242 Time-Limited Trial of Treatment: A Time-to-Death Analysis Among Older Adults Receiving Emergency Department Intubation

Abstract

Approximately 70% of older adults report that they prioritize quality of life over longevity. Yet an increasing number of older adults who develop critical illness are being treated with high-intensity medical interventions, including emergency department (ED) intubation. In-hospital mortality among elderly, non-surgical patients receiving invasive mechanical ventilation is estimated to be 35-40%; however, predicting which patients are likely to benefit from ED intubation is limited by a paucity of literature. In the face of such uncertainty, emergency physicians may propose a “time-limited trial” (TLT) of treatment when initiating ED intubation. The objective of this study is to characterize hospital outcomes and time to death (TTD) among adults age greater than age 65 who received ED intubation. This information will enhance clinical decisionmaking regarding the length and scope of TLTs. We used the Vizient Clinical Database™ to analyze all hospitalizations of adults age >65 years who underwent non-traumatic ED intubation from 2008-2015 at 262 U.S. academic, non-profit hospitals. ED intubation was determined by procedure code. Patients with a principal diagnosis of trauma and out-of-hospital intubation were excluded. Demographic and clinical data were abstracted and analyzed. The primary outcome was likelihood of death per day. The secondary outcome was likelihood of death per day by principal hospital diagnosis using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS, formerly CCHPR). We identified 41,463 patients 65 years or older who underwent non-traumatic ED intubation. 6,427 patients were excluded based on missing variables. 54% of patients were female, 64% were white, and 54% were greater than 74 years old. Overall hospital mortality was 33% (95% confidence interval (CI) 34–35%). Among non-survivors, median time-to-death was 3 days (IQ 1-8). The likelihood of death was highest on day 1. Patients with infectious and cerebrovascular diagnosis had the shortest TTD, as did patients older than 85 years. For older adults the decision to intubate in the ED is often fraught with uncertainty. In a large cohort of older adults undergoing ED intubation, we found that the mortality rate was high and the time from intubation to death was brief, particularly among patients greater than 85 years old, and those with respiratory failure or septicemia. Improved understanding of prognosis after ED intubation may help ED and ICU clinicians structure TLTs of aggressive care and provide families with more accurate anticipatory guidance.