Doctors Admit Rationing Medications

Poll finds that 'bedside rationing' is used in certain cases

WEDNESDAY, July 10, 2002 (HealthDayNews) -- Limited supplies of medications and testing facilities, along with the increasing costs of health care, appear to be forcing some doctors to use "bedside rationing."

In a recent poll, conducted by the Society of Critical Care Medicine (SCCM), almost 76 percent of the 502 physicians surveyed said that if resources were limited, they might withhold or ration a medication or a diagnostic test from a patient who would get limited benefit from it so they could provide that service to another patient who would get more benefit from it.

Slightly more than half the physicians who responded to the survey revealed they had already withheld medication or services from a patient because the cost outweighed the potential benefit. Medications were the most commonly withheld service, followed by diagnostic tests. Other resources, such as intensive care beds, were also rationed, but less frequently.

Nearly 90 percent of those polled felt it would be unethical to withhold a beneficial treatment solely because of cost, but less than 25 percent felt it was unethical to do so if the benefits of the treatment weren't clear-cut.

Bedside rationing is when doctors, pharmacists or hospitals must decide if a medication or treatment will provide enough benefit to justify the expense or risk, explains Dr. Timothy G. Buchman, president-elect of the SCCM and a professor of surgery and anesthesiology at Washington University School of Medicine in St. Louis.

For example, Buchman says, there are new antibiotics that are highly effective against some resistant strains of bacteria. Their use is restricted by most hospitals, not because they're expensive -- which they are -- but because if bacteria are repeatedly exposed to an antibiotic, they develop a resistance to it. By limiting the use of these antibiotics, physicians can preserve their bacteria-fighting ability.

Another example is a very expensive medication that treats septic shock, a potentially fatal blood condition, says Dr. Raul de Velasco, a nephrologist who chairs the Baptist Health South Florida Ethics Committee in Miami.

He says the drug costs more than $4,000 for a single injection, but is very effective. However, it also has side effects that could be dangerous for certain patients. For young patients in relatively good health, de Velasco says this medication would clearly be a good choice. However, if a physician has an elderly patient with a history of stroke who is in septic shock, he says the benefit is not clear, so the decision to spend thousands on a medication becomes much more difficult.

Most of the physicians polled felt bedside rationing undermined the doctor-patient relationship, and said patients or their families should be offered the choice to pay for a treatment that might be of benefit that would otherwise not be offered because of rationing.

Almost 50 percent of the physicians would prefer that a task force develop national guidelines for rationing, such as those already in place for determining who gets an organ transplant.

De Velasco agrees, and says these decisions shouldn't be solely up to the physicians.

"There is a danger with bedside rationing," he adds, explaining that by having physicians make these decisions there is a chance that their biases will come into play as they decide if a treatment will improve a patient's quality of life.

He concedes rationing is sometimes necessary, but says it's critical that it is done solely on the basis of need, without regard to race, religion, sex, income level or insurance status.

Buchman adds that rationing occurs throughout the health-care system all the time. Insurers, the federal government, health organizations, hospitals, physicians and even patients are all involved in rationing.

"There simply are not enough health-care dollars to go around," he explains.

Buchman says it's important to note the survey was sent to more than 5,000 physicians and only 502 responded, so the results may not be statistically significant.

What To Do

For a more detailed look at bedside rationing, read this article from the Annals of Internal Medicine. This article from the Texas Medical Association looks at bedside rationing and other managed health-care quandaries.

SOURCES: Timothy G. Buchman, M.D., Ph.D., Edison professor, surgery, and professor, anesthesiology, Washington University School of Medicine, St. Louis; Raul de Velasco, M.D., nephrologist, and chairman, ethics committee, Baptist Health South Florida, Miami
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