New strategies are needed to curb the proliferation of life-sustaining therapies that rarely benefit patients. We propose a model for appropriate use of such therapies that incorporates effectiveness, utility, and marginal costs. If a therapy is rarely effective and rarely desirable, it is considered medically inappropriate. If the marginal cost-effectiveness ratio is inordinately high, it is considered economically inappropriate. If a therapy is either medically or economically inappropriate, it should not be automatically offered. The model provides an operational definition of futility and is illustrated with an analysis of out-of-hospital cardiopulmonary resuscitation for chronically ill older people. Advance directives, explicit health care rationing, and defining futile therapy based on survival predictions are alternatives to the appropriate care model, but are insufficient strategies to solve the problem of inappropriate life-sustaining care.
KIE: The authors propose a mathematical model for deciding appropriate use of life-sustaining care, using as an example out-of-hospital cardiopulmonary resuscitation for chronically ill older persons. Incorporating determinations of effectiveness, utility, and marginal costs, the model helps physicians and patients decide which life-sustaining treatments are medically and/or economically appropriate. Physicians need not automatically offer patients therapies that have been shown to be neither medically nor economically appropriate. Murphy and Matchar discuss advance directives, health care rationing, and identifying futile therapies based on survival predictions as other mechanisms for limiting life-sustaining care. They conclude that these three options are inadequate alternatives to the appropriate care model.