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Editorial
May 10, 2019

Challenging the Pessimism in Providing Critical Care for Elderly Patients

Author Affiliations
  • 1Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 3Sunnybrook Research Institute, Sunnybrook Hospital, Toronto, Ontario, Canada
JAMA Netw Open. 2019;2(5):e193201. doi:10.1001/jamanetworkopen.2019.3201

The study by Atramont et al1 investigates the association of age with long-term mortality after discharge from an intensive care unit (ICU). This is a common question in the minds and on the tongues of clinicians in acute care hospitals around the world. Among patients admitted to hospitals and to the ICU, critically ill elderly patients have higher mortality and longer lengths of stay in the ICU prior to death compared with younger patients.2 Historically, there has been a perception that a disproportionate amount of health care spending is directed toward people in the last year of life.3,4 This establishes a framing for perceptions of outcomes of older patients. In most health care systems, there is a finite and limited capacity of intensive care services. The combination of having too few ICU-based resources to care for all critically ill patients and an identifiable segment of the population vying for these resources typically having worse outcomes could lead clinicians to consider the utility, or futility, of providing critical care to elderly patients.

Of late, there has been a welcome shift in the end-of-life care conversation from attempting to consume fewer resources toward attempting to increase the quality of end-of-life health care.5 Highlighting the importance of this approach, a 2006 study6 found that most elderly patients, when asked, preferred end-of-life care that reflects a focus on symptom and pain reduction as opposed to a technologically focused or aggressive course in the hospital and ICU. A fundamental challenge in attempting to improve care at the end of life is the inability to know prospectively when exactly the end of life is. Two population-based studies of elderly patients admitted to a hospital or the ICU found that a somewhat surprising proportion of elderly patients not only survived critical illness but were discharged from the hospital and to independent functioning.2,7

This is the context in which Atramont et al1 described 133 966 patients admitted to French ICUs, with in-hospital mortality at 19% and 3-year mortality at 40%. They found that the risk of death increased across all age strata after age 35 years, “but with a sharp increase in those 80 years and older,”1 after which the mortality risk among elderly patients was close to that of the age- and sex-matched general population. However, during the 3-year follow-up, compared with population age- and sex-matched controls, excess long-term mortality was actually highest among young surviving patients, not in elderly patients.

A first question in assessing any study might be whether the findings are internally valid. A strength of this study is the description of population-wide care and outcomes for approximately 76% of the French population with negligible loss to follow-up. Another is knowledge of patients’ severity of illness by the Simplified Acute Physiology Score II at admission and ability to risk adjust among critically ill patients and perform age- and sex-based standardization of mortality rates across the population. Limitations of this study might include those common to all observational studies—the potential for selection bias among those included in the cohort and for residual confounding of the associations described.

A second question might be whether the findings are externally valid, ie, whether they are sufficiently representative of non-French populations and hospitalization outcomes. Patients 80 years older accounted for 17% of the cohort, similar to many other studies.2 And yet, there may be both unmeasured and measured differences in this French ICU patient population that reflect unique differences in ICU bed capacity and in models of admission decision making. The authors highlight that a potential “selection bias herein of elderly patients with perceived good functional status might explain, at least in part, why ICU survivors have a postdischarge outcome close to that of the general population not admitted to the ICU.”1 As with most population-based health administrative data sets, we have limited knowledge of both preexisting frailty-focused functional status and specific health-related quality of life among survivors. It is not clear that survival and quality-of-life are directly proportionate among elderly ICU survivors.6-8

The integration of these findings for clinicians depends on a combination of prior experiences, beliefs, an optimistic or pessimistic perspective, and sense of appropriateness in generalizing population-based findings to individual patient decisions. On the one hand, a 3-year 40% mortality rate among patients admitted to the ICU seems high—especially from a US perspective, where the average severity of illness and mortality rates among patients admitted to the ICU is low in comparison with other countries. On the other hand, most patients admitted to the ICU, even elderly patients, do not die, and most elderly patients are alive after 3 years, with a standardized mortality rate that approaches that of the general population. Although many comorbid conditions are associated with greater relative risks of death, this study1 and others2,7 have been unable to derive even multiple combinations of common patient factors and in-hospital events that have sufficient predictive ability for death to apply findings to individual patients.

How might these results stimulate further investigation or changes in our approach to clinical care? We propose that this and other studies provide data to better inform our perceptions of outcomes of critical illness for elderly patients and the conversations we have with patients and families. However, these data should inform in broad strokes and not be taken as evidence that elderly patients cannot survive critical illness—in fact, most do. We should instead focus on promoting proactive goals-of-care discussions that help patients, families, and clinicians integrate this data with patient preferences. For elderly patients who receive critical care, the focus should be on ensuring that we continue to match care with preferences during the journey, update the goals, and focus on meeting their needs in the post-ICU and posthospital period, including discussions about whether they would want to go through the process again.

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Article Information

Published: May 10, 2019. doi:10.1001/jamanetworkopen.2019.3201

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Fowler RA et al. JAMA Network Open.

Corresponding Author: Robert A. Fowler, MDCM, MS(Epi), Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room D478, Toronto, ON M4N 3M5, Canada (rob.fowler@sunnybook.ca).

Conflict of Interest Disclosures: None reported.

References
1.
Atramont  A, Lindecker-Cournil  V, Rudant  J,  et al.  Association of age with short-term and long-term mortality among patients discharged from intensive care units in France.  JAMA Netw Open. 2019;2(5):e193215. doi:10.1001/jamanetworkopen.2019.3215Google Scholar
2.
Hill  AD, Fowler  RA, Burns  KE, Rose  L, Pinto  RL, Scales  DC.  Long-term outcomes and health care utilization following prolonged mechanical ventilation.  Ann Am Thorac Soc. 2016;14(3):355-362. doi:10.1513/AnnalsATS.201610-792OCGoogle ScholarCrossref
3.
Riley  GF, Lubitz  JD.  Long-term trends in Medicare payments in the last year of life.  Health Serv Res. 2010;45(2):565-576. doi:10.1111/j.1475-6773.2010.01082.xPubMedGoogle ScholarCrossref
4.
French  EB, McCauley  J, Aragon  M,  et al.  End-of-life medical spending in last twelve months of life is lower than previously reported.  Health Aff (Millwood). 2017;36(7):1211-1217. doi:10.1377/hlthaff.2017.0174PubMedGoogle ScholarCrossref
5.
Jha  A.  End-of-life care, not end-of-life spending. https://newsatjama.jama.com/2018/07/13/jama-forum-end-of-life-care-not-end-of-life-spending/. Accessed March 22, 2019.
6.
Heyland  DK, Dodek  P, Rocker  G,  et al; Canadian Researchers End-of-Life Network.  What matters most in end-of-life care: perceptions of seriously ill patients and their family members.  CMAJ. 2006;174(5):627-633. doi:10.1503/cmaj.050626PubMedGoogle ScholarCrossref
7.
Heyland  DK, Garland  A, Bagshaw  SM,  et al.  Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study.  Intensive Care Med. 2015;41(11):1911-1920. doi:10.1007/s00134-015-4028-2PubMedGoogle ScholarCrossref
8.
Andersen  FH, Flaatten  H, Klepstad  P, Romild  U, Kvåle  R.  Long-term survival and quality of life after intensive care for patients 80 years of age or older.  Ann Intensive Care. 2015;5(1):53. doi:10.1186/s13613-015-0053-0PubMedGoogle ScholarCrossref
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