Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians

Goals of care discussions and treatment limitation decisions in European acute geriatric units: a one-day cross-sectional study

BACKGROUND

It is important to pursue goal-concordant care and to prevent non-beneficial interventions in older people.

AIM

To describe serious illness communication and decision-making practices in hospitalised older people in Europe.

SETTING/PARTICIPANTS

Data on advance directives, goals of care (GOC) discussions and treatment limitation decisions were collected about patients aged 75-years and older admitted to 23 European acute geriatric units (AGUs).

RESULTS

In this cohort of 590 older persons [59.5% aged 85 and above, 59.3% female, median premorbid Clinical Frailty Score (CFS) 6], a formal advance directive was recorded in 3.3% and a pre-hospital treatment limitation in 14.0% with significant differences between European regions (respectively P < 0.001 and P = 0.018).Most prevalent GOC was preservation of function (46.8%). GOC were discussed with patients in 64.0%, with families in 73.0%, within the interprofessional hospital team in 67.0% and with primary care in 13.4%. The GOC and the extent to which it was discussed differed between European regions (both P < 0.001). The prevalence of treatment limitation decisions was 53.7% with a large difference within and between countries (P < 0.001). The odds of having a treatment limitation decision were higher for patients with pre-hospital treatment limitation decisions (OR 39.1), residing in Western versus Southern Europe (OR 4.8), belonging to an older age category (OR 3.2), living with a higher number of severe comorbidities (OR 2.2) and higher premorbid CFS (OR 1.3).

CONCLUSIONS

There is large variability across European AGUs concerning GOC discussions and treatment limitation decisions. Sharing of information between primary and hospital care about patient preferences is noticeably deficient.

Perspectives on cardiopulmonary resuscitation in the frail population: a scoping review

Frail and elderly persons approaching end of life who suffer cardiac arrest are often subject to rigorous, undignified, and inappropriate resuscitation attempts despite poor outcomes. This scoping review aims to investigate how people feel about the appropriateness of CPR in this population. This review was guided by the PRISMA-ScR methodological framework. A search strategy was developed for four online databases (MEDLINE, EMCARE, PSYCHINFO, CINAHL). Two reviewers were utilised for title/abstract screening, full text review and data extraction. Full text, peer reviewed studies were eligible for inclusion which discussed perspectives in the frail and/or elderly population with a focus on cardiopulmonary resuscitation (CPR). The database search yielded 3693 references (MEDLINE n = 1417, EMCARE n = 1505, PSYCHINFO n = 13, CINAHL n = 758). Following removal of duplicates (n = 953), title and abstract screening was performed on 2740 papers. A total of 2634 articles did not meet the inclusion criteria. Twenty-five studies were included in the scoping review and analysed for data extraction. Five themes emerged: (i) Preferences towards CPR, (ii) Preferences against CPR, (iii) Poor knowledge of CPR/Estimated survival rates, (iv) Do Not Resuscitate Orders, and (v) Decisional authority. This scoping review maps and describes the common perspectives shared by CPR stakeholders in the frail/elderly population. Findings revealed CPR decisions are often made based on incorrect knowledge, DNAR orders are frequently underused, CPR decisional authority remains vague and healthcare professionals have mixed views on the appropriateness of CPR in this population.

EMPOWERING END-OF-LIFE CONVERSATIONS: The Role of Specialized Nursing Teams in Facilitating Code Status Changes at Discharge

Objectives: Hospitalized patients may require goals of care (GOC) or Advance Health Care Planning (ACP), which can be time-consuming and emotionally tolling for providers. A nursing team specializing in code status (CODE), GOC, and ACP was developed to provide meaningful support for patients and families and decrease provider burden. Interest in CODE, GOC, ACP, and effectiveness of a nursing team to lead these conversations prompted this study. Methods: A collaborative nursing team was trained to address CODE, GOC, and ACP with patients demonstrating illness or geriatric syndrome. This team conducted 3 visits per patient on average during hospitalization using structured CODE templates to establish longer term goals and document what matters in the healthcare journey. Comprehensive narratives for ACP and GOC were included in charting, syncing the medical team, nursing, patient, and family. Consults were tracked over nine months with data reviewed retrospectively from medical charts. Descriptive analyses of cohort demographics, CODE and outcomes were completed. Results: The study group comprised 3342 patients between October 2022 and June 2023. Patients ranged in age from 18-106 years, with majority (88%) age 65 years and older. Mean length of stay (LOS) was 6.8 days with CODE documented for 91% upon admission. Of the 3166 older adults with known CODE on admission, 946 (30%) changed CODE by discharge, of which 95% were de-escalated. 83% of older patients arriving with limited CODE maintained limitations at discharge, with a small portion converting to comfort (16%). Conclusion: Employing a focused nursing team to conduct CODE, GOC, and ACP conversations may be an effective use of time and resources and result in de-escalation of resuscitation orders for patients demonstrating illness or geriatric syndrome.

