The Very Elderly Admitted to ICU: A Quality Finish?

Daren Heyland, MD, MSc; Deborah Cook, MD, MSc; Sean M. Bagshaw, MD; Allan Garland, MD; Henry T. Stelfox, MD, PhD; Sangeeta Mehta, MD; Peter Dodek, MD, MHSc; Jim Kutsogiannis, MD; Karen Burns, MD, MSc; John Muscedere, MD; Alexis F. Turgeon, MD; Rob Fowler, MDCM; Xuran Jiang, MSc; Andrew G. Day, MSc

Disclosures

Crit Care Med. 2015;43(7):1352-1360. 

In This Article

Abstract and Introduction

Abstract

Objective: Very elderly persons admitted to ICUs are at high risk of death. To document life-sustaining interventions (mechanical ventilation, vasopressors, renal replacement therapy) provided in the ICU and outcomes of care.

Design: Multicenter, prospective cohort study.

Setting: ICUs of 24 Canadian hospitals.

Participants/Setting: Patients 80 years old or older admitted to the ICU.

Interventions: None.

Measurements and Main Results: One thousand six hundred seventy-one patients were included. The average age of the cohort was 85 years (range, 80–100 yr). Median total length of stay in ICU was 4 days (interquartile range, 2–8 d) and in hospital was 17 days (interquartile range, 8–33 d). Of all patients included, 502 (30%) stayed in ICU for 7 days or more and 344 (21%) received some form of life-sustaining treatment for at least 7 days. ICU and hospital mortality were 22% and 35%, respectively. For nonsurvivors, the median time from ICU admission to death was 10 days (interquartile range, 3–20 d). Of those who died (n = 5 85), 289 (49%) died while receiving mechanical ventilation, vasopressors, or dialysis. The presence of frailty or advance directives had little impact on limiting use of life-sustaining treatments or shortening the time from admission to death.

Conclusions: In this multicenter study, one third of very elderly ICU patients died in hospital, many after a prolonged ICU stay while continuing to receive aggressive life-sustaining interventions. These findings raise questions about the use of critical care at the end of life for the very elderly.

Introduction

At or near the end of life (EOL), most seriously ill, hospitalized, elderly patients prefer to avoid unnecessary prolongation of life by life-sustaining therapy.[1] In addition, many very elderly persons are reluctant to accept any use of life-sustaining therapy, such as that provided in an ICU, because preserving quality of life is more important to them than prolonging their survival.[2,3] Despite often being able to express their preferences, more than 70% of seriously ill hospitalized elderly patients do not discuss these preferences with their healthcare providers. As a result, medical orders for life-sustaining therapy are incongruent with their previously stated preferences 70% of the time.[3] Furthermore, life-sustaining therapy is often provided to patients during their final months of life, even when these patients prefer care that is focused on comfort and quality of life.[4–7] This kind of discordant care, or care that is inconsistent with patient preferences, may be considered a misallocation of healthcare resources.[8]

Recent reports of critical illness among the very elderly suggest that ICU admission may fail to improve, or even worsen survival and quality of life for these patients.[9,10] This questionable evidence of benefit, coupled with the preferences of many elderly patients for less technologically intense care at the EOL raises questions about the appropriateness of admission to an ICU for this population. Describing current ICU practices and outcomes is foundational before trying to improve the quality of communication and decision-making with respect to the use of life-sustaining treatments for critically ill elders. Therefore, our primary objective was to describe the treatments and outcomes of care of patients 80 years old or older who were admitted to 22 participating ICUs in Canada; our secondary objective was to describe the treatments and outcomes of those patients who have a prolonged dying experience.

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