Background/Objectives To assess symptoms in older (age ≥65 years) intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs. Design A prospective cohort study. Setting An urban tertiary-care hospital and community hospital. Participants One-hundred and twenty-five medical-ICU survivors of mechanical ventilation age ≥65 years. Measurements Baseline measurements of the Edmonton Symptom Assessment Scales (ESAS), categorized as mild (0–3), moderate (4–6), and severe (7–10), and the frailty phenotype were made during the week prior to hospital discharge. Functional recovery was defined as a return to a Katz Activities of Daily Living dependency count less than or equal to the pre-hospitalization dependency count within 3 months. In the last 29 participants, we made additional assessments of fatigue and ESAS at baseline and 1 month after discharge. Results Fatigue was the most prevalent moderate-to-severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1 month follow-up, there were no significant differences in the proportions of participants with moderate-to-severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with a 55% lower odds of functional recovery (OR 0.45, 95% CI 0.24–0.84), independent of age, sex, comorbidities, and critical illness severity. Compared to non-frail participants, frail participants had a higher median (IQR) baseline total ESAS symptom distress score (13 [9–22] versus 34 [23–44], p <0.001). Conclusions Older ICU survivors have a high burden of palliative care needs that persist at 1 month after discharge. Fatigue is the most prevalent symptom and may interfere with recovery. Post-ICU frailty may be both a useful palliative care consultation trigger and treatment target.

The DASI improves the construct and predictive validity of frailty assessment in adults with advanced lung disease or recent critical illness. This simple questionnaire should replace the more complex MLTA in assessing the frailty phenotype in these populations.

Objective To determine whether minority race or ethnicity are associated with mortality and mediated by health insurance coverage among older (age ≥65 years) survivors of critical illness. Design A retrospective cohort study. Setting Two New York City academic medical centers. Patients A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge. Interventions None. Measurements and Main Results We obtained demographic, insurance, and clinical data from electronic health records, determined each patient’s neighborhood-level socioeconomic data from 2010 US Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 (8.6) years and median (IQR) follow-up time of 1.6 (0.4–3.0) years. Blacks and Hispanics had similar mortality rates compared to whites (adjusted-hazard ratio [HR] 0.92, 95% CI 0.76–1.11 and adjusted-HR 0.92, 95% CI 0.76–1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted-HR 1.43, 95% CI 1.03–1.98) and Medicaid (adjusted-HR 1.30, 95% CI 1.10–1.52). Medicaid recipients who were the oldest ICU survivors (age >82 years), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction 0.08, 0.03, and 0.17, respectively). Conclusions Mortality after critical illness among older adults varies by insurance coverage, but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance.

Background: Moral distress is a reason for burnout in healthcare professionals, but the clinical settings in which moral distress is most often experienced by medical students, and whether moral distress is associated with burnout and career choices in medical students is unknown. We assessed moral distress in medical students while caring for older patients, and examined associations with burnout and interest in geriatrics. Methods: A cross-sectional survey study of second-, third-, and fourth-year medical students at an American medical school. The survey described 12 potentially morally distressing clinical scenarios involving older adult patients. Students reported if they encountered each scenario, and whether they experienced moral distress, graded on a 1-10 scale. We conducted a principal axis factor analysis to assess the dimensionality of the survey scenarios. A composite moral distress score was calculated as the sum of moral distress scores across all 12 scenarios. Burnout was assessed using the Maslach Abbreviated Burnout Inventory, and interest in geriatrics was rated on a 7-point Likert scale. Results: Two-hundred and nine students responded (47%), of whom 90% (188/209) reported moral distress in response to ≥1 scenario with a median (IQR) score of 6 (4-7). Factor analysis suggested a unidimensional factor structure of the 12 survey questions that reliably measured individual distress (Cronbach alpha = 0.78). Those in the highest tertile of composite moral distress scores were more likely to be burnt out (51%) than those in the middle tertile of scores (34%), or lowest tertile of scores (31%) (p = 0.02). There was a trend towards greater interest in geriatrics among those in the higher tertiles of composite moral distress scores (16% lowest tertile, 20% middle tertile, 25% highest tertile, p-for-tend = 0.21). Respondents suggested that moral distress might be mitigated with didactic sessions in inpatient geriatric care, and debriefing sessions with peers and faculty on the inpatient clerkships on medicine, neurology, and surgery, where students most often reported experiencing moral distress. Conclusions: Moral distress is highly prevalent among medical students while caring for older patients, and associated with burnout. Incorporating geriatrics education and debriefing sessions into inpatient clerkships could alleviate medical student moral distress and burnout.