Development of a Predictive Model for Survival Over Time in Patients With Out-of-Hospital Cardiac Arrest Using Ensemble-Based Machine Learning

As of now, a model for predicting the survival of patients with out-of-hospital cardiac arrest has not been established. This study aimed to develop a model for identifying predictors of survival over time in patients with out-of-hospital cardiac arrest during their stay in the emergency department, using ensemble-based machine learning. A total of 26 013 patients from the Korean nationwide out-of-hospital cardiac arrest registry were enrolled between January 1 and December 31, 2019. Our model, comprising 38 variables, was developed using the Survival Quilts model to improve predictive performance. We found that changes in important variables of patients with out-of-hospital cardiac arrest were observed 10 minutes after arrival at the emergency department. The important score of the predictors showed that the influence of patient age decreased, moving from the highest rank to the fifth. In contrast, the significance of reperfusion attempts increased, moving from the fourth to the highest rank. Our research suggests that the ensemble-based machine learning model, particularly the Survival Quilts, offers a promising approach for predicting survival in patients with out-of-hospital cardiac arrest. The Survival Quilts model may potentially assist emergency department staff in making informed decisions quickly, reducing preventable deaths.

Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales

Background

During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment.

Methods

A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not.

Results

Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation.

Conclusion

During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.

Attitudes toward End-of-Life Resuscitation: A Psychometric Evaluation of a Novel Attitude Scale

AIM

With the advent of an aging society and the development of end-of-life care, there is an increasing need to understand the older generation's attitude toward end-of-life resuscitation. The study aimed to develop and validate a novel attitude scale toward end-of-life resuscitation in older inpatients.

METHOD

Instrumental development and a psychometric evaluation were used. First, a new attitude scale toward end-of-life resuscitation was formulated from literature views, expert content validity, and face validity. Next, the new scale was evaluated using a principal component analysis and internal consistency reliability in a sample from 106 medical-surgical inpatients in a southern Taiwan hospital 1 enrolled through convenience sampling. Serving as an indicator of concurrent validity, a logistic regression analysis was performed to analyze the association between scores on the scale and intention to discuss end-of-life CPR issues.

RESULTS

After being validated by the expert content validity and face validity, a draft of a 20-item scale was created. Throughout the exploratory factor analysis, two items with low factor loadings were removed from the draft scale and an 18-item scale of attitude was generated. This 18-item scale had a three-factor structure that accounted for 64.1% of the total variance; the three components were named 'stress, avoidance, and ignorance', 'a peaceful death', and 'self-determination and ambivalence'. The Cronbach's alpha of the total scale and three components were 0.845, 0.885, 0.879, and 0.857, respectively, which indicated a favorable reliability. Scores on the scale were significantly associated with the intention to discuss end-of-life CPR issues, which also indicated a favorable concurrent validity.

CONCLUSIONS

A 18-item attitude scale with three factors is a valid scale to measure the attitude toward end-of-life resuscitation. The result provides preliminary evidence of the psychometric properties of the scale. Further research with larger samples or other populations is required.

Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age?

BACKGROUND

The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases.

RESEARCH QUESTION

Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians?

STUDY DESIGN AND METHODS

This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests.

RESULTS

Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001).

INTERPRETATION

Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.

Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home

BACKGROUND

Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly.

METHOD

We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression.

RESULT

We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%).

CONCLUSION

Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.

Transferring nursing home residents to emergency departments by emergency physician-staffed emergency medical services: missed opportunities to avoid inappropriate care?

BACKGROUND

The decision to transfer a nursing home (NH) resident to an emergency department (ED) is multifactorial and challenging but many of the emergency physician-staffed emergency medical service (EP-EMS) interventions and ED transfers are probably inappropriate.

METHODS

We conducted a retrospective, cross-sectional study in three EP-EMSs in Belgium over a period of three years. We registered indicators that are potentially associated with inappropriate transfers: patient characteristics, availability of written do not resuscitate (DNR) orders or treatment restrictions, involvement of a general practitioner (GP) and availability of transfer notes. We also explored the association between age, the Charlson Comordity Index (CCI), polypharmacy, dementia, and the availability of DNR documents.

