The Ethical and Economic Impact of Defaults

Mark D. Siegel; Renee Stapleton; Hannah Wunsch

doi:10.1055/s-0032-1322402

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2012; 33(04): 382-392
DOI: 10.1055/s-0032-1322402

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Ethical and Economic Impact of Defaults

Mark D. Siegel

¹Department of Internal Medicine, Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, Connecticut

,

Renee Stapleton

²Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont

,

Hannah Wunsch

³Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York

⁴Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York

› Author Affiliations

Abstract

Medical care offered to the critically ill often occurs by default, unfolding automatically unless concerted effort is made to do otherwise. In their scope, defaults include traditional approaches to treatment and decision making, as well as policies deliberately set to promote specific health outcomes. Defaults are ethically sound to the extent that they foster patient well-being and autonomy. Unfortunately in practice, some defaults lead to ineffective, unwanted, and expensive care. This article reviews the ethical and economic impact of defaults, paying special attention to their influence on the practice of cardiopulmonary resuscitation and admission to the intensive care unit.

Keywords

default - cardiopulmonary resuscitation (CPR) - intensive care unit (ICU) admission - behavioral economics - decision making

Full Text

References

References
1 Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med 2007; 357 (13) 1340-1344
2 Anonymous; The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. [see comment] N Engl J Med 2000; 342 (18) 1301-1308
3 Girard TD, Kress JP, Fuchs BD , et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371 (9607) 126-134
4 Morrison LJ, Kierzek G, Diekema DS , et al. Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (18, Suppl 3) S665-S675
5 Anonymous; The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). [erratum appears in JAMA 1996 Apr 24;275(16):1232] JAMA 1995; 274 (20) 1591-1598
6 Hejblum G, Chalumeau-Lemoine L, Ioos V , et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. Lancet 2009; 374 (9702) 1687-1693
7 Brauner DJ. Reconsidering default medicine. J Am Geriatr Soc 2010; 58 (3) 599-601
8 Braun UK, McCullough LB. Preventing life-sustaining treatment by default. Ann Fam Med 2011; 9 (3) 250-256
9 Volandes AE, Abbo ED. Flipping the default: a novel approach to cardiopulmonary resuscitation in end-stage dementia. J Clin Ethics 2007; 18 (2) 122-139
10 Simmonds A. Decision-making by default: experiences of physicians and nurses with dying patients in intensive care. Hum Health Care Int 1996; 12 (4) 168-172
11 Wright AA, Zhang B, Ray A , et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008; 300 (14) 1665-1673
12 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. New York: Oxford University Press; 2009
13 Johnson EJ, Steffel M, Goldstein DG. Making better decisions: from measuring to constructing preferences. Health Psychol 2005; 24 (4, Suppl) S17-S22
14 Blumenthal-Barby JS, Burroughs H. Seeking better health care outcomes: the ethics of using the “nudge”. Am J Bioeth 2012; 12 (2) 1-10
15 Antman EM, Anbe DT, Armstrong PW , et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110 (9) e82-e292
16 Mandell LA, Wunderink RG, Anzueto A , et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 (Suppl. 02) S27-S72
17 Thornton JD, Pham K, Engelberg RA, Jackson JC, Curtis JR. Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences. Crit Care Med 2009; 37 (1) 89-95
18 Faber-Langendoen K. Resuscitation of patients with metastatic cancer. Is transient benefit still futile?. Arch Intern Med 1991; 151 (2) 235-239
19 Cher DJ, Lenert LA. Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients. [erratum appears in JAMA 1998 Jun 17;279(23):1876] JAMA 1997; 278 (12) 1001-1007
20 Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. [see comment] N Engl J Med 2002; 346 (14) 1061-1066
21 Layson RT, McConnell T. Must consent always be obtained for a do-not-resuscitate order?. Arch Intern Med 1996; 156 (22) 2617-2620
22 Becker KJ, Baxter AB, Cohen WA , et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 2001; 56 (6) 766-772
