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The Very Elderly Admitted to ICU: A Quality Finish?*

Heyland, Daren MD, MSc1; Cook, Deborah MD, MSc2,3; Bagshaw, Sean M. MD4; Garland, Allan MD5,6; Stelfox, Henry T. MD, PhD7,8; Mehta, Sangeeta MD9; Dodek, Peter MD, MHSc10; Kutsogiannis, Jim MD4; Burns, Karen MD, MSc11; Muscedere, John MD12; Turgeon, Alexis F. MD13; Fowler, Rob MDCM14; Jiang, Xuran MSc1; Day, Andrew G. MSc1

doi: 10.1097/CCM.0000000000001024
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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.

1Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.

2Department of Medicine, McMaster University, Hamilton, ON, Canada.

3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.

4Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.

5Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.

6Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

7Department of Critical Care Medicine, Institute for Public Health, University of Calgary, Calgary, AB, Canada.

8Alberta Health Services—Calgary Zone, Calgary, AB, Canada.

9Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.

10Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada.

11Interdepartmental Division of Critical Care, St Michael’s Hospital, University of Toronto, Toronto, ON, Canada.

12Department of Critical Care Medicine, Queens University, Kingston, ON, Canada.

13Department of Anesthesiology and Critical Care Medicine and Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Center, Université Laval, Québec City, QC, Canada.

14Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada.

* See also p. 1526 and 1527.

ClinicalTrials.gov number: NCT01293708.

All authors contributed to the conception and design of the study and to the drafting of the article. Ms. Jiang and Mr. Day were responsible for the analysis. All authors contributed to the analysis and interpretation of data, revised the article for important intellectual content, gave final approval of the version to be published, and agree to act as guarantor of the work.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

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Supported, in part, by Canadian Institutes for Health Research.

Dr. Heyland’s institution received grant support from the Canadian Institutes of Health Research. Dr. Bagshaw served as a board member, consulted, and lectured for Baxter Healthcare. His institution received grant support from Baxter Healthcare. Dr. Dodek’s institution received grant support from the Canadian Institutes of Health Research. Dr. Kutsogiannis’ institution received grant support from the Canadian Institutes of Health Research. Dr. Burns holds a CIHR Clinician Scientist – Phase 2 Award and a Ministry of Research and Innovation Early Researcher Award. Dr. Burns’ institution received grant support (per patient recruitment) from the Canadian Institutes of Health Research. Dr. Muscedere’s institution received grant support from the Canadian Institutes of Health Research (peer reviewed funding). Dr. Turgeon received grant support from the Canadian Institutes of Health Research (operating grant). Mr. Day’s institution received support for article writing/review and support for article preparation from Kingston General Hospital (some of Mr. Day’s time is cost recovered by his institution). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: dkh2@queensu.ca

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