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Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

Authors:
  • French Institute of Health and Medical Research U1136

Abstract

Purpose: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU. Methods: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up. Results: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries. Conclusions: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country. Trial registration: ClinicalTrials.gov (ID: NTC03134807).
Intensive Care Med
https://doi.org/10.1007/s00134-018-5196-7
ORIGINAL
Withholding or withdrawing
of life-sustaining therapy in older adults
( 80 years) admitted to the intensive care unit
Bertrand Guidet1,2* , Hans Flaatten3,4, Ariane Boumendil1*, Alessandro Morandi5,6, Finn H. Andersen7,8,
Antonio Artigas9, Guido Bertolini10, Maurizio Cecconi11, Steffen Christensen12, Loredana Faraldi13,
Jesper Fjølner12, Christian Jung14, Brian Marsh15, Rui Moreno16, Sandra Oeyen17, Christina Agwald Öhman18,
Bernardo Bollen Pinto19, Ivo W. Soliman20, Wojciech Szczeklik21, Andreas Valentin22, Ximena Watson11,
Tilemachos Zafeiridis23 and Dylan W. De Lange20 on behalf of The VIP1 study group.
© 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
Abstract
Purpose: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a popula-
tion of very old patients admitted to the ICU.
Methods: This prospective study included intensive care patients aged 80 years in 309 ICUs from 21 European
countries with 30-day mortality follow-up.
Results: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a
withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older,
more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more fre-
quently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in
the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and
southern European countries than in northern Europe. The patient-independent factors associated with LST limita-
tion were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42),
increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95%
CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in
religious countries.
Conclusions: The most important patient variables associated with the instigation of LST limitation were acute
admission, frailty, age, admission SOFA score and country.
Trial registration: ClinicalTrials.gov (ID: NTC03134807).
Keywords: Elderly, Intensive care, Ethics, Life sustaining treatment, Withholding, Withdrawal
*Correspondence: bertrand.guidet@aphp.fr;
ariane.boumendil@gmail.com
1 Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation
médicale, 184 rue du Faubourg Saint Antoine, 75012 Paris, France
Full author information is available at the end of the article
The VIP-LST collaborators are listed in the Acknowledgements and in the
Electronic Supplementary Material.
Introduction
Life expectancy in many countries is steadily increasing.
As a result, patients admitted to hospital and ultimately
to the ICU will be older. At present, > 10% of the patients
admitted to the ICU are 80years old [1]. e propor-
tion of older adults is estimated to increase to 30% by
2050, with a huge impact on total hospital expenditures
[2]. As a consequence, many ICUs across the globe must
adapt their policies to these increased demands. Some
estimate that the need for ICU beds will increase by 50%
owing to these developments [3]. However, once an older
adult has been admitted to the ICU for an acute medical
reason, his/her risk of dying within 30days is high. For
frail patients the 30-day mortality is 40.7% [4].
As a result, ICU physicians are increasingly faced with
difficult decisions on continuation of life sustaining treat-
ment (LST) in older adults. In these situations, decisions
are being made to withhold LST if patients deteriorate or
even to withdraw already instigated LST if the short-term
prognosis is poor. Differences in ethics, religion, culture
and predictive capacity add to the difficulty of formu-
lating a consistent approach to treatment limitation in
critical illness. Previous publications have highlighted the
huge variation in admission policies for older adults in
Europe [1, 5, 6]. At present, there is a strong consensus
that age should not be considered as a sole decision-mak-
ing criterion [79]. Older adults (like any other patients)
should be admitted to the ICU only with a predefined,
reasonable goal of care. Finally, considering their inherent
frailty, all older adults should undergo systematic reas-
sessment a few days after ICU admission to evaluate the
appropriateness of their level of care. is concept of an
“ICU trial” is attractive and has been proposed for cancer
patients requiring mechanical ventilation [11]. However,
this should be well organised, explicit, and shared with
all ICU staff and the patients’ relatives. In most cases,
important information is lacking when deciding to admit
an older patient in ICU: no living will, incomplete infor-
mation, and no clarity concerning life expectancy.
Differences in admission policies and health care sys-
tems, together with insufficient information from the
patients or their relatives (i.e. advanced directives), result
in huge variability in end-of-life (EOL) care in the ICU
[12]. In addition, there is considerable variation in the
proportion of deaths that occur after a decision to limit
life support and this cannot be explained solely by patient
characteristics [13, 14] or patients’ preferences [15]. In
the present study we aim to examine the incidence and
determinants of LST limitation decisions (withholding
and withdrawal) in patients older than 80years admitted
to ICUs in European countries.
Methods
Study design and setting
e methods and patients have been described in a pre-
vious publication [4]. Briefly, VIP1 is a prospective Euro-
pean multicentre study. Each participating ICU could
choose to include either consecutive patients through-
out a 3-month period or the first 20 consecutive patients
within this period. Individual ICUs started data collec-
tion between October 2016 and February 2017, depend-
ing on the speed of local ethics committee approval. A
website was set up to facilitate sharing of information
about the study and to allow data entry using an elec-
tronic case report form (CRF). e study was registered
on ClinicalTrials.gov (ID: NTC03134807).
