Abstract
IntroductionThe proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset.MethodsThis was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score.ResultsThe median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates.ConclusionsOlder critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.
Highlights
The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising
Patients aged 70 to 79 years old had the shortest median time from acute lung injury (ALI) onset to a limitation in life support, and patients ≥80 years old were most likely to have a limitation in life support before ICU discharge or cardiac arrest (Table 2)
Older age was not significantly associated with the rate of ICU discharge (RH, 1.04; confidence interval (CI), 0.94 to 1.15) or cardiac arrest (RH, 0.86; CI, 0.70 to 1.05). In this multisite, prospective cohort study of 490 patients with acute lung injury, each 10-year increase in patient age was associated with a 24% increase in the rate of new limitations in life support, after accounting for differences in baseline status, ICU severity of illness, daily organ dysfunction, and the competing risks of ICU discharge and cardiac arrest
Summary
The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset. The proportion of older Americans utilizing intensive care in the last month of life has steadily increased over the past two decades [1,2]. In 2003, Cook and colleagues examined predictors of withdrawing ventilator support using longitudinal data and found no association with age after controlling for physician predictions about both short-term and long-term patient outcomes [8] To further investigate this question, we analyzed a prospective cohort of critically ill patients with acute lung injury (ALI), which includes longitudinal data on daily organ dysfunction status throughout their ICU stay. We hypothesized that organ dysfunction during hospitalization is likely to impact decisions to limit life support, patient age is directly associated with the rate of new limitations independent of organ dysfunction
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