By definition, triage implies that patients who might benefit from the ICU may be denied admission. The decision to deny admission could bring harm, including death, to the patient. Hospitals should seek to avoid the need to triage by investing sufficiently in resources to meet demand by ensuring a sufficient supply of qualified staff, beds, and equipment. In addition, steps should be taken to safely decrease ICU length of stay by promoting good practices, such as timely weaning from mechanical ventilation, making timely end-of-life decisions, and encouraging efficient throughput by transferring patients out of the ICU as soon as they are eligible. Institutions should maximize their ability to care for patients outside the unit, for example by increasing skills and staffing of non-ICU personnel. Denying ICU admission should not be equated with the decision to forgo life support, although sometimes that may be the implication.

The goal of triage is to maximize utilization of the ICU by patients most likely to benefit (Table 17.1). In choosing among patients, two key factors to consider are severity of illness and potential to benefit. Patients requiring life support technology such as intubation and mechanical ventilation, continuous renal replacement therapy, or left ventricular support devices generally have a more compelling need for ICU care than those requiring monitoring alone. At the same time, factors such as severity of the acute illness and chronic comorbidities strongly influence the likelihood of benefit. Patients who are moribund and unlikely to survive despite aggressive care are often less likely to benefit than those that are less ill. The same holds for patients with severe underlying illnesses, like advanced cancer, in whom the prognosis is likely to be poor regardless of the intervention provided.

Basic principles of fairness should govern triage. It is inappropriate to discriminate on the basis of race, gender, sexual orientation, ability to pay, or political connections. Whether to discriminate on the basis of age or functional status is controversial. Objective scoring systems should be used to maximize fairness. To minimize conflicts of interest, triage responsibility should be delegated to physicians not directly involved in patient care. Physicians responsible for triage require institutional support to support their authority while the hospital administration, attorneys, and ethics committee should be enlisted to provide oversight and guidance. Finally, when admission is denied, decisions must be made to determine if life saving efforts will be attempted outside the ICU or whether the focus should shift to palliation alone.

At least in theory, identifying futility should transform decision-making and relieve families from considering treatments that cannot alter outcome, shifting the focus to those that can. Offering futile care makes little ethical sense: it cannot help, it may cause harm, and it may waste resources and deny other patients access to care.

Surrogate decision makers will occasionally request care that physicians consider futile. Professional societies have opined that physicians are not obligated to provide care that cannot achieve treatment goals, even if requested.⁵ Careful, informative, empathic discussions will generally resolve most disputes. In the minority that persist, a deliberate approach that incorporates second opinions and opportunities to transfer care may ultimately lead to unilateral decisions to forgo treatment. However, not all physicians agree that unilateral decisions are appropriate and some suggest deferring to families in the small minority where impasse cannot be resolved.⁴

For practical reasons, the futility rationale should probably be curtailed for all but the most obvious cases. Physicians and nurses are often unable to accurately identify futility, raising the possibility of error. Concerns about self-fulfilling prophecies suggest that poor outcomes may occur simply because physicians consider the prognosis poor. Finally, survival appears to be improving for some patients with traditionally devastating illnesses, such as stem cell transplant recipients with respiratory failure, suggesting that prior beliefs about futility may be obsolete. For these reasons, we believe futility designations should be limited to obvious cases, while favoring traditional approaches that balance risk, benefit, and patient preferences when there is doubt.