Participants
All patients aged 80years or older admitted to the par-
ticipating ICUs were eligible. Patients were followed until
death or for 30days after ICU admission.
Variables
e study collected a consistent set of data: age, gender,
reason for ICU admission from a predefined list of 12
categories, length of stay (LOS) prior to ICU admission,
Clinical Frailty Scale (CFS) score [16], admission SOFA
score [17], any period of non-invasive or invasive ven-
tilation with endotracheal intubation or tracheostomy
during the ICU stay, use of vasoactive drugs, and renal
replacement therapy. Severity scores such as SAPS2 were
optional. ICU outcome (death or survival) and survival at
day 30 after ICU discharge were collected for all included
patients. All decisions to withhold and/or withdraw ther-
apy were at the discretion of the treating physician(s) but
were documented according to international recommen-
dations [18]. However, we did not collect information on
the timing of such a decision relative to ICU admission
and/or commencement of organ support.
e CRF and database ran on a secure server at Aarhus
University, Denmark.
Take‑home message
Among 5021 very old ( 80 years) patients admitted to 309 ICUs in
21 European countries, the most important patient variables associ-
ated with the instigation of life-sustaining treatment (LST) limitation
were acute admission, frailty, age and SOFA score. The frequency
of LST limitation was higher in countries with high GDP and lower
where more inhabitants considered their religion’s deity very impor-
tant. For patients with only a withholding decision, ICU and 30-day
mortality were respectively 29.1 and 53.1%.
Country’s characteristics
Gross domestic product (GDP) and health expenditure
from individual countries were extracted from EURO-
STAT (http://ec.europ a.eu/euros tat/stati stics -expla ined/
index .php/Healt hcare _expen ditur e_stati stics ). Propor-
tions of elderly patients per country were extracted from
Health at a Glance 2013: OECD Indicators. Numbers
of ICU beds per inhabitants were extracted from data
derived from Rhodes etal. [37].
Data on religious beliefs were extracted from the Euro-
pean Values Study (http://www.europ eanva luess tudy.
eu/).
Bias and study size
e participating ICUs included consecutive patients,
and decisions to withhold or withdraw LST were docu-
mented. e relationship with 30-day outcome was
assessed retrospectively after closure of the database. No
formal sample-size calculation was performed for this
observational study.
Statistical analysis
Baseline patient characteristics, treatment and outcomes
were compared among three LST groups: (1) no limita-
tions, (2) withholding alone and (3) withdrawal, whether
or not preceded by a withholding decision. Continuous
variables were compared among the groups using the
Mann–Whitney U test, categorical variables using the
Chi squared test. Normally distributed continuous data
were described as medians with 25th to 75th percentiles
(interquartile range, IQR). Associations between vari-
ables and treatment limitation—i.e. withholding or with-
drawal of LST—were estimated using a logistic regression
model. To account for the clustering of patients within
countries, a multilevel logistic regression model was
used. Two models were built to estimate (a) the effect of
patient characteristics on treatment limitation and (b)
the effect of patient and country characteristics on treat-
ment limitation. In order to quantify the country effect,
we used intraclass coefficient correlation (ICC) and
median odds ratio (MOR). e ICC represents the pro-
portion of the total observed individual variation in the
outcome (treatment limitation, i.e. withholding or with-
drawal) that is attributable to between-country variation.
e higher this proportion, the higher is the general con-
textual effect. If one were to repeatedly sample at ran-
dom two subjects with the same covariates from different
countries, then the MOR is the ratio between the subject
at higher risk of the outcome and the subject at the lower
risk of the outcome (differences in risk are entirely quan-
tified by the country-specific random effects).
Standardized treatment limitation ratios were esti-
mated for each country, defined as the ratio of the
observed number of treatment limitations in a country
and the sum of the predicted individual probabilities of
treatment limitation (estimated from model 1) in the
same country. e 95% confidence intervals of the ratios
were estimated using Byar’s approximation.
Associations between variables and survival at 30days
after ICU admission were estimated using a Cox pro-
portional hazard regression model. All patients were
censored at 30days. Adjusted survival curves were pro-
duced using inverse probability weighting. e weights
were estimated using frailty, age, gender, type of admis-
sion and SOFA score. Mid-point imputations were used
for patients discharged from ICU and dead at day 30. A p
value less than 0.05 was considered to show a statistically
significant difference.
All analyses were performed with R software, version
3.2.2 (R Foundation for Statistical Computing).
Ethics
Institutional research ethics board approval was obtained
from each study site. No specific funding was received,
but the study was endorsed by ESICM.
Results
In total, 309 ICUs from 21 European countries partici-
pated and included 5132 patients. Follow-up at 30days
was completed in 98% (5021/5132) of the patients. e
median recruited number of patients per country was
114 and the median number of patients per ICU was
16. e median age of all patients was 84 years (IQR
81–86); 52.1% were male. See Table1 for more baseline
characteristics.
