Intended for healthcare professionals


Intensive care: balancing risk and benefit to facilitate informed decisions

BMJ 2018; 363 doi: (Published 19 October 2018) Cite this as: BMJ 2018;363:k4135
  1. Jamie Gross, consultant in intensive care medicine1,
  2. Barry Williams, patient and public representative2,
  3. Premila Fade, consultant geriatrician1,
  4. Stephen J Brett, consultant in intensive care medicine and professor of critical care3
  1. 1London North West University Healthcare NHS Trust, Watford Road, Harrow HA1 3UJ, UK
  2. 2Bishops Caundle, Dorset
  3. 3Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
  1. Correspondence to: J Gross j.gross{at}

More efforts are needed to engage with the wider healthcare community and the public about what intensive care can—and can’t—achieve, say Jamie Gross and colleagues

Changing population demographics and improved chronic disease management have led to a growing proportion of patients being admitted to intensive care units (ICUs) with co-existing chronic disease and frailty.12 This has contributed to greater demand for intensive care services, which is steadily increasing at a rate of about 4% a year.3 Limited bed capacity in ICUs results in cancelled urgent operations and in non-clinical transfers to other such units.4 Given that intensive care is an expensive resource with healthcare costs for survivors that commonly extend well beyond admission,5 this trend is unlikely to be sustainable. Crucially, for patients with chronic disease and established frailty, undergoing the burden of a prolonged stay in intensive care for an acute illness may not deliver sustainable benefit,56 with the important caveat that the definition of “benefit” is a very individual thing.

Can anything be done to tackle the mismatch between supply and demand for intensive care? Perhaps part of this increasing demand is due to unrealistic expectations of what medicine—in particular intensive care—can achieve, along with an underappreciation of the burdens of both a critical care stay and future survivorship.7 One approach might be to increase public awareness about what admission to intensive care could mean for patients and their families, to facilitate informed decision making.

Pitfalls of intensive care

The onset of critical illness can be a highly stressful time for patients and their families. Most people do not express their wishes for the management of a future hypothetical life threatening crisis, so when a patient is incapacitated by acute illness relatives are often faced with the burden of trying to determine what that …

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