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Can we identify futility of care in the sickest critically ill patients on the third ICU day?


Various models are used to predict mortality of patients admitted to the intensive care unit (ICU) based on the first ICU day findings. Some of these models have developed daily scoring systems for the subsequent ICU days. There is no consensus regarding the definition of futility and there are no reliable ways of identifying patients for whom ICU care is futile. The purpose of this retrospective study was to determine whether we can identify factors associated with futility in the sickest patients admitted to the ICU. We hypothesized that any increase in the acute physiology score (APS) from the first ICU day to the third ICU day would identify very sick patients with futile care.


We defined the sickest critically ill patients as those with a first day APACHE III predicted mortality rate of 80% or higher. Among 43,605 ICU admissions entered in the APACHE III database from 1994 to 2002, 15,512 stayed in the ICU for 3 or more days and 748 (1.7%) had a first day predicted mortality rate of 80% or higher. Only 308 of the 748 patients (41%) survived 3 days in the ICU. Excluding six patients who did not authorize their medical records to be reviewed for research, 302 admissions were included in the study. Demographics, first and third day APSs and probability of hospital death, and date of death were obtained.


The patients were predominantly (92%) Caucasians; 54% were male. The first and third ICU day mean APSs were 106.8 and 70.5, respectively, and predicted mortality rates were 87.8% and 86.5%, respectively. The observed hospital mortality rate was 61.3%. There was an increase in APS on the third ICU day, compared with the first ICU day, in 34 patients (11.3%). Only two of the 34 patients (6%) with increased APS survived to hospital discharge, compared with 115 of 268 (43%) without increase (P < 0.0001). Of the two patients who survived to hospital discharge, one died within 24 hours of discharge and the second one, who was admitted to the ICU for multiple trauma, died 3 years after hospital discharge.


An increase in the APS on the third ICU day of the sickest patients identifies a group of patients whose short-term and long-term prognoses are dismal.

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Afessa, B., Keegan, M., Mohammad, Z. et al. Can we identify futility of care in the sickest critically ill patients on the third ICU day?. Crit Care 8 (Suppl 1), P327 (2004).

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