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Abstract

Introduction: Shortage of ICU beds, increased life expectancy, and future reduction of resources allocated to health care will soon lead to an increasing need to ration beds and expenses in the intensive care unit (ICU). Methods: The electronic medical record and order sets for mechanical ventilation (MV) were used to identify all newly mechanically ventilated patients on the GMF. Demographic and clinical data included age, gender, race, living arrangements, Charlson-comorbidity index (CCI), Karnofsky performance status scale (KPSS), diagnosis on admission, APACHE II score, clinical evaluations, days on MV, and palliative care intervention. Outcomes included all cause mortality, rate of self-extubation, weaning trials and successful extubation, tracheostomies, and hospital length of stay (LOS). Results: Over a 7-month period 68 patients met inclusion criteria. Patients were mostly male (56%), Caucasian (47.1%), elderly (80+/-16years), admitted from a nursing home (68%), with high CCI (8.1+/-2.5) and low functional status (KPSS 10–30% in 86% of patients). Patients were intubated 4+/-6.6 days after admission; the APACHE II score at the time was 23+/-10 and the most common admitting diagnosis was severe sepsis (72%). The ICU team evaluated 79% of patients and frequent reasons for non-admission were poor functional status (47%) and irreversible disease processes (25%). The average duration of days on MV was 11+/-11.7 days and hospital LOS was 19+/-14.4 days. 35 patients had weaning trials, but only 5 patients were successfully extubated; 8 patients underwent tracheostomies. Self-extubation occurred in 9 patients and decision for comfort measures was made in 5 of them. Palliative care evaluated 50% percent of patients; overall, 43% of patients were transitioned to comfort care and 72% of patients were made DNR. The majority of patients (60%) died during hospital stay, 31% were transferred to chronic ventilator centers and 1.5% were transferred to hospice. Conclusions: In our institution patients with multiple co-morbidities, poor functional status, and with an irreversible disease process, are managed on the GMF after MV. Early intervention by the palliative care team helps with transition to comfort measures and discussions of advance directives in the majority of these patients. Admitting these patients to the ICU is unlikely to change outcomes or improve quality of life, and will increase health care costs. Larger multi-center trials to evaluate these results are urgently needed as the health care system continues to use costly and aggressive measures for a terminally ill population in times of financial crisis.