23 Benoit DD, Vandewoude KH, Decruyenaere JM, Hoste EA, Colardyn FA. Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med 2003; 31 (1) 104-112
24 Pope TM. DNAR as default status: desirable in principle, difficult in practice. Am J Crit Care 2008; 17 (6) 500 , author reply 501
25 Daly BJ. An indecent proposal: withholding cardiopulmonary resuscitation. Am J Crit Care 2008; 17 (4) 377-380
26 Eliott J, Olver I. Choosing between life and death: patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient. Bioethics 2008; 22 (3) 179-189
27 Silveira MJ, DiPiero A, Gerrity MS, Feudtner C. Patients' knowledge of options at the end of life: ignorance in the face of death. JAMA 2000; 284 (19) 2483-2488
28 Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med 1996; 334 (24) 1578-1582
29 Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients?. J Gen Intern Med 1995; 10 (8) 436-442
30 Cox CE, Martinu T, Sathy SJ , et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 2009; 37 (11) 2888-2894 , quiz 2904
31 Nelson JE, Mercado AF, Camhi SL , et al. Communication about chronic critical illness. Arch Intern Med 2007; 167 (22) 2509-2515
32 Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med 2010; 153 (4) 256-261
33 Swindell JS, McGuire AL, Halpern SD. Shaping patients' decisions. Chest 2011; 139 (2) 424-429
34 Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340: c1345
35 Siegel MD. End-of-life decision making in the ICU. Clin Chest Med 2009; 30 (1) 181-194 , x
36 Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest 2008; 134 (4) 835-843
37 Nelson JE, Walker AS, Luhrs CA, Cortez TB, Pronovost PJ. Family meetings made simpler: a toolkit for the intensive care unit. J Crit Care 2009; 24 (4) 626 , e7–e14
38 Swig L, Cooke M, Osmond D , et al. Physician responses to a hospital policy allowing them to not offer cardiopulmonary resuscitation. J Am Geriatr Soc 1996; 44 (10) 1215-1219
39 Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA 2007; 298 (20) 2415-2417
40 Torke AM, Alexander GC, Lantos J, Siegler M. The physician-surrogate relationship. Arch Intern Med 2007; 167 (11) 1117-1121
41 Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med 2011; 154 (5) 336-346
42 Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166 (5) 493-497
43 Pochard F, Azoulay E, Chevret S , et al; French FAMIREA Group. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med 2001; 29 (10) 1893-1897
44 Murphy DJ. Do-not-resuscitate orders: time for reappraisal in long-term-care institutions. JAMA 1988; 260 (14) 2098-2101
45 Gries CJ, Engelberg RA, Kross EK , et al. Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2010; 137 (2) 280-287
46 Azoulay E, Pochard F, Kentish-Barnes N , et al; FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005; 171 (9) 987-994
47 Frankl D, Oye RK, Bellamy PE. Attitudes of hospitalized patients toward life support: A survey of 200 medical inpatients. Am J Med 1989; 86 (6 Part 1) 645-648
48 Lo B. Unanswered questions about DNR orders. JAMA 1991; 265 (14) 1874-1875
49 Hofmann JC, Wenger NS, Davis RB , et al; SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment. Patient preferences for communication with physicians about end-of-life decisions. Ann Intern Med 1997; 127 (1) 1-12
50 Burns JP, Edwards J, Johnson J, Cassem NH, Truog RD. Do-not-resuscitate order after 25 years. Crit Care Med 2003; 31 (5) 1543-1550
51 Biegler P. Should patient consent be required to write a do not resuscitate order?. J Med Ethics 2003; 29 (6) 359-363
52 Johnson EJ, Goldstein D. Medicine. Do defaults save lives?. Science 2003; 302 (5649) 1338-1339
53 Kressel LM, Chapman GB. The default effect in end-of-life medical treatment preferences. Med Decis Making 2007; 27 (3) 299-310
54 Kressel LM, Chapman GB, Leventhal E. The influence of default options on the expression of end-of-life treatment preferences in advance directives. J Gen Intern Med 2007; 22 (7) 1007-1010
55 Fagerlin A. The case for frugal default options in patient-doctor communication. J Eval Clin Pract 2010; 16 (2) 382-383
56 Youngner SJ. Do-not-resuscitate orders: no longer secret, but still a problem. Hastings Cent Rep 1987; 17 (1) 24-33
57 Ditillo BA. Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come. J Palliat Med 2002; 5 (1) 107-116
58 Loewy EH. The uncertainty of certainty in clinical ethics. J Med Humanit Bioeth 1987; 8 (1) 26-33
59 Vincent JL. Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 1999; 27 (8) 1626-1633
