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22-09-2023 | Tracheostomy | Original

Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study

Authors: Karen E. A. Burns, Deborah J. Cook, Keying Xu, Peter Dodek, Jesús Villar, Andrew Jones, Farhad N. Kapadia, David J. Gattas, Scott K. Epstein, Paolo Pelosi, Kallirroi Kefala, Maureen O. Meade, Leena Rizvi, on behalf of the Canadian Critical Care Trials Group

Published in: Intensive Care Medicine | Issue 10/2023

Abstract

Purpose

The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65–80 years) and very elderly (> 80 years) intensive care unit (ICU) patients.

Methods

We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States).

Results

We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2–8) vs. 7 (4–13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission.

Conclusions

Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.

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Title: Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study
Authors: Karen E. A. Burns
Deborah J. Cook
Keying Xu
Peter Dodek
Jesús Villar
Andrew Jones
Farhad N. Kapadia
David J. Gattas
Scott K. Epstein
Paolo Pelosi
Kallirroi Kefala
Maureen O. Meade
Leena Rizvi
on behalf of the Canadian Critical Care Trials Group
Publication date: 22-09-2023
Publisher: Springer Berlin Heidelberg
Keywords: Tracheostomy
Cardiopulmonary Resuscitation
Care
Published in: Intensive Care Medicine / Issue 10/2023
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-023-07188-4

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Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study

Abstract

Purpose

Methods

Results

Conclusions

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Abstract

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