Why is it so hard to stop doing things that are unwanted, non-beneficial or unsustainable

We recognise that critical care is sometimes provided in situations that are unwanted, non-beneficial, or unsustainably resource intense. In this issue of The Lancet Respiratory Medicine, a Series of three articles 1, 2, 3 review the published literature on avoiding unwanted intensive care unit (ICU) care, and identify the drivers of non-beneficial or cost-ineffective ICU use. Although to stop doing something that is unwanted, ineffective, and expensive should be easy, previous attempts to reduce the use of critical care in these situations have not always been met with success. Observational studies have routinely shown that advance care planning documents and palliative care consultation are associated with low rates of ICU use near the end of life. However, prospective interventional studies of palliative care or advance care planning have shown small to modest effects at best, and some have shown concerning negative effects on family members, such as increased rates of post-traumatic stress disorder. Moreover, the resources required to deliver some of these interventions are substantial, and might be hard to justify on the basis of the resources they save or the outcomes that they achieve. The efforts to reduce unwanted, non-beneficial, or unsustainable critical care can themselves be unwanted, non-beneficial, or unsustainable. 

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