Murphy D J, Matchar D B
Department of Health Care Sciences, George Washington University Medical Center, Washington, DC 20037.
JAMA. 1990;264(16):2103-8.
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.
需要新的策略来遏制那些很少能使患者受益的维持生命疗法的扩散。我们提出了一个适用于此类疗法的使用模型，该模型纳入了有效性、实用性和边际成本。如果一种疗法很少有效且很少被需要，那么它在医学上被认为是不适当的。如果边际成本效益比过高，那么它在经济上被认为是不适当的。如果一种疗法在医学上或经济上是不适当的，就不应自动提供。该模型提供了一个无效性的操作性定义，并通过对慢性病老年人院外心肺复苏的分析进行了说明。预先指示、明确的医疗保健配给以及基于生存预测来定义无效治疗是适当护理模型的替代方案，但它们是解决不适当维持生命护理问题的不充分策略。
