Can the Intensive Care Unit Be Harmful?-Reply

In Reply.— Using clinical trials to evaluate ICU use would be one good way to improve our use of these units. In my opinion, the best way to reach Dr Spodick's objective of identifying patients for whom ICU care is harmful would be to select patients from diagnostic groups that we already know contain a substantial number of patients who may not benefit from intensive care.1,2This would make it possible to use random allocation rather than an expert panel to select which patients to admit to the unit. Another way to investigate the value both of ICU care and of the many invasive aspects of its use is to scrutinize the natural differences in use that occur among hospitals. For example, within our current research effort in 15 tertiary-care ICUs, we find substantial variation in admitting practices and the use of pulmonary artery catheters. Whether we use classical