Jan 082012

Many argue that as a limited resource serving unlimited needs, medical care is "rationed" by definition, and ICU resources (being more limited and expensive) are simply more overtly rationed. For example, in France, ICU admission is often denied to the very elderly critically ill, explicitly because of their age (this happens in the U.K., too, probably). In the U.S., where there are seven times as many ICU beds per capita as elsewhere, if there's an ICU bed, there's (anecdotally) no barrier to an octogenarian getting it. (Of course we ration in the U.S. too, but we do it the American way.)

Call it "age-ism" or what you like, but this European bias is arguably based on a utilitarianist higher valuation of the care provided to younger patients (not a higher value on their lives, mind you) as compared to the care provided to the very elderly. I suggest that's based on two prevalent beliefs:

  • Care provided to younger patients is more effective and more likely to be successful, because of their resiliency and ability to recover.
  • If care is successful and the patient recovers, a young person gains more years of life to live than an elderly person.

But are these beliefs based in truth? Although we all "know" intuitively that critically ill old people don't do well, there's surprisingly scant data to support it. There are lots of (useless) single-center series, but to my knowledge the only robust data comes from Amber Barnato of Pittsburgh. She showed (using a Medicare database) that among the elderly (~76 years old) undergoing mechanical ventilation, 72% die within one year, and another 12% are disabled (needing help with at least one activity of daily living). This was a U.S.-wide population sample of all the Americans on Medicare who ended up on a ventilator. Those are grim odds, but you could point out that 1 in 6 elderly alive without disability after one year is still a lot of people, and that many of those considered "disabled" may be quite happy with life (maybe even moreso after surviving an ICU stay). And if you happen to be that 1 in 6 destined for recovery, you undoubtedly want your doctor to be feeling optimistic and "aggressive" about your care as you enter respiratory failure.

Jose G. M. Hofhuis, Peter Spronk et al find that same taut tension of optimism and realism in their prospective observational case series in December's CHEST. They followed 129 people 80+ years old and 620 people <80 years old in the Netherlands, admitted to an ICU for >48 hours. The elderly patients were ~83 and had median APACHE II scores of 18, median ventilator days 3.

Their interest and primary outcome was health-related quality of life (the SF-36 questionnaire) before and after ICU admission. Their main conclusion and the "angle" they want us to see was that HRQOL recovered to pre-ICU baseline by 6 months, and in fact were close to age-matched controls. That's an interesting finding. "Denying admission to the ICU should not just rely on old age," they argue, and I wholeheartedly agree.

What Hofhuis et al don't delve into are the downer data from their tables: 49 of 129 octogenarians survived to be analyzed at 6 months (62% mortality rate). The ~67 year old cohort did better, although still poorly, with a 43% mortality at 6 months.

A small study from Spain we reviewed earlier this year had a similar story: the elderly who survived the ICU (about half) had fairly good quality of life.

I argue that the likely selection bias here makes these (relatively) optimistic findings inapplicable our practice in the U.S. Due to European age-ist rationing of ICU beds, there was a likely bias toward admitting healthier elderly patients to the ICU; authors acknowledge this possibility. This is supported by the fact that 80-year-olds' HRQOL was close to age-matched controls, suggesting the patients were relatively healthy pre-ICU (or subjectively inflated their HRQOL scores post-ICU).

Clinical Takeaway: In this small, single-center Dutch study, barely a third of octogenarians survived 6 months after critical illness, despite a likely bias granting ICU admission preferentially to those with the best chance for survival. Among survivors of this selected group, most reported a return to premorbid functioning and quality of life. These findings contradict more pessimistic results in a larger, multi-center U.S. sample, likely reflecting differences in practice between nations and systems. Authors are surely correct that "denying admission to the ICU should not just rely on old age," but this advice may have more relevance in Europe. In the U.S., where the elderly are commonly admitted to ICUs without regard for age, counseling of critically ill elderly patients and families realistically on the potential for poor outcomes is probably not done often enough, and is the essential co-ingredient of a cautious optimism.

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Elderly critically ill who survive ICU rationing live well (CHEST)