This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

A Model for Appropriate Use

Donald J. Murphy, MD; David B. Matchar, MD

JAMA. 1990;264(16):2103-2108.

Abstract
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.

(JAMA. 1990;264:2103-2108)

Author Affiliations
From the Intensive Care Research Unit and the Division of Geriatrics, Department of Health Care Sciences, George Washington University Medical Center, Washington, DC (Dr Murphy); and the Center for Health Policy Research and Education, Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC (Dr Matchar).

Footnotes
Reprint requests to Intensive Care Research Unit, George Washington University Medical Center, 2300 K St NW, Washington, DC 20037 (Dr Murphy).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Withdrawal of Life Support: Intensive Caring at the End of Life
Prendergast and Puntillo
JAMA 2002;288:2732-2740.
ABSTRACT | FULL TEXT  

Elderly Patients' Preferences for Long-term Life Support
Murphy and Santilli
Arch Fam Med 1998;7:484-488.
ABSTRACT | FULL TEXT  

Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders in the Nursing Home
Zweig
Arch Fam Med 1997;6:424-429.
ABSTRACT  

When Everything Is Too Much: Quantitative Approaches to the Issue of Futility
Ebell
Arch Fam Med 1995;4:352-356.
ABSTRACT  

Reasons for Curtailing Cardiopulmonary Resuscitation-Reply
Murphy and Finucane
Arch Intern Med 1994;154:1539-1540.
ABSTRACT  

Setting Limits in Clinical Medicine
Murphy et al.
Arch Intern Med 1994;154:505-512.
ABSTRACT  

The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation
Murphy et al.
NEJM 1994;330:545-549.
ABSTRACT | FULL TEXT  

Do-Not-Resuscitate Orders in Intensive Care Units: Current Practices and Recent Changes
Jayes et al.
JAMA 1993;270:2213-2217.
ABSTRACT  

New Do-Not-Resuscitate Policies: A First Step in Cost Control
Murphy and Finucane
Arch Intern Med 1993;153:1641-1648.
ABSTRACT  

Outcome of Cardiopulmonary Resuscitation in the Intensive Care Setting
Landry et al.
Arch Intern Med 1992;152:2305-2308.
ABSTRACT  

The Utility of CPR in Elderly Persons
Jacobs
JAMA 1991;265:866-866.
ABSTRACT  

Life-Sustaining Therapies in Elderly Persons
Tuteur and Tuteur
JAMA 1990;264:2118-2118.
ABSTRACT