Distributive justice across generations. Epidemiology of ICU care for the very young and the very old.

Babies of extremely low birthweight and elderly adults both require expensive and scarce resources, and both have a relatively poor prognosis for survival if they require intensive care. Thus, proposals for rationing often target one or both of these groups. We suspected that although mortality rates might be higher in the neonatal intensive care unit (NICU) than in the adult intensive care unit (ICU), NICU care might nevertheless be more cost effective, where cost efficiency is measured along the dimension of resources targeted to survivors. We examined mortality patterns in our NICU and for adults admitted to our medical intensive care units. We found that adult ICU patients who died consumed many times more ICU resources before their death than did their NICU confreres, independent of the severity of illness or likelihood of dying. Although there may be many legitimate concerns about justice and ethics in the NICU, undue expenditure of society's resources prolonging the dying of extremely low birthweight infants is not among them. To the extent that concerns about distributive justice drive allocation decisions in ICU care, it would seem more justifiable to ration intensive care for the very old, not the very young.