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Joseph G. Murphy, MD, FCCP; William F. Dunn, MD, FCCP
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Affiliations: Dr. Murphy is Professor of Medicine and Chair, Scientific Publications, and Dr. Dunn is Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic.

Correspondence to: Joseph G. Murphy, MD, FCCP, Mayo Clinic, Cardiology Division, 10 Plummer Building, Rochester, MN 55905; e-mail: murphy.joseph@mayo.edu


Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(5):1444. doi:10.1378/chest.09-1897
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“Whoever destroys the life of a single human being … it is as if he had destroyed an entire world; and whoever preserves the life of a single human being … it is as if he had preserved an entire world.”

Talmud Sanhedrin 37a

To the Editor:

We thank Dijkema et al for their thoughtful letter on our recent editorial.1 We agree that the essential function of an ICU is to prolong meaningful patient survival in individuals with reversible critical illnesses, using high-technology care, but not to act as a substitute for end-of-life hospice care or as a way station for those patients with irreversible critical illness. It is clear that admissions to the ICU are overutilized in the United States compared with other developed countries such as Holland. The essential dilemma is about who makes the decision on ICU admission: the patients, their relatives, or ICU physicians. Several points are worth making:

  1. The ICU is a triaged unit, meaning that scarce ICU resources should be used to help those patients who are likely to benefit from intensive care.

  2. Death in the ICU is rarely a dignified death.

  3. Death is an experience that we must all meet: death in an ICU is an entirely optional experience.

  4. Demographic and health-care funding changes will force better utilization of ICU resources.

  5. Death and the process of dying is a cultural process as well as a health-care process.

In summary, we agree with the positions of Dijkema et al. The expensive dilemma within which the United States finds itself is, of course, multifactorial. Nonetheless, better utilization of ICU admission and discharge policies toward realistic outcomes in meaningful survival remains an important, and often elusive, goal.

Dunn W, Murphy J. Should intensive care medicine itself be on the critical list? Chest. 2009;135:892-894. [PubMed] [CrossRef]
 

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Dunn W, Murphy J. Should intensive care medicine itself be on the critical list? Chest. 2009;135:892-894. [PubMed] [CrossRef]
 
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