling this fact with rising expectations amongst pat ients and increasing costs in critical care leads to a con \202 ict between expressed need s and our ability to meet them. The ensuing balancing act may have untoward consequences; a systematic review of rationing of critical care beds in the UK has shown that people die t hat other- wise might have lived. For the most part, choosing between competing patients is often a matter of logistics as alterna- tive arrangements can often be made. Notwithstandi ng that, at the bedrock of rationing and discussion thereof is the question that is health or life itself so special that we should improves its quality or longevity at any cost? Thi s chapter examines the ethical and economic principles behind rationing in critical care. Terminology \200\224ethics Any discussion of rationing must inevitably involve ethical prin ciples. Deciding what ought to be done involves using principles of ethics or moral philoso phy. Allocating resources may involve the use of utilitarian principles as mentioned in CEA analysis above, where resources are used to maximize the bene \201 t for the greatest num ber of patients. Utilitarianism in this context articulates an important concept, that of c onsequentialism. That it is the consequences of actions that matter. When looking at ration ing decisions using consequentialism, everybody counts equally. However, a pure utilitarian system may not necessarily produce a \200\230fair \200\231 result for an individual, inde ed a rigid utilitarian might argue that it is right to harvest organs from one living perso n to save the lives of many others. This would clearly be unacceptable and to most people m orally wrong. Alternatively, resources may be allocated equally to all regardless of expres sed need as in an egalitarian system, or the resources may be allocated in response to expr essed health needs or capacity to bene \201 t. De \201 ning need, how- ever, is complex; a critically sick patient with a very poor prognosis will still have healthcare needs. Usin g a concept of capacity to bene \201 t raises the issue of unmeetable needs. If a healthca re need cannot be met,then it may be argued that there is no moral obligation to provide he althcare. This has particular resonance for critical care; using resources to attempt to me et an unmeetable need might be unethical. Of particular recent popularity is the concept of the four principles of medical ethics: \200 Terminology \200\224economics In all but a perfect situation of unlimited supply of health- care goods, every healthcare decision involves an eco- nomic trade-off. If supply of healt h goods is limited and demand (i.e. health needs) is not, then any decision of resource all ocation is one of rationing. This maxim is true of any economic decision; an allocation of health dollars to one area inevitably involves a reduction in expenditure, current or futur e, in another area. As well as the cost of treating patient X, such allocation involves a c ost of not treating patient Y or perhaps restricting the treatment of patient Y; this is th e opportunity cost of treating patient X, or building hospital X. Decisions made about reso urce allocation may be related to hospitals or Primary Care Trusts, regionally or nationall y; these may be considered as Macro economic decisions. Decisions may also be made about in dividual patients or patient groups when they can be described as Micro economic decisions. Rationing for a speci \201 c patient has also been described as bedside rationing. It has been suggested that for bedside rationing to occur three conditions are met; doctors shoul d have control over the use a beneficial service which they withdraw or withhold and that i n so doing they act in the interests of someone other than the patient. Decisions made abou t rationing healthcare often use cost-effective analysis (CEA). CEA is a methodology of max imizing health bene \201 ts within a given budget. At its sim- plest, it examines how a mo derately expensive treatment bringing large bene \201 ts compares with a moderately expen- sive treatment bringing moderate bene \201 ts. Such analysis also uses concepts such as t he quality-adjusted life year, the QALY approach looks at cost-effectiveness aggregated ove r time to produce an integer \200\224a quality-adjusted life Autonomy (self-rule) \200\224in the critical care setting most patients \200\231 autonomy i s signi \201 cantly impaired if not absent. Bene \201 cence or doing good implies promoti ng what is best for the patient. Non-maleficence \200\224not doing harm, seems fairly strai ghtforward as in the clinical setting most doctors strive to avoid harm. Avoiding harm at a ll costs, the old adage primum non-nocere, is impossible in practically all healthcare sett ings as all treatments have some associ- ated risk. In the critical care setting, the conce pt of harm vs bene \201 t may be more \201 nely balanced. Justice or fairness forms the fourth principle. In critical care we are concerned both with fairness, which man- dates th at similar patients get equal access to healthcare, but also more with distributive justice , i.e. fair allocation of resources. In the latter context, we are concerned with the effec t of resource usage on other or future patients. 545 CHAPTER 33.2 Rationing in critical care \200 there should be a mechanism for appeal there should be some enforcement procedure to ensure such conditions are met. The American Thoracic Society has articulated this concept well, \200\230Marginally bene \201 cial intensive care may be justi \201 ably limited on the basis of societal consensus that its cost is too high in relation to the value of its outcome \200 extraordinary exp enditures of resources for marginal gains unfairly compromise the availability of a basic m inimum level of health care services for all \200\231. None of these conditions is easy to meet, not least in the charged atmosphere of a critical care unit. However, it seems reasonable to ask that clinicians consider rationing services that bring marginal bene \201 t at great cost. CEA may guide us in concert with ethical t heories to making good decisions, but there may be an innate tension between concepts of be ne \201 cence and cost-effectiveness values. Our shared normative values determine the sor t of healthcare we provide and to whom we provide it. Doing well, albeit at times inef \201 ciently in cost terms, may have a signi \201 cant societal value. Rationing decisions Making dif \201 cult decisions that affect patients \200\231 lives is a day-to-day activity in critical care. Decisions as to triage, and withholding and withdra wing active treatment all involve some degree of resource allocation whether directly or in directly. Interestingly critical care providers seem reticent to allocate resources purely on the basis of maximizing bene \201 t. This may be in part due to the rule of rescue. Wit hin Western societies there is a powerful sense of a \200\230rule of rescue \200\231, whic h obliges us to throw a rope to a drowning man for example. Rescuing a lone sailor from the Southern Ocean at immense expense would go against a utilitarian calculus but would certai nly fit in with concepts of virtue, solidarity and duty. There is enormous symbolic and rhe torical force from rescuing identi \201 ed persons or treating named patients in peril, bu t allocating resources to the sickest patient may not maximize outcomes. How can such decis ions be made when none of the theories will give us an answer? Daniels has speci \201 ed f our conditions to implement what is described as \200\230 accountability for reasonablenes s \200\230 in resource allocation; \200 \200 Further reading ATS Bioethics Task Force. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997; 156: 1282 \200\223301. Daniels N. Accountability for reasonableness in private and public health insurance. In: Co ulter A, Ham C, eds. The global challenge of health care rationing. Buckingham: Oxford Univ ersity Press, 2000: 89 \200\223106. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985 \200\2232000: an analysis of bed numbers, use, and costs. Crit Care Med 2004; 32: 1254 \200 \2239. Sinuff T, Kahnamoui K, Cook DJ, et al. Rationing critical care beds: a systematic review. Crit Care Med 2004; 32: 1588 \200\22397. Society of Critical Care Medicine. Attitudes of critical care medi- cine professionals conc erning distribution of intensive care resources Crit Care Med 1994; 22: 358 \200\22362.