Patients with no LST limitation accounted for
3656/5021 (72.8%) patients with only withholding com-
prised 15.0% and patients with withdrawal (including
those with previous withholding) made up 12.2% of the
total. Patients with LST limitation were older, more frail,
more severely ill and less frequently electively admitted
(Table 1). Patients with withdrawal of LST were more
frequently male and had a longer ICU LOS. e propor-
tion of LST limitations varied according to diagnostic
category (ESM3), with a very low frequency for patients
admitted after elective surgery. Among the non-survivors
at day 30, 24.3% had a withholding and 34.6% had a with-
drawing LST decision (ESM5). e ICU and 30-day mor-
tality were respectively 29.1 and 53.1% in the withholding
group and 82.2 and 93.1% in the withdrawal group. e
unadjusted and adjusted survival curves are depicted in
Fig.1.
Provision of organ support also differed according to
LST decision, with more instances of organ supports in
the withdrawal group (Table2).
LST limitation was less frequent in eastern and south-
ern European countries than in other parts of Europe
(ESM6). e ICUs located in northern Europe had higher
rates of LST limitation (up to 45.2%).
Country was found to have a significant effect on the
decision whether or not to limit LST. e multivariate
analysis identified independent factors for LST limitation
decision (Table3). e most important patient factors
associated with LST limitation were: acute ICU admis-
sion, CFS score, higher age and admission SOFA score.
A sensitivity analysis focusing only on urgent admission,
thus excluding scheduled surgery, found similar results.
Among the different country characteristics (ESM1) and
patient characteristics (ESM2), high GDP was associ-
ated with a higher rate of LST limitation, while religios-
ity, defined as the proportion of inhabitants agreeing with
the statement “God is important”, was associated with
low rates of LST limitation (Table3) (Fig.2). e num-
ber of ICU beds and the age distribution of the popula-
tionhad no impact on LST limitation.
e ICC was 0.14 (empty model), 0.23 (model with
individual patient characteristics) and 0.08 (model with
individual patient and country level characteristics). In
this last model, 8% of the total variation in patients’ treat-
ment limitation is due to country.
e MOR was 2.06 (empty model), 2.57 (model with
individual patient characteristics) and 1.66 (model with
individual patient and country level characteristics).
When comparing two patients with the same frailty level,
age, gender, SOFA score and type of admission from ran-
domly selected countries, the MOR for the patient from
the country with the higher risk of treatment limitation
relative to the patient from the country with the lower
risk of treatment limitation was 1.66. us, in half such
comparisons, the odds of treatment limitation would be
less than 1.66 for a patient in the country of higher risk
relative to an “identical” patient in the country of lower
risk.
Among patients with withdrawal, invasive mechani-
cal ventilation was highly associated with LST limitation
decisions (ESM6).
Discussion
Our prospective European study included 5021 patients
aged 80years or older. Limitation of LST was instigated
in 27.2% of these patients. Such limitations were associ-
ated with 30-day mortality of 54.8% in the withholding
group and 94.2% in the withdrawal group. In this very
old patient population, several factors other than chrono-
logical age are associated with limitations in LST, such as
country, urgent admission, frailty and severity of illness
(SOFA score).
Our findings are potentially important for policy mak-
ers. ere was considerable geographical variation in
preparedness to instigate limitations in LST in older
adult patients. Using the MOR, we have shown that
country effects (i.e. ‘culture’) are as important as, or in
some instances more important than, patient characteris-
tics in terms of the association with decisions to withhold
or withdraw treatment. An advantage to use of the MOR
for quantifying the contextual effect is that the MOR is
on the same scale as that used for estimating measures
of association when quantifying the effect of subject-level
(and country-level) covariates on the odds of the out-
come. us, one can compare the magnitude of the MOR
with that of the association between characteristics of the
subject and the outcome. In examining the odds ratios for
the model including patient and country characteristics,
we observed that only two of the six patient characteris-
tics had an odds ratio above 1.66. us, the magnitude of
the effect of clustering (the contextual effect) was higher
than that of four of the six patient characteristics.
High GDP was associated with higher standard-
ized treatment limitation ratio, while religiosity had the
opposite effect. is may seem paradoxical, with more
resources used in countries with lower GDP. From an
ethical point of view, countries with low GDP potentially
jeopardize the allocation of resources by postponing (or
not formalizing) EOL decision making.
Such differences have been noted previously. For
example, there is lower prevalence of withdrawal of life
support in Asia than in the USA or in Europe [15, 19].
Regional variations have also been reported in the UK
[20]. ese studies suggest that although some variability
is driven by ICU bed availability, much of the variability
is driven by the views of individual physicians (culture,
religion, profile) [21]. is indirectly indicates potential
violation of the patients’ autonomy (besides inappropri-
ate allocation of resources) and suggests physician- or
culture-centred care instead of patient-centred care.
