Rule of rescue or the good of the many? An analysis of physicians’ and nurses’ preferences for allocating ICU beds

A new study from the University of Pennsylvania published in the July 2011 Intensive Care Medicine indicates that the so-called “rule of rescue” – whereby clinicians are prone to try to save their own patients as opposed to opening up a bed for a new patient – often prevails even in the face of substantial social benefit in terms of cost containment and procurement of organ donations.

The researchers analyzed mixed methods questionnaires from 1,122 ICU clinicians in the U.S., 648 physicians and 438 nurses. The questionnaires addressed the clinicians’ preferences for allocating their last bed in the ICU to a gravely ill patient already being treated, but with little chance to survive, versus an incoming deceased or dying patient for whom aggressive management could help others through organ donation.

Physicians were more likely than nurses to adhere to the ‘‘rule of rescue’’ by allocating the last bed to the gravely ill patient (45.9 vs. 32.6 percent). The questionnaire also revealed that the magnitude of the “social benefit” to be obtained through organ donor management (5 or 30 life-years added for transplant recipients) had small and inconsistent effects on clinicians’ willingness to prioritize the donor, suggesting that clinicians’ willingness to act to promote society’s interests does not depend prominently on the magnitude of those interests.  

In sum, the ‘rule of rescue’ represents a substantial and persistent barrier to the efficient allocation of scarce resources and may impede efforts to improve patient triage or constrain costs.  The authors conclude that future research is needed to identify the actual frequencies with which clinicians prioritize individual patients when doing so carries real social costs, and to further explore factors related to the observed variability in allocation patterns among clinicians.