Abstract
BackgroundThe use of out-of-hospital emergency medical services by old and very old individuals is increasing. These patients frequently require complex evaluation and decision-making processes to determine a strategy of care, therapeutic choices or withdrawal of care in life-threatening situations. During out-of-hospital missions, thorough decision-making is difficult because of the limited amount of time and lack of direct access to medical charts or to pre-existing advance directives. In this setting, age may be used as a proxy to determine strategy of care, therapeutic choices or withdrawal of care, particularly in relation to advanced medical interventions. We aimed to determine how an emergency physician’s initiation of out-of-hospital advanced medical interventions varies with the patient’s age.MethodsWe performed a retrospective analysis of the missions conducted by the emergency physicians-staffed emergency medical services in a Swiss region. We used logistic regression analysis to determine whether the probability of receiving an advanced medical intervention was associated with the patient’s age.ResultsAmong 21,922 out-of-hospital emergency adult missions requiring an emergency physician, the probability of receiving an advanced medical intervention decreased with age. It was highest among those aged 18 – 58 years and significantly lower among those aged ≥ 89 years (OR = 0.66; 95 % CI: 0.53 – 0.82). The probability of cardiopulmonary resuscitation attempts progressively decreased with age and was significantly lower for the three oldest age deciles (80 – 83, 84 – 88 and ≥ 89 years).ConclusionThe number of out-of-hospital advanced medical interventions significantly decreased for patients aged ≥ 89 years. It is unknown whether this lower rate of interventions was related only to age or to other medical characteristics of these patients, such as the number or severity of comorbidities. Thus, further studies are needed to confirm whether this observation corresponds to underuse of advanced medical interventions in very old patients.
Highlights
The use of out-of-hospital emergency medical services by old and very old individuals is increasing
We evaluated whether the probability of receiving advanced medical interventions (ADMI) in a emergency physicians (EP)-staffed emergency medical services (EMS) varies with age in out-of-hospital emergency situations
The probability of a mission at home or in nursing homes increased progressively with advancing age, whereas trauma requiring an EP decreased with advancing age
Summary
The use of out-of-hospital emergency medical services by old and very old individuals is increasing. During out-of-hospital missions, thorough decision-making is difficult because of the limited amount of time and lack of direct access to medical charts or to pre-existing advance directives In this setting, age may be used as a proxy to determine strategy of care, therapeutic choices or withdrawal of care, in relation to advanced medical interventions. Studies have reported that the functional status of the survivors of an out-of-hospital cardiac arrest depended more on other factors, including comorbidities, a non-cardiac origin, or the presence of pre-existing dementia or functional dependency [7, 9] Most of these factors are associated with age, age did not appear to be an independent risk factor of poor prognosis [9]. Comorbidities, quality of life, and patients’ expectations were better predictors of outcome [10, 11]
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