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Critical Care RationingRationing Critical Care: International Comparisons

Timothy W. Evans, MD, PhD; Stefano Nava, MD; Guillermo Vazquez Mata, MD, PhD; Bertrand Guidet, MD; Elisa Estenssoro, MD; Robert Fowler, MD; Leslie P. Scheunemann, MD; Douglas White, MD; Constantine A. Manthous, MD; for the Task Force on Values, Ethics, and Rationing in Critical Care (VERICC)
Author and Funding Information

From the Department of Critical Care (Dr Evans), Imperial College School of Medicine, Royal Brompton Hospital, London, England; Respiratory and Critical Care Unit (Dr Nava), Sant’Orsola Malpighi Hospital, Bologna, Italy; Universidad Autonoma de Barcelona (Dr Mata), Barcelona, Spain; Service de Réanimation Médicale (Dr Guidet), Paris, France; Hospital Interzonal de Agudos San Martin de La Plata (Dr Estenssoro), Buenos Aires, Argentina; Sunnybrook Health Science Center (Dr Fowler), Toronto, ON, Canada; University of North Carolina at Chapel Hill (Dr Scheunemann), Chapel Hill, NC; University of Pittsburgh (Dr White), Pittsburgh, PA; and Yale University School of Medicine (Dr Manthous), Bridgeport, CT.

Correspondence to: Constantine A. Manthous, MD, Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06518; e-mail: pcmant@bpthosp.org

% GDP = percentage of gross domestic product spent on health care; PCE = per capita expenditure, where the first number is the total and the number in parentheses is government spending per capita (both in US dollars); WC = without consent.

a

Those answering that admission could be withheld stressed that the decision to withhold admission could be made based on clinicians’ assessment of physiologic need and potential benefit.

b

Some states (eg, Texas) have instituted a formal process whereby futile life-sustaining therapies can be legally withdrawn without consent of surrogates.

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


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

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


Chest. 2011;140(6):1618-1624. doi:10.1378/chest.11-0957
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Every country has finite resources that are expended to provide citizens with social “goods,” including education, protection, infrastructure, and health care. Rationing—of any resource—refers to distribution of an allotted amount and may involve withholding some goods that would benefit some citizens. Health-care rationing is controversial because good health complements so many human endeavors. We explored (perceptions regarding) critical care rationing in seven industrialized countries. Academic physicians from England, Spain, Italy, France, Argentina, Canada, and the United States wrote essays that addressed specific questions including: (1) What historical, cultural, and medical institutional features inform my country’s approach to rationing of health care? (2) What is known about formal rationing, especially in critical care, in my country? (3) How does rationing occur in my ICU? Responses suggest that critical care is rationed, by varying mechanisms, in all seven countries. We speculate that while no single “best” method of rationing is likely to be acceptable or optimal for all countries, professional societies could serve international health by developing evidence-based guidelines for just and effective rationing of critical care.


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