Rule of rescue or the good of the many? An analysis of physicians' and nurses' preferences for allocating ICU beds

Abstract

Purpose: To examine intensive care unit (ICU) clinicians' willingness to trade off societal benefits in favor of a small chance of rescuing an identifiable critically ill patient.

Methods: We sent mixed-methods questionnaires to national samples of US ICU clinicians, soliciting their preferences for allocating their last bed to a gravely ill patient with little chance to survive, versus a deceased or dying patient for whom aggressive management could help others through organ donation.

Results: Complete responses were obtained from 684 of 2,206 physicians (31.0%) and 438 of 988 nurses (44.3%); there was no evidence of non-response bias. Physicians were more likely than nurses to adhere to the "rule of rescue" by allocating the last bed to the gravely ill patient (45.9 vs. 32.6%, difference = 13.2%; 95% CI 9.1-17.3%). The magnitude of the social benefit to be obtained through organ donor management (5 or 30 life-years added for transplant recipients) had small and inconsistent effects on clinicians' willingness to prioritize the donor. In qualitative analyses, the most common reason for allocating the last bed to an identifiable patient (identified by 65% of physicians and 75% of nurses) was that clinicians perceived strong obligations to identifiable living patients.

Conclusions: More than one-third of ICU clinicians forewent substantial social benefits so as to devote resources to an individual patient unlikely to benefit from them. Such allegiance to the rule of rescue suggests challenges for efforts to reform ICU triage practices.