In northern European countries intensivists are appar-
ently more willing to withhold or withdraw LST than in
eastern and southern European countries. In our study,
this difference was even more striking for decisions to
withdraw treatment: 5.5% in eastern Europe vs 17.7% in
northern Europe. Religion may play a part: the European
ETHICUS study reported that withholding occurred
more often than withdrawal if the physician was Jewish
(81%), Greek Orthodox (78%) or Moslem (63%) [22].
e rate of LST limitation in our study is higher than
previously reported in the general ICU population. For
example, LST was limited in 11.0% of patients in France
[23] and 9.8% in Europe [22]. Several factors may explain
these differences: a much younger population (the
median age was 57 and 66, respectively, in the French and
European studies); less severely ill patients (lower SAPS
II scores, lower overall mortality); or the time when the
study was conducted, with changes in the perceptions of
society in general and ICU physicians in particular as the
population ages.
Several studies have documented higher rates of treat-
ment limitation in aged patients compared with their
younger counterparts [18, 2426]. In the SUPPORT
study, older age was associated with higher rates of with-
holding ventilator support and dialysis in adjusted analy-
ses [24, 25]. In a study by Hakim etal. in the USA, the
rate of do-not-resuscitate orders increased with age (from
21% in patients < 54years to 55% in patients > 84 years)
[26]. In a study by Hoel etal. in Norway, medical and
unscheduled surgical patients with LST limitation were
older [27]. Other factors besides age have been associ-
ated with increased odds of decisions to forgo LST in US
ICUs: female sex, white race, poor baseline functional
status [13] and the treatments given to such patients [24].
In our study, the decision to limit LST was associated
with increased 30-day mortality (54.8% in the withhold-
ing group and 94.2% in the withdrawal group). e same
result was found in a recent multicentre observational
study in France, in which withdrawing or withholding
Table 1 Patient and ICU stay characteristics according to LST limitation
All No treatment limitation Withholding alone Withdrawing +/ with-
holding p value
N 5021 3656 753 612
% 100 72.8 15.0 12.2
Age
Median (range) (IQR) 84 (range 80–102) (IQR:
81–86) 83 (range 80–102) (IQR
81–86) 85 (range 80–99) (IQR
82–87) 84 (range 80–96) (IQR
82–87) < 0.0001
Clinical frailty score
Median (range) (IQR) 4 (range 1–9) (IQR: 3–6) 4 (range 1–9) (IQR 3–5) 5 (range 1–9) (IQR 4–6) 5 (range 1–9) (IQR 3–6) < 0.0001
Hospital length of stay prior ICU admission (days)
Median (range) (IQR) 1 (range 0–168) (IQR: 0–3) 1 (range 0–168) (IQR 0–3) 1 (range 0–151) (IQR 0–3) 0 (range 0–108) (IQR 0–3) 0.0016
SOFA score
Median (range) (IQR) 7 (range 0–24) (IQR: 4–10) 6 (range 0–24) (IQR 3–9) 7 (range 0–22) (IQR 4–10) 10 (range 0–20) (IQR 7–13) < 0.0001
ICU length of stay (days)
Median (range) (IQR) 2.33 (range 0–145.58) (IQR:
1–5.92) 2.29 (range 0–145.58) (IQR
1–5.66) 2.12 (range 0–125.38) (IQR
0.92–6) 2.92 (range 0.02–75) (IQR
1–7.03) 0.0406
Patient’s sex
Female 2404 (47.9%) 1737 (47.5%) 395 (52.5%) 272 (44.4%) 0.009
Male 2617 (52.1%) 1919 (52.5%) 358 (47.5%) 340 (55.6%)
Main reason for ICU
admission Missing: 114/ available:
4907 Missing: 97/ available:
3559 Missing: 12/available: 741 Missing: 5/ available: 607
Resp failure 965 (19.7%) 627 (17.6%) 207 (27.9%) 131 (21.6%) < 0.0001
Circ failure 569 (11.6%) 372 (10.5%) 96 (13%) 101 (16.6%)
Resp + Circ fail 484 (9.9%) 300 (8.4%) 84 (11.3%) 100 (16.5%)
Sepsis 502 (10.2%) 315 (8.9%) 111 (15%) 76 (12.5%)
Multi trauma without
head injury 63 (1.3%) 43 (1.2%) 9 (1.2%) 11 (1.8%)
Multi trauma with head
injury 66 (1.3%) 44 (1.2%) 5 (0.7%) 17 (2.8%)
Isolated head injury 124 (2.5%) 78 (2.2%) 23 (3.1%) 23 (3.8%)
Post elective surgery 906 (18.5%) 853 (24%) 38 (5.1%) 15 (2.5%)
Intoxication 14 (0.3%) 12 (0.3%) 2 (0.3%) 0 (0%)
Non trauma CNS causes 315 (6.4%) 196 (5.5%) 56 (7.6%) 63 (10.4%)
