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

Abstract

The benefit of ICU in older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU clinicians combined with objective patient data in real-life cases. Is there a difference in treatment limitation decisions and one-year outcomes in patients above and below 75 years, with and without concordant perceptions of excessive care by two or more ICU clinicians? Reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Clinicians (nurses, 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 endpoint (death, poor quality of life or not being at home) at one year across age groups via Cox-regression with propensity score weighing and Fisher-exact tests. Of 1641 patients, 405 (25%) were ≥75 years. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% versus 8.5%, p<0.001).In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (one-year mortality 83% in both groups, p=1, HR after weighing 1.11, 95%CI 0.74-1.65); treatment limitation decisions (33% versus 31%, HR after weighing 1.11, 95%CI 0.69-2.17) and reaching the combined endpoint at one year (90% versus 93%, p=0.546).In patients without concordant perceptions of excessive care, we found a difference in risk of death (one-year mortality 41% versus 30%, p<0.001, HR after weighting 1.38, 95%CI 1.11-1.73) and treatment limitation decisions (11% versus 5%, p<0.001; HR 2.11, 95%CI 1.37-3.27), though treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined endpoint was higher in the older (61.6% versus 52.8%, p<0.001). Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and one-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, pleading against ageism in ICU clinicians.