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Comment & Response | Less Is More

Management of Critically Ill Patients—Reply

Matthijs Kox, PhD1,2,3; Peter Pickkers, MD, PhD1,3
[+] Author Affiliations
1Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
2Department of Anesthesiology, Radboud University Medical Centre, Nijmegen, the Netherlands
3Nijmegen Institute for Infection, Inflammation, and Immunity, Nijmegen, the Netherlands
JAMA Intern Med. 2014;174(3):477-478. doi:10.1001/jamainternmed.2013.13682.
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In Reply We thank Mahmoodpoor and Golzari for their letter in response to our special communication.1 The authors argue that reductions in treatment intensity inevitably result in the need for increased vigilance. While we acknowledge that the intensive care unit (ICU) is, and will always remain, a high-intensity monitoring and treatment environment, in our article we explicated that more intensive monitoring and treatment is in many cases not associated with better outcome and may even do harm. We therefore do not agree with the authors’ suggestion that any reduction in vigilance, monitoring, and treatment intensity will lead to undesirable clinical outcomes because there is simply no evidence to support this. For instance, with regard to monitoring, a recent meta-analysis confirmed the results found in the observational study2 we initially referred to by showing that a restrictive chest radiograph policy is not associated with harmful effects.3 Furthermore, the authors point out that reduction of sedation levels might increase posttraumatic stress disorders (PTSDs). However, daily interruption of sedatives during the ICU stay was shown not to be associated with adverse long-term psychological outcomes.4 In fact, PTSDs were less likely to develop in intermittently sedated patients.4 We already discussed exceptions to the “less is more” rule in our article. For instance, as the authors correctly point out, high-intensity physician and nurse staffing is associated with better outcome. However, there even appears to be a limit to this because nighttime in-hospital intensivist staffing was recently shown not to improve patients outcomes.5 As such, reallocation of resources in the expensive ICU environment might be considered.


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March 1, 2014
Ata Mahmoodpoor, MD; Samad E. J. Golzari, MD
1Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
2Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
JAMA Intern Med. 2014;174(3):477. doi:10.1001/jamainternmed.2013.13686.
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