60 Yaguchi A, Truog RD, Curtis JR , et al. International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med 2005; 165 (17) 1970-1975
61 Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. Am J Bioeth 2010; 10 (1) 61-67
62 Sprung CL, Maia P, Bulow HH , et al; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med 2007; 33 (10) 1732-1739
63 Sprung CL, Cohen SL, Sjokvist P , et al; Ethicus Study Group. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290 (6) 790-797
64 Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998; 158 (4) 1163-1167
65 Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173: 1064-1067
66 Waisel DB, Truog RD. The cardiopulmonary resuscitation-not-indicated order: futility revisited. Ann Intern Med 1995; 122 (4) 304-308
67 Mello M, Jenkinson C. Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and an American teaching hospital. Soc Sci Med 1998; 46 (3) 415-424
68 Bowker L. A doctor's experience of resuscitation decision making for older patients: coping with change. Postgrad Med J 2009; 85 (1009) 569-572
69 Blackhall LJ. Must we always use CPR?. N Engl J Med 1987; 317 (20) 1281-1285
70 Nava S, Santoro C, Grassi M, Hill N. The influence of the media on COPD patients' knowledge regarding cardiopulmonary resuscitation. Int J Chron Obstruct Pulmon Dis 2008; 3 (2) 295-300
71 Adams DH, Snedden DP. How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. J Am Osteopath Assoc 2006; 106 (7) 402-404
72 Ehlenbach WJ, Barnato AE, Curtis JR , et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009; 361 (1) 22-31
73 Peberdy MA, Kaye W, Ornato JP , et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003; 58 (3) 297-308
74 Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983; 309 (10) 569-576
75 Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation 2010; 81 (11) 1479-1487
76 Nichol G, Stiell IG, Hebert P, Wells GA, Vandemheen K, Laupacis A. What is the quality of life for survivors of cardiac arrest? A prospective study. Acad Emerg Med 1999; 6 (2) 95-102
77 Edgren E, Kelsey S, Sutton K, Safar P. Brain Resuscitation Clinical Trial I Study Group. The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival. Acta Anaesthesiol Scand 1989; 33 (4) 265-271
78 Johnson SK, Bautista CA, Hong SY, Weissfeld L, White DB. An empirical study of surrogates' preferred level of control over value-laden life support decisions in intensive care units. Am J Respir Crit Care Med 2011; 183 (7) 915-921
79 Lederberg MS. Doctors in limbo: the United States 'DNR' debate. Psychooncology 1997; 6 (4) 321-328
80 Lee KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death?. Crit Care Med 1996; 24 (12) 2046-2052
81 Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer 2002; 10 (5) 425-429
82 Ebell MH, Kruse JA. A proposed model for the cost of cardiopulmonary resuscitation. Med Care 1994; 32 (6) 640-649
83 American Heart Association, American National Red Cross, Industrial Medical Association. The closed chest method of cardiopulmonary resuscitation benefits and hazards [editorial]. Circulation 1962; 26: 324
84 Foley GE, Lazarus H, Farber S, Uzman BG, Boone BA, McCarthy RE. The closed-chest method of cardiopulmonary resuscitation—revised statement. Circulation 1965; 31: 641-643
85 Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences NAoS-NRC. Cardiopulmonary resuscitation. JAMA 1966; 198 (4) 372-379
86 Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med 1976; 295 (7) 364-366
87 Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1980; 244 (5) 453-509
88 Brauner DJ, Grusin SL. In-hospital cardiopulmonary resuscitation. N Engl J Med 2009; 361 (17) 1708-1709 , author reply 1708–1709
89 American College of Physicians. American College of Physicians Ethics Manual. Part 1: History; the patient; other physicians. Ann Intern Med 1989; 111 (3) 245-252
90 Tomlinson T, Brody H. Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988; 318 (1) 43-46
91 Anonymous; American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med 1991; 115 (6) 478-485
92 Luce JM. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Crit Care Med 1995; 23 (4) 760-766
93 Anonymous. Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281 (10) 937-941
94 Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med 2000; 343 (4) 293-296