RESULTS

We registered 308 EP-EMS interventions in NH residents. In 98% the caller was a health-care professional. In 75% there was no GP present and 40% had no transfer note. Thirty-two percentage of the patients had dementia, 45% had more than two comorbidities and 68% took five medications or more. In 6% cardiopulmonary resuscitation was performed. DNR orders were available in 25%. Eighty-eight percentage of the NH residents were transferred to the ED. Forty-four percent had a CCI >5. In patients of ≥90 years, with a CCI >5, with dementia and with polypharmacy, DNR orders were not available in 81%, 67%%,and 69%, respectively.

CONCLUSIONS

Improved EMS dispatch centre-NH caller interaction, more involvement of GP's, higher availability of DNR orders and better communication between GPs/NHs and EP-EMS could prevent inappropriate interventions, futile prehospital aactions,and ED transfers.

Outcomes in adults living with frailty receiving cardiopulmonary resuscitation: A systematic review and meta-analysis

Background

Frailty is a clinical expression of adverse ageing which could be a valuable predictor of outcomes from cardiac arrest. The aim of this systematic review was to evaluate survival outcomes in adults living with frailty versus adults living without frailty receiving cardiopulmonary resuscitation (CPR) following cardiac arrest.

Methods

A comprehensive search of MEDLINE, EMBASE, CINAHL, and Web of Science databases was performed using pre-defined search terms, with no date or language restrictions applied. Prospective and retrospective observational studies measuring outcomes from CPR in adults assessed for frailty using an accepted clinical definition were selected.

Results

Eight eligible studies were included. Seven retrospective observational studies presenting high methodological quality were included in a meta-analysis comprising 1704 participants. Frailty was strongly associated with an increased likelihood of mortality after CPR, with moderate inter-study heterogeneity (OR = 3.56, 95% CI = 2.74–4.63, I² = 71%).

Discussion

This review supports the consideration of frailty status in a holistic approach to CPR. The present findings suggest that frailty status provides valuable prognostic information and could complement other known pre-arrest prognostic factors such as comorbidities in the context of Do Not Attempt CPR consideration. Awareness of the poorer outcomes in those living with frailty could support the identification of individuals less likely to benefit from CPR. Validation of our findings and evaluation of quality-of-life in frail individuals surviving cardiac arrest are prerequisites for the future integration of frailty status into CPR clinical decision-making.

Registration

Prospectively registered on PROSPERO: CRD42020223670.

Pre-arrest Prediction of Survival Following In-hospital Cardiac Arrest: A Systematic Review of Diagnostic Test Accuracy Studies

AIM

To evaluate the test accuracy of pre-arrest clinical decision tools for in-hospital cardiac arrest survival outcomes.

METHODS

We searched Medline, Embase, and Cochrane Library from inception through January 2022 for randomized and non-randomized studies. We used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We report sensitivity, specificity, positive predictive outcome, and negative predictive outcome for prediction of survival outcomes. PROSPERO CRD42021268005.

RESULTS

We searched 2517 studies and included 23 studies using 13 different scores: 12 studies investigating 8 different scores assessing survival outcomes and 11 studies using 5 different scores to predict neurological outcomes. All were historical cohorts/ case control designs including adults only. Test accuracy for each score varied greatly. Across the 12 studies investigating 8 different scores assessing survival to hospital discharge/ 30-day survival, the negative predictive values (NPVs) for the prediction of survival varied from 55.6% to 100%. The GO-FAR score was evaluated in 7 studies with NPVs for survival with cerebral performance category (CPC) 1 ranging from 95.0% to 99.2%. Two scores assessed survival with CPC ≤2 and these were not externally validated. Across all prediction scores, certainty of evidence was rated as very low.

CONCLUSIONS

We identified very low certainty evidence across 23 studies for 13 different pre-arrest prediction scores to outcome following IHCA. No score was sufficiently reliable to support its use in clinical practice. We identified no evidence for children.

Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients

BACKGROUND

The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.

METHODS

This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physicians' behaviour was compared to that predicted by the model taking into account the entire agency.

RESULTS

Age, location of event, bystander CPR and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.

CONCLUSIONS

Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review

Aim

This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest.

Methods

We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings.

Results

We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.

Conclusions

Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01004-6.