Emergency surgery 403 (8.2%) 327 (9.2%) 45 (6.1%) 31 (5.1%)
Other 496 (10.1%) 392 (11%) 65 (8.8%) 39 (6.4%)
Type of ICU admission
Elective 906 (18%) 853 (23.3%) 38 (5%) 15 (2.5%) < 0.0001
Acute 4115 (82%) 2803 (76.7%) 715 (95%) 597 (97.5%)
care accounted for half of all deaths [28]. In Italy, with-
drawal or withholding preceded 62% of deaths [29]. In
our study, among the elderly patients dead at day 30,
41.1% had no LST decision, 24.3% withholding and 34.6%
withdrawal. However, it should be emphasised that a LST
limitation decision is not equal to an EOL decision. In
fact, among the elderly patients with a decision to with-
hold care, the ICU mortality and 30-day mortality were
only 29.1 and 53.1%, respectively. For patients in whom
LST was withdrawn, ICU mortality and 30-day mortal-
ity were 82 and 94.2%. Clearly, not all LST limitations are
EOL decisions, since the mortality rate is low for patients
Fig. 1 Survival curves according to LST limitation: a unadjusted; b adjusted
Table 2 Treatments, frailty level and outcomes
All No treatment limitation Withholding alone Withdrawing +/ withholding p value
5021 3656 753 612
Non invasive mechanical ventilation
No 3872 (77.1%) 2910 (79.6%) 509 (67.6%) 453 (74%) < 0.0001
Yes 1149 (22.9%) 746 (20.4%) 244 (32.4%) 159 (26%)
Invasive mechanical ventilation
No 2501 (49.8%) 1892 (51.8%) 460 (61.1%) 149 (24.3%) < 0.0001
Yes 2520 (50.2%) 1764 (48.2%) 293 (38.9%) 463 (75.7%)
Vasoactive drugs
No 2408 (48%) 1894 (51.8%) 360 (47.8%) 154 (25.2%) < 0.0001
Yes 2613 (52%) 1762 (48.2%) 393 (52.2%) 458 (74.8%)
Renal replacement therapy
No 4559 (90.8%) 3355 (91.8%) 682 (90.6%) 522 (85.3%) < 0.0001
Yes 462 (9.2%) 301 (8.2%) 71 (9.4%) 90 (14.7%)
Frailty level
Fit 1893 (37.7%) 1545 (42.3%) 161 (21.4%) 187 (30.6%) < 0.0001
Vulnerable 972 (19.4%) 726 (19.9%) 140 (18.6%) 106 (17.3%)
Frail 2156 (42.9%) 1385 (37.9%) 452 (60%) 319(52.1%)
Death in ICU
No 3911 (77.9%) 3268 (89.4%) 534 (70.9%) 109 (17.8%) < 0.0001
Yes 1110(22.1%) 388 (10.6%) 219 (29.1%) 503 (82.2%)
Death at day 30
No 3373 (67.2%) 2978 (81.5%) 353 (46.9%) 42 (6.9%) < 0.0001
Yes 1648 (32.8%) 678 (18.5%) 400 (53.1%) 570(93.1%)
with only withholding of treatment and not 100% at
30days for patients with withdrawal of LST. Apparently,
LST limitation is proposed when such LST is considered
disproportionate to the patient’s chances of survival with
a good quality of life [27, 30]. e impact of LST limi-
tation on mortality is greatest in the first week of ICU
Table 3 Multilevel logistic regression for withholding or withdrawing vs no LST limitation (level 1 = patient/level
2 = country)
Empty model Patients characteristics Patients and countries charac-
teristics
OR (95% CI) p value OR (95% CI) p value
Frailty 4 vs 1–3 1.59 (1.3–1.95) < 0.0001 1.59 (1.3–1.95) < 0.0001
Frailty 5–9 vs 1–3 2.33 (1.98–2.75) < 0.0001 2.33 (1.98–2.74) < 0.0001
Age (5 years increase) 1.23 (1.11–1.35) < 0.0001 1.22 (1.11–1.35) < 0.0001
Male vs female patient 1.02 (0.89–1.18) 0.754 1.03 (0.89–1.18) 0.7305
Acute vs elective admission 5.61 (4.13–7.62) < 0.0001 5.59 (4.12–7.59) < 0.0001
Sofa score (one point increase) 1.12 (1.1–1.14) < 0.0001 1.12 (1.1–1.14) < 0.0001
GDP per capita (one point increase) 1 (1–1) 0.01976
Religiosity (one point increase) 0.96 (0.94–0.99) 0.00498
Country effect Point estimate Point estimate Point estimate
MOR 2.06 2.57 1.66
ICC 0.14 0.23 0.08
GDP per capita
Standardized treatement limitation ratio
0 20000 40000 60000 80000
0.0 0.51.0 1.52.0
Religiosity
Standardized treatement limitation ratio
010203040506
07
0
0.00.5 1.0 1.52.0
AB
Fig. 2 Standardized treatment limitation ratio. The range lines are 95% confidence intervals. a According to the volume index of GDP per capita; b
according to religiosity, defined as the proportion of the population considering God as very important
treatment [31], depending on what kind of treatment is
withdrawn and the number of organs failing at the time
of LST limitation [31, 32]. We found that the impact of
LST limitation on survival was discernible until 2weeks
after ICU admission (Fig.1).