95 Billings JA, Krakauer EL. On patient autonomy and physician responsibility in end-of-life care. Arch Intern Med 2011; 171 (9) 849-853
96 Marco CA, Schears RM. Societal opinions regarding CPR. Am J Emerg Med 2002; 20 (3) 207-211
97 Lloyd CB, Nietert PJ, Silvestri GA. Intensive care decision making in the seriously ill and elderly. Crit Care Med 2004; 32 (3) 649-654
98 Murphy DJ, Burrows D, Santilli S , et al. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330 (8) 545-549
99 Barnato AE, Herndon MB, Anthony DL , et al. Are regional variations in end-of-life care intensity explained by patient preferences? A Study of the US Medicare Population. Med Care 2007; 45 (5) 386-393
100 Lantos JD, Singer PA, Walker RM , et al. The illusion of futility in clinical practice. Am J Med 1989; 87 (1) 81-84
101 Caplan AL. Odds and ends: trust and the debate over medical futility. Ann Intern Med 1996; 125 (8) 688-689
102 Nolan K. In death's shadow: the meanings of withholding resuscitation. Hastings Cent Rep 1987; 17 (5) 9-14
103 Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent”. Chest 2007; 132 (3) 748-751 , discussion 755–756
104 Kelley MA, Angus D, Chalfin DB , et al. The critical care crisis in the United States: a report from the profession. Chest 2004; 125 (4) 1514-1517
105 Angus DC, Kelley MA, Schmitz RJ, White A, Popovich Jr J. Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?. JAMA 2000; 284 (21) 2762-2770
106 Halpern NA, Pastores SM. Critical care medicine in the United States 2000–2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38 (1) 65-71
107 Lynn J, Teno JM, Phillips RS , et al; SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 1997; 126 (2) 97-106
108 Wunsch H, Angus DC, Harrison DA , et al. Variation in critical care services across North America and Western Europe. Crit Care Med 2008; 36 (10) 2787-2793 , e1–e9
109 Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med 2009; 180 (9) 875-880
110 Metcalfe MA, Sloggett A, McPherson K. Mortality among appropriately referred patients refused admission to intensive-care units. Lancet 1997; 350 (9070) 7-11
111 Carr BG, Addyson DK, Kahn JM. Variation in critical care beds per capita in the United States: implications for pandemic and disaster planning. JAMA 2010; 303 (14) 1371-1372
112 Seymour CW, Iwashyna TJ, Ehlenbach WJ, Cooke CR. Hospital-level variation in the use of critical care services [abstract]. Am J Respir Crit Care Med 2011; 183: A2931
113 Sprung CL, Geber D, Eidelman LA , et al. Evaluation of triage decisions for intensive care admission. Crit Care Med 1999; 27 (6) 1073-1079
114 Kraiss LW, Kilberg L, Critch S, Johansen KJ. Short-stay carotid endarterectomy is safe and cost-effective. Am J Surg 1995; 169 (5) 512-515
115 Sobol JB, Wunsch H. Triage of high-risk surgical patients for intensive care. Crit Care 2011; 15 (2) 217
116 Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life?. Am J Respir Crit Care Med 2002; 165 (6) 750-754
117 Gozalo P, Teno JM, Mitchell SL , et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011; 365 (13) 1212-1221
118 Mitchell SL, Teno JM, Kiely DK , et al. The clinical course of advanced dementia. N Engl J Med 2009; 361 (16) 1529-1538
119 Eachempati SR, Hydo LJ, Barie PS. The effect of an intermediate care unit on the demographics and outcomes of a surgical intensive care unit population. Arch Surg 2004; 139 (3) 315-319
120 Lilly CM, De Meo DL, Sonna LA , et al. An intensive communication intervention for the critically ill. Am J Med 2000; 109 (6) 469-475
121 Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 (2) 139-146
122 Esmonde L, McDonnell A, Ball C , et al. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32 (11) 1713-1721
123 Scales DC, Dainty K, Hales B , et al. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA 2011; 305 (4) 363-372
124 Barnato AE, Chang CC, Farrell MH, Lave JR, Roberts MS, Angus DC. Is survival better at hospitals with higher “end-of-life” treatment intensity?. Med Care 2010; 48 (2) 125-132
125 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003; 138 (4) 288-298
126 Carson SS, Cox CE, Holmes GM, Howard A, Carey TS. The changing epidemiology of mechanical ventilation: a population-based study. J Intensive Care Med 2006; 21 (3) 173-182
127 Needham DM, Bronskill SE, Calinawan JR, Sibbald WJ, Pronovost PJ, Laupacis A. Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers. Crit Care Med 2005; 33 (3) 574-579