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[ICU Management & Practice]: 老年患者重症医疗中的悲观论调
2019年07月18日 时讯速递, 进展交流 暂无评论

Pessimism in providing critical care for elderly patients

recent study conducted in France investigated the association of age with long-term mortality after discharge from the ICU. Another subset of this discussion relates to the critically ill elderly patients who have higher mortality compared to younger patients as well as longer lengths of stay in the ICU prior to death. 

There has been a great deal of discussion on how a disproportionate amount of healthcare spending is directed towards such patients in the last years of their life. Since the healthcare system has finite and limited capacity, and too few ICU-based resources to care for all critically ill patients, the fact that there is a certain patient segment that typically has worse outcomes despite care could lead healthcare providers to consider the futility of providing care to elderly patients. 

However, the question should not be whether healthcare resources should be invested in elderly patients who will eventually die. The question should be as to how the end-of-life care for these patients can be improved and how the quality of life during their last few years can be improved. 
A study conducted in 2006 found that elderly patients wanted end-of-life care that focused on symptom and pain reduction as opposed to a technologically focused or aggressive course of treatment in the ICU. Also, the assumption that all elderly patients will die in the ICU is not exactly accurate. Two population-based studies of elderly patients showed a surprising proportion of elderly patients who not only survived critical illness but were also discharged from the hospital and were able to resume independent functioning. 

Maybe it's time to change our thinking and switch from a pessimistic perspective related to the survival rate of elderly patients to an optimistic perspective where the goal should be to increase the quality of life for these patients rather than wait for them to die. Despite the perception, most patients admitted to the ICU, including elderly patients, do not die. In fact, most elderly patients are still alive after 3 years, and while they may have comorbid conditions and a greater risk of death, compared to others, they are still patients who are alive and who deserve high-quality care and attention. 

It is time to change our perceptions of outcomes of critical illness when it comes to elderly patients. We should not assume that elderly patients will not survive critical illness, because many of them do. Our focus should be on ensuring that we are able to provide care that matches their preferences; that we are able to meet their needs in the post-ICU and post-hospital period; and that we are able to have valid and relevant conversations with these patients and their families regarding their goals-of-care. 

Source: JAMAImage Credit: iStock

References:

Fowler, RA et al. (2019) Challenging the Pessimism in Providing Critical Care for Elderly Patients. JAMA, 2(5):e193201

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