Ethical Issues in the Chronically Critically Ill Patient

The chronically critically ill represent a unique subgroup of patients. They typically are seriously ill patients who are discharged from an intensive care unit (ICU) with multiple medical problems. They present a distinct spectrum of ethical dilemmas.

The definition of the chronically critically ill patient continues to evolve. For our purposes, these patients are defined best as those being discharged from the ICU earlier in the course of their disease than in previous years, in an effort to increase the availability of costly ICU beds.¹⁹ Hospitals have strived to reduce their sizes to remain financially competitive in the face of limited or fixed reimbursement. This financial reality has been largely responsible for the development of long-term acute care (LTAC) facilities to treat the chronically ill, as discussed in another article in this edition. It therefore seems that chronic critical care provided at LTAC facilities is an outgrowth of the financial constraints that are an everyday fact of life in medicine in the new millenium.⁹ This change in location of care does not seem to be based on pre-existing scientific data indicating that outcomes such as survival or quality of life are improved in the LTAC setting. By its nature, therefore, most of the current data generated about this group are, by definition, observational or retrospective. Review studies have shown this population has lower serum albumin levels, wider A-a gradients, and increased prevalence of ulcers.¹⁹ As a result, LTAC facilities are admitting more acutely ill patients, with resultant increases in morbidity and mortality.