title: Escalation of Commitment in the Surgical ICU.
abstract: OBJECTIVE
  Escalation of commitment is a business term that describes the continued investment of resources into a project even after there is objective evidence of the project's impending failure. Escalation of commitment may be a contributor to high healthcare costs associated with critically ill patients as it has been shown that, despite almost certain futility, most ICU costs are incurred in the last week of life. Our objective was to determine if escalation of commitment occurs in healthcare settings, specifically in the surgical ICU. We hypothesize that factors previously identified in business and organizational psychology literature including self-justification, accountability, sunk costs, and cognitive dissonance result in escalation of commitment behavior in the surgical ICU setting resulting in increased utilization of resources and cost.
  
  
  METHODS
  A descriptive case study that illustrates common ICU narratives in which escalation of commitment can occur. In addition, we describe factors that are thought to contribute to escalation of commitment behaviors.
  
  
  RESULTS
  Escalation of commitment behavior was observed with self-justification, accountability, and cognitive dissonance accounting for the majority of the behavior. Unlike in business decisions, sunk costs was not as evident. In addition, modulating factors such as personality, individual experience, culture, and gender were identified as contributors to escalation of commitment.
  
  
  CONCLUSIONS
  Escalation of commitment occurs in the surgical ICU, resulting in significant expenditure of resources despite a predicted and often known poor outcome. Recognition of this phenomenon may lead to actions aimed at more rational decision making and may contribute to lowering healthcare costs. Investigation of objective measures that can help aid decision making in the surgical ICU is warranted.
authors.affiliation: 1Department of Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Carla C
authors.initials: CC
authors.lastname: Braxton
authors.forename: Celia N
authors.initials: CN
authors.lastname: Robinson
authors.forename: Samir S
authors.initials: SS
authors.lastname: Awad
mesh_terms: D000368:Aged; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003073:Cognitive Dissonance; D003466:Cultural Characteristics; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000191:economics; D018447:Medical Futility; D010551:Personality; D010818:Practice Patterns, Physicians'; D012737:Sex Factors; D012941:Social Responsibility