In our study, the ICU LOS of patients with LST with-
drawal was a little longer than the other patients but was
still below 3days, suggesting an early decision to limit
LST. In a study from Australia and New Zealand, the
LOS of older adults was 3.9 days in non-survivors and
2.5days in survivors, suggesting that EOL decisions were
made later in patients older than 80years [33]. On the
other hand, data from Scandinavia show shorter LOS for
non-survivors than survivors in the ICU, particularly for
older patients [34].
Our study has several strengths: the focus on patients
older than 80 years, the large number of participating
ICUs from 21 European countries, the separate docu-
mentation of withholding and/or withdrawal of LST and
the 30-day follow-up. However, it also has limitations.
We have no documentation of the timing of the LST
limitation decision, which could bias the results; patient
inclusion was mostly during the winter, which may have
contributed to the high rate of LST limitation; and the
participating ICUs cannot necessarily be considered
as representative of their countries. In order to combat
these weaknesses, we grouped countries into five Euro-
pean regions; we did not document any possible influ-
ence of advance directives or patients’ and/or relatives’
preferences in the decision;and included no health eco-
nomic data or bed access/pressure data that could help to
develop a resource-based argument for deciding on LST
limitation.
In the older adult population, LST limitation occurs
frequently. e best criteria for the appropriateness of
such decision include post-discharge functional capacity,
mortality and quality of life [35]. A dialogue with fam-
ily members (or care givers) about the possibilities and
potential outcomes should take place within 72 h of a
patient being admitted to the ICU [10, 21, 36].
Conclusion
Given the limited survival chances of very old patients
and the cost and scarcity of ICU resources, an active
policy for limiting life-sustaining therapy should be advo-
cated for patients who are not responding to treatment
or not willing to continue ICU treatment. is should
be accompanied by a campaign encouraging patients to
express their preferences and wishes before they become
ill. Better definition of which elderly patients will benefit
from ICU procedures, rather than drawing up exclusion
criteria, is a challenge for future studies.
Electronic supplementary material
The online version of this article (https ://doi.org/10.1007/s0013 4-018-5196-7)
contains supplementary material, which is available to authorized users.
Author details
1 Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale,
184 rue du Faubourg Saint Antoine, 75012 Paris, France. 2 Institut Pierre Louis
d’Epidémiologie et de Santé Publique, Sorbonne Universités, UPMC Univ
Paris 06, INSERM, UMR_S 1136, 75013 Paris, France. 3 Department of Clinical
Medicine, University of Bergen, Bergen, Norway. 4 Department of Anaesthesia
and Intensive Care, Haukeland University Hospital, Bergen, Norway. 5 Depart-
ment of Rehabilitation, Hospital Ancelle di Cremona, Cremona, Italy. 6 Geriatric
Research Group, Brescia, Italy. 7 Department of Anaesthesia and Intensive Care,
Ålesund Hospital, Ålesund, Norway. 8 Department of Circulation and Medical
Imaging, NTNU, Trondheim, Norway. 9 Department of Intensive Care Medicine,
CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc
Tauli, Autonomous University of Barcelona, Sabadell, Spain. 10 Laboratorio
di Epidemiologia Clinica, Centro di Coordinamento GiViTI Dipartimento di
Salute Pubblica, IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri” Villa
Camozzi, 24020, Ranica, Bergamo, Italy. 11 St George’s University Hospital, Lon-
don, UK. 12 Department of Anaesthesia and Intensive Care Medicine, Aarhus
University Hospital, Åarhus, Denmark. 13 Grande Ospedale Metropolitano
Niguarda, Milan, Italy. 14 Department of Cardiology, Pulmonology and Angiol-
ogy, University Hospital, Düsseldorf, Germany. 15 Mater Misericordiae Univer-
sity Hospital, Dublin, Ireland. 16 Unidade de Cuidados Intensivos Polivalente
Neurocríticos, Hospital de São José, Centro Hospitalar de Lisboa Central,
Faculdade de Ciência Médicas de Lisboa, Nova Médical School, Lisbon, Portu-
gal. 17 Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent,
Belgium. 18 Karolinska University Hospital, Solna, Sweden. 19 Geneva University
Hospitals, Geneva, Switzerland. 20 Department of Intensive Care, University
Medical Center, University Utrecht, Utrecht, The Netherlands. 21 Intensive Care
and Perioperative Medicine Division, Jagiellonian University Medical College,
Kraków, Poland. 22 Kardinal Schwarzenberg Hospital, Schwarzach, Austria.
