Rationing intensive care

Preventing critical illness is better, and cheaper, than cure

Lassen's now classic description of the polio epidemic in Copenhagen in 1952 has many messages for modern intensive care. He showed that deaths from respiratory failure fell from 87% to 40% with the change from cuirasse ventilation (the iron lung), with an unprotected airway, to manual positive pressure ventilation through a cuffed tracheostomy tube using medical students as the power source.1 He was the first to describe the geographical concentration of scarce resources for the intensive care of critically ill patients and the first to show the benefits and expense of the continuous presence of an attendant at each patient's bedside. Lassen was also the first to show that skilled support of organ systems may defer death rather than prevent it: despite the fall in mortality more of those who died did so later in their illness.

Forty years later the case mix in intensive care has changed substantially, although the challenges identified in Lassen's report have not. For example, none of the new and very expensive treatments for sepsis has impressively affected survival. The mortality from multiple organ failure remains high.2 The financial (and emotional) costs of care are also high: it costs twice as much to die in intensive care as it does to survive,3 and in a recent British study the 15% of 3600 patients who died after admission to the intensive care unit consumed 38% of the unit's budget.4 …