Moving and Handling Children After Death: An Inductive Thematic Analysis of the Factors That Influence Decision Making by Children's Hospice Staff

Hospices for children and adolescents in the United Kingdom provide care to the bodies of deceased children in specially designed chilled bedrooms called "cool rooms." In an effort to develop resources to support hospice practitioners to provide this specialist area of care, this study aimed to identify the factors that influence decision making when moving and handling children's bodies after death in a hospice cool bedroom. An internet-based survey was sent to all practitioners employed by 1 children's hospice. A total of 94.9% of eligible staff responded (n = 56). An inductive approach to thematic analysis was undertaken, using a 6-phase methodological framework. Three core themes were identified that inform practitioners' perception of the appropriateness of moving and handling decisions: care of the body, stages of care, and method of handling. The complexity of decision making and variation in practice was identified. Practitioners relied on both analytical and initiative decision making, with more experienced practitioners using an intuitive approach. Evidence-based policy and training influence the perception of appropriateness and the decisions and behavior of practitioners. The development of a policy and education framework would support practitioners in caring for children's bodies after death, standardizing expectations and measures of competence in relation to moving and handling tasks.

What are the care needs of families experiencing cardiac arrest?: A survivor and family led scoping review

AIM

The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, "What are the needs of families experiencing cardiac arrest?" from the moment of collapse until the outcome is known.

METHODS

This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information.

RESULTS

We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest.

CONCLUSION

Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.

Management and outcomes in critically ill nonagenarian versus octogenarian patients

Background

Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients.

Methods

We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians.

Results

The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90–1.74; p = 0.19)).

Conclusion

After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered– together with illness severity and pre-existing functional capacity - to effectively guide triage decisions.

Trial registration

NCT03134807 and NCT03370692.

Can primary palliative care education change life-sustaining treatment intensity of older adults at the end of life? A retrospective study

Background

Palliative care education has been carried out in some hospitals and palliative care has gradually developed in mainland China. However, the clinical research is sparse and whether primary palliative care education influence treatment intensity of dying older adults is still unknown. This study aims to explore the changes to the intensity of end-of-life care in hospitalized older adults before and after the implementation of primary palliative care education.

Methods

A retrospective study was conducted. Two hundred three decedents were included from Beijing Tongren Hospital’s department of geriatrics between January 1, 2014 to December 31, 2019. Patients were split into two cohorts with regards to the start of palliative care education. Patient demographics and clinical characteristics as well as analgesia use, medical resources use and provision of life-sustaining treatments were compared. We used a chi-square test to compare categorical variables, a t test to compare continuous variables with normal distributions and a Mann–Whitney U test for continuous variables with skewed distributions.

Results

Of the total participants in the study, 157(77.3%) patients were male. The median age was 88 (interquartile range; Q1-Q3 83–93) and the majority of patients (N = 172, 84.7%) aged 80 years or older. The top 3 causes of death were malignant solid tumor (N = 74, 36.5%), infectious disease (N = 74, 36.5%), and cardiovascular disease (N = 23, 11.3%). Approximately two thirds died of non-cancer diseases. There was no significant difference in age, gender, cause of death and functional status between the two groups (p > 0.05). After primary palliative care education, pain controlling drugs were used more (p < 0.05), fewer patients received electric defibrillation, bag mask ventilation and vasopressors (p < 0.05). There was no change in the length of hospitalization, intensive care admissions, polypharmacy, use of broad-spectrum antibiotics, blood infusions, albumin infusions, nasogastric/nasoenteric tubes, parenteral nutrition, renal replacement and mechanical ventilation (p > 0.05).

Conclusions

Primary palliative care education may promotes pain controlling drug use and DNR implementation. More efforts should be put on education about symptom assessment, prognostication, advance care planning, code status discussion in order to reduce acute medical care resource use and apply life-sustaining treatment appropriately.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Cardiac arrest in older adult patients

PURPOSE OF REVIEW

To describe the epidemiology, prognostication, and treatment of out- and in-hospital cardiac arrest (OHCA and IHCA) in elderly patients.

RECENT FINDINGS

Elderly patients undergoing cardiac arrest (CA) challenge the appropriateness of attempting cardiopulmonary resuscitation (CPR). Current literature suggests that factors traditionally associated with survival to hospital discharge and neurologically intact survival after CA cardiac arrest in general (e.g. presenting ryhthm, bystander CPR, targeted temperature management) may not be similarly favorable in elderly patients. Alternative factors meaningful for outcome in this special population include prearrest functional status, comorbidity load, the specific age subset within the elderly population, and CA location (i.e., nursing versus private home). Age should therefore not be a standalone criterion for withholding CPR. Attempts to perform CPR in an elderly patient should instead stem from a shared decision-making process.

SUMMARY

An appropriate CPR attempt is an attempt resulting in neurologically intact survival. Appropriate CPR in elderly patients requires better risk classification. Future research should therefore focus on the associations of specific within-elderly age subgroups, comorbidities, and functional status with neurologically intact survival. Reporting must be standardized to enable such evaluation.