23 Intensive Care Unit General Hospital of Larissa, Larissa, Greece.
Acknowledgements
VIP1 study group members: René Schmutz, B5, Hospital of St. John of God
Vienna , Austria; Franz Wimmer, Interne Intensiv, Kardinal
Schwarzenberg´sches Krankenhaus, Austria; Philipp Eller, Intensivstation der
Univ.-Klinik für Innere Medizin, Medical University Graz, Austria; Klemens
Zotter, MICU, University Hospital Innsbruck, Austria; Pieter De Buysscher,
Department of Intensive Care, AZ Sint-Lucas Ghent, Belgium; Nikolaas De
Neve, Department of Intensive Care, O.L.Vrouwhospital Aalst , Belgium; Sandra
Oeyen, Department of Intensive Care, Ghent University Hospital, Belgium;
Walter Swinnen, Department of Intensive Care Medicine, AZ Sint-Blasius
Dendermonde , Belgium; Bernardo Bollen Pinto, Peri-interventional
Intermidate Care (SINPI), Geneva University Hospitals, Belgium; Paul Abraham,
Adult Intensive Care (SIA), Geneva University Hospitals, Belgium; Leila Hergafi,
Service des Soins intensifs, Hôpital fribourgeois, Fribourg, Belgium; Joerg C.
Schefold, Universitätsklinik für Intensivmedizin, Inselspital, Bern University
Hospital, University of Bern, Belgium; Ewelina Biskup, Medical ICU, University
Hospital Basel, Belgium; Petr Piza, KARIP, IKEM, Checkoslovakia; Ioannis
Taliadoros, CY001, Nicosia General Hospital, Cyprus; Jesper Fjølner, ITA, Randers
Regional Hospital, Denmark; Nilanjan Dey, Intensiv Herning, Regions Hospital
Herning, Denmark; Christoffer Sølling, I-25, Regionshospital Viborg, Denmark;
Bodil Steen Rasmussen, ICU, Aalborg University Hospital, Denmark; Steffen
Christensen, OPI Ost, Aarhus University Hospital Skejby, Denmark; Xavier
Forceville, Réanimation médico chirurgical, Centre Hospitalier de Meaux,
France; Guillaume Besch, Département d´Anesthésie Réanimation Chirurgi-
cale, Centre Hospitalier Régional Universtaire de Besançon, France; Herve
Mentec, Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy
Argenteuil, France; Philippe Michel, Réanimation médico-chirurgicale, CH
Carnelle - Portes de l’Oise, France; Philippe Mateu, Réanimation Polyvalente,
CH de Charleville-Mézières, France; Philippe Michel, Réanimation médico-
chirurgicale, CH René Dubos, France; Lucie Vettoretti, Réanimation Médicale,
CHRU de Besançon, France; Jeremy Bourenne, Reanimation des Urgences et
Médicale, CHU Marseille - Timone, France; Nathalie MARIN, reanimation
médicale, hopital cochin, France; Max Guillot, Réanimation médicale, Hôpital
de Hautepierre, France; Naida Aissaoui , Réanimation médicale, hopital
européen georges pompidou, France; Cyril Goulenok , Réanimation Médicale,
Hopital Privé Jacques CARTIER, France; Nathalie Thieulot-Rolin , Intensive care
medicine department, Hospital Marc Jacquet 77000 Melun, France; Jonathan
Messika, Réanimation Médico-Chirurgicale, Louis Mourier, France; Lionel
Lamhaut, Polyvalente adult ICU, Necker (APHP), France; Bertrand Guidet,
Réanimation médicale, Saint Antoine, France; Cyril Charron, Medical-surgical
ICU, University Hospital Ambroise Paré, de Paris Boulogne-Billancourt, France,
France; Alexander Lauten, 1) Department of Cardiology, 2) DZHK Berlin partner
side, Charité Universitaetsmedizin Berlin, Germany; Anna Lena Sacher,
Department of Anesthesiology , Charité Universitaetsmedizin Berlin, Germany;
Thorsten Brenner, Department of Anesthesiology, Heidelberg University
Hospital, Germany; Marcus Franz, Department of Internal Medicine, Jena
University Hospital, Friedrich-Schiller University, Germany; Frank Bloos,
Department of Anesthesiology, Jena University Hospital, Friedrich-Schiller
University, Germany; Henning Ebelt, Department for Medicine II, Catholic
Hospital “St. Johann Nepomuk”, Germany; Stefan J Schaller, Department of
Anesthesiology, Klinikum rechts der Isar, Technical University of Munich,
Munich, Germany; Kristina Fuest, Department of Anesthesiology, Klinikum
rechts der Isar, Technical University of Munich, Munich, Germany, Germany;
Christian Rabe, Department Of Clinical Toxicology, Klinikum rechts der Isar,
Technical University of Munich, Munich, Germany, Germany; Thorben Dieck,
Department of Anaesthesiology and Intensive Care, Medical School Hospital
Hannover, Germany; Stephan Steiner, Department of Cardiology, Pneumology
and Intensive Care, St. Vincenz Krankenhaus Limburg, Germany; Tobias Graf,
Department of Cardiology, University Heart Center Luebeck, Germany; Amir M
