Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome

Geriatric critical care

Demographic compulsions are inescapable. There has been a 50% increase in life expectancy at birth for persons born in 1980 compared to those born in 1900. Not only do critical care units utilize up to a third of hospital expenditures and about 1% of GNP, the critically ill elderly consume a disproportionate amount of ICU resources. Outcome prediction models for very elderly critically ill patients have been proposed with age as one of numerous model variables; but such models have not been widely validated. Despite the burgeoning emphasis on evidence-based population approach to health care, there is insufficient research to guide the critical care clinician. There remains a modicum of subjectivity in crucial decisions that affect the elderly patient receiving intensive care. Older age is also one of the factors that lead to a physician bias in refusing ICU admission; this has recently been borne out in a multivariate analysis. Physicians generally consider their older patients' quality of life to be worse than do the patients, although other studies that have assessed the quality of live show no age-related differences among ICU survivors. Furthermore, physicians' estimations of patient quality of life significantly influence physicians' attitudes to futility of care issues, in contrast to patients' perceptions. Threshold for life-sustaining treatment in the elderly will continue to be different among the ICUs. In critical care of the elderly, geography may well be destiny. Clinical decisions will be subjected to many ethical, legal, and socioeconomic pressures. Personal and religious beliefs will inevitably influence societal expectations and clinician practices. Severity of illness has the biggest influence on outcome in a critical illness. Age alone is not a predictor of short-term or long-term outcome in the older patient who is critically ill. Critical illness in the elderly remains a fertile area for future research.

End-of-life decisions during intensive care treatment

PURPOSE OF REVIEW

End-of-life decisions play an important role in the intensive care unit. This review discusses the most important studies on end-of-life decisions published from October 2001 to October 2002.

RECENT FINDINGS

Refusal of admission to the intensive care unit in itself is frequently an end-of-life decision. However, some patients survive rejection. The main end-of-life decisions during intensive care unit stay are withholding or withdrawal of therapy. Some patients have do-not-resuscitate orders on admittance to a unit. The effect of family participation and involvement of other caregivers in such decisions has been extensively studied. Such participation can lead to anxiety and depression in the family. A procedural guideline for decision making is of clinical interest. The background of physicians plays an important role. Terminal sedation and analgesia play an important role in execution of end-of-life decisions. During intensive care unit admission there is a continuous change in circumstances, which causes continuous differences in the wishes of the patients and relatives. The small contribution of the cost of the last days of life to total healthcare cost was reconfirmed.

SUMMARY

The new studies put emphasis on the facts that all care providers should participate in the decision and that communication with surrogates is of extreme importance. Many valid points from other medical fields also apply to the intensive care unit situation.