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Audit of the cost of futile invasive care in Paediatric Intensive Care
  1. C Pady,
  2. G Subramanian
  1. 1St George's University of London, London, UK
  2. 2NICU/PICU, Great Ormond Street Hospital, London, UK

Abstract

Aim When a critically ill child sustained on invasive technology does not recover; consensus between professionals and the family is usually reached regarding cessation of ‘futile’ therapy, and the adoption of a more palliative approach. However, resolution can ultimately require the Court if agreement cannot be reached. No one can be under any illusion that NHS funding is reducing. This audit aimed to quantify the cost of futile invasive care on a Children's Hospital Paediatric and Neonatal Intensive Care (P/NICU), and to identifying early triggers for review to reduce it.

Methods All P/NICU deaths 2008-2010 were reviewed. Inclusion: children receiving futile care (defined - on-going invasive care after the point at which intensivists and referring clinicians had reached consensus that this was inadvisable and burdensome to the child, for more than a few days). Exclusions –children with unpredictable relapsing illness. Overall NHS expenditure on such futile care was calculated.

Results Of 154 deaths, 8 children clearly received futile care. Establishing the exact date of consensus required careful scrutiny of medical documentation, but was clarified in each case. The NHS spends £2800 for 1 child to spend 1 day in ICU, so this PICU costs the NHS £67,200/day. In all 8 children there were significant challenges to adopting the appropriate palliative approach, despite ethical reviews, PALS and chaplaincy involvement together with out-of-hospital religious and cultural leaders. Based on ‘futile care days’ wasted expenditure was: £148,400: 2008; were £506,800: 2009 but only £5,600:2010 - hence an average 0.9% (£220,000) of the annual budget was lost every year to futile invasive care. Triggers identified include parents of non-UK/Western healthcare country of origin, significant religious influence in the family and early statements suggesting the sanctity-of-life would always preclude stopping invasive support.

Conclusion Protracted futile invasive care on this P/NICU costs the NHS an average of £230,000 per year. If extrapolated nationwide, this is a significant waste of resources. Healthcare cost reduction should surely focus on aggressively addressing such waste, before reducing other services. Potential trigger factors may enable early resolution of cases, perhaps by direct court access.

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