Nia, Division of Cardiology and Intensive Care, University Hospital Düsseldorf,
Heinrich-Heine University, Germany; Christian Jung, Division of Cardiology and
Intensive Care, University Hospital Düsseldorf, Heinrich-Heine University,
Germany; Rolf Alexander Janosi, Department of Cardiology and Vascular
Diseases, University Hospital Essen, Germany; Philipp Simon, Department of
Anaesthesiology and ICM, University Hospital of Leipzig, Germany; Stefan
Utzolino, Department of General and Visceral Surgery , Universitätsklinikum
Freiburg, Germany; Tim Rahmel, Department of Anaesthesiology, Intensive
Care Medicine, University Hospital Knappschaftskrankenhaus Bochum,
Germany; Eberhard Barth, Department of Anaesthesiology, University of Ulm,
Germany; Christian Jung, University Hospital Düsseldorf, Heinrich-Heine-
University Düsseldorf, Medical Faculty, Division of Cardiology, Pulmonology
and Vascular Medicine, Düsseldorf, Germany, Germany; Michael Schuster,
Department of Anaesthesiology, University Hospital Mainz, Germany; Zoi
Aidoni , ICU, UGHT AHEPA, Greece; Stavros Aloizos , ICU , Army Share Fund
Hospital, Athens, Greece; Polychronis Tasioudis , ICU, G. Gennimatas hospital of
Thessaloniki, Greece; Kleri Lampiri , ICU, General Hospital Of Kavala, Greece;
Vasiliki Zisopoulou, ICU1, General Hospital Of Larissa, Greece; Ifigenia Ravani ,
ICU, General hospital of Patras, Greece; Eumorfia Pagaki , ICU, General hospital
of Trikala, Greece; Angela Antoniou , ICU, Volos General Hospital, Greece;
Theodoros A. Katsoulas, ICU, “Ag Anargyroi” General Hospital, Greece; Aikaterini
Kounougeri , ICU , Konstantopouleion General Hospital, Athens, Greece;
George Marinakis, ICU, “Korgialenio-Benakio” G. Hospital of Athens, Greece;
Fotios Tsimpoukas, ICU, Lamia General Hospital, Greece; Anastasia Spyropou-
lou, ICU, Panarkadian General Hospital of Tripolis, Greece; Paris Zygoulis,
General ICU, University hospital of Larisa, Greece; Aikaterini Kyparissi , ICU,
“HIPPOCRATEIO” General Hospital of Athens , Greece; Manish Gupta , MICU,
MAX SUPER SPECIALTY HOSPITAL , Vaishali , India; Mohan Gurjar, Department
of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical
Sciences , India; Ismail M Maji , MICU, St Johns Medical Colleg Hospital,
Bangaluri, India; Ivan Hayes, CUH GICU, Cork University Hospital, Ireland; Brian
Marsh, Department of Critical Care Medicine, Mater Misericordiae University
Hospital, Ireland; Yvelynne Kelly, General ICU, St. Jamess Hospital, Ireland;
Andrew Westbrook, ICU, St. Vincents University Hospital, Ireland; Gerry
Fitzpatrick, Tallaght intensive Care, Tallaght Hospital, Ireland; Darshana
Maheshwari, UHG ICU, University hospital galway, Ireland; Catherine
Motherway, ICU, University Hospital limerick, Ireland; Giovanni Negri,
Rianimazione, A.S.S.T. Ovest Milanese - Presidio Di Magenta - Ospedale G.
Fornaroli (Magenta), Italy; Savino Spadaro, Unità di Terapia Intensiva del
Servizio di Anestesia , Azienda Ospedaliera Universitaria Sant Anna (Ferrara),
Italy; Giuseppe Nattino, Rianimazione generale, ASST Lecco - Ospedale
A.Manzoni (Lecco), Italy; Matteo Pedeferri, Rianimazione, AO della Provincia di
Lecco - Presidio Ospedaliero S.Leopoldo Mandic, Merate , Italy; Annalisa
Boscolo, Giustiniani I e II (Istar), Azienda Ospedaliera di Padova (Padova), Italy;
Simona Rossi, Servizio Anestesia Rianimazione, Azienda Ospedaliera G.Salvini
- Presidio Ospedaliero di Rho , Italy; Giuseppe Calicchio, Centro di Rianimazi-
one, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d’Aragona ,
Italy; Lucia Cubattoli, Rianimazione Generale , Azienda Ospedaliera
Universitaria Senese (Siena), Italy; Gabriella Di Lascio, Terapia Intensiva di
Emergenza, Azienda Ospedaliero Universitaria Careggi (Firenze), Italy; Maria
Barbagallo, UO 2 Anestesia Rianimazione Terapia Intensiva, Azienda
Ospedaliero-Universitaria di Parma (Parma), Italy; Francesco Berruto,
rianimazione, Ospedale E. Agnelli (Pinerolo), Italy; Daniela Codazzi, Unità
Terapia Intensiva, Fondazione IRCCS Istituto Nazionale dei Tumori (Milano),
Italy; Andrea Bottazzi, Rianimazione 2, Fondazione IRCCS Policlinico S.Matteo
(Pavia), Italy; Paolo Fumagalli, Rianimazione 1, Fondazione Policlinico San
Matteo (Pavia), Italy; Giancarlo Negro, Anestesia e Rianimazione 1, Ospedale
Francesco Ferrari (Casarano), Italy; Giuseppe Lupi, Servizio Anestesia e
Rianimazione, Ospedale