Variability of Intensive Care Admission Decisions for the Very Elderly

Abstract

Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.Trial RegistrationClinicalTrials.gov NCT00912600

The status of intensive care medicine research and a future agenda for very old patients in the ICU

“…Hospital mortality was 8.2% for the too well patients, 32.7% for those admitted to the ICU and 68.2% for those too sick. Interestingly, 6 months after referral, patients considered too well for ICU admission had a mortality rate (40.6%) approaching those admitted to the ICU (47.5%) [20]. A decision to admit an elderly patient to ICU with initial full code treatment (no restriction) does not preclude secondary decision to withdraw or withhold treatment.…”

“…The VOP cohort is probably the most vulnerable for functional decline. In a prospective cohort study in the ED, 2646 patients over 80 years old potentially qualified for ICU admission [20]. Among the 1230 patients who were alive 6 months after the ED visit, 1085 (88%) had their functional status evaluated.…”

“…Yet, there currently is no robust or validated clinical prediction tool that is able to reliably indicate the VOP who will substantially benefit from ICU care. Evidently, survival chances of VOPs are highly variable [6,20,44]. Substantially more data is required to be able to answer these questions if we want to improve the consistency and accuracy of admission decisions concerning VOPs.…”

Is this critically ill patient elderly or too old?

“…The ethical dilemma lies on the will to not admit old patients because they are believed to have a poor prognosis or perceived poor quality of life, thereby possibly refusing to admit those old patients for whom ICU care can make a difference. This conundrum is illustrated by the wide variation in admission rates of the very elderly seen between hospitals [4].…”

“Are you sure it’s about ‘age’?”

“…Several studies have confirmed the very poor long-term prognosis of elderly patients admitted to the ICU [2][3][4][5][6][7][8][9] (Table 1). Importantly, factors such as an atypical presentation with delayed diagnosis and treatment, suboptimal management (because guidelines are not tailored for an elderly population), lower physiologic reserve, immuno-senescence coupled with an inadequate immune response, more frequent and earlier treatment limitations, and finally inadequate discharge policies (location, timing) may account for or at least contribute to excess mortality.…”