Elsevier

Journal of Critical Care

Volume 35, October 2016, Pages 206-212
Journal of Critical Care

Ethics/End of Life
A clinical prediction tool for hospital mortality in critically ill elderly patients,☆☆

https://doi.org/10.1016/j.jcrc.2016.05.026Get rights and content

Abstract

Background

Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive.

Objective

The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs.

Design

This was a prospective, multicenter cohort study.

Setting

Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed.

Interventions

A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool.

Main results

We included 1033 elderly patients in the analyses. Mean age was 84.6 ± 3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1 ± 7.9, Sequential Organ Failure Assessment score was 5.3 ± 3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; > 90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; > 300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (< 7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60]).

Conclusion

We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making.

Introduction

The eldest sector of the population is growing faster than all other age groups, both in Canada and around the world [1], [2]. In 1931, less than 60% of Canadian males and 62% of females survived to age 65 years, compared with 84% and 90% respectively, in 2001. The main causes of death in this demographic group were degenerative diseases and cancer [3]. Only 20% of these deaths occurred in Canadian intensive care units (ICUs) [4], [5]. Currently, patients older than 65 years account for half of ICU admissions and nearly 60% of all ICU days [6], [7], [8]. This large change in our demographics is straining our health care system, in general, and critical care services, specifically. There is conflicting evidence regarding the effect of age on ICU mortality [9], [10], [11], [12], [13], [14]. Meanwhile, it is known that elderly ICU patients can have very good survival [15], [16], [17], [18], [19].

Based on survey data from both Canada and abroad, most people would prefer to be cared for and to die in their own homes [5], [6], [7]. In addition, although 70% of elderly Canadian patients state a preference for comfort care over high-technology life-prolonging treatment in an inpatient setting, 54% are still admitted to ICUs [10], [11]. More concerning was the fact that 57% of these respondents stated that they would decline a subsequent life-sustaining ICU admission in the event of a recurrent critical illness [12]. A 2006 study by Heyland et al identified that elderly Canadians value quality, not quantity of life, and do not want technology-supported life-prolonging measures. Notwithstanding, intensivists in Canadian ICUs continue to provide mechanical ventilation and use life-prolonging technology in the elderly even when there is little chance of meaningful recovery. There is currently a significant disconnect between the wishes of the Canadian population and actual clinical practice. This discrepancy may disrespect patient autonomy and prolong the dying process at significant expense to the health care system.

Use of a clinical prediction tool can complement clinician judgment, enhance confidence in end-of-life decision making, optimize the alignment between goals of care and realistic clinical outcomes, and improve health care resource utilization. Our goal was to develop a clinical prediction tool using information available at the time of ICU referral. Our prediction tool for hospital mortality in critically ill elderly patients is derived from the largest prospective data set to date in this elderly population.

Section snippets

Design and setting

This is a secondary analysis of the Realities, Expectations and Attitudes to Life Support Technologies in Intensive Care for Octogenarians (REALISTIC-80) Study, clinicaltrials.gov NCT01293708, a multicenter (22 ICUs), prospective, observational cohort study conducted from September 2009 to February 2013. Waived consent was obtained from the Research Ethics Boards of all participating centers. All patients older than 80 years who were admitted to ICU were eligible.

Study population

We included a consecutive

Results

We included 1033 patients in this study. No patient was missed and no patients were lost while in the study hospitals. All patients admitted to participating study sites during the enrollment period were included (Fig. 1). Because of the ICU- and hospital-based nature of this study, there were no losses to follow-up.

We included 1033 elderly patients in the analyses. Mean age was 84.6 ± 3.5 years, 55% were male, mean APACHE II score was 23.1 ± 7.9, SOFA score was 5.3 ± 3.4, median ICU length of stay

Discussion

Among the critically ill elderly patients in this cohort, we observed a significant hospital mortality that increased proportionally to their Preliminary Risk Scale. We identified that a small number of predictors available at the time of ICU referral are strongly associated with hospital mortality: patient age, GCS, serum creatinine, and serum pH. Importantly, these risk factors do not require sophisticated testing, advanced imaging, or invasive procedures.

The Preliminary Risk Scale is very

Conclusions

We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making.

Acknowledgments

The authors wish to acknowledge the Canadian Institute of Health Research and Queen's University for their support of this project.

We would also like to acknowledge the Canadian Critical Care Trials Group and Dr Daren Heyland for their support and contributions.

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    The work for this manuscript was performed at Queen's University in Kingston, Ontario, Canada, and Western University in London, Ontario, Canada.

    ☆☆

    Financial support for this study was provided by a Canadian Institute of Health Research Grant (funding reference no. 93610) that was awarded to the Principal Investigator of the REALISTIC-80 Study, Dr Daren Heyland. The work was also supported by a Queen's University Research Initiation Grant awarded to Dr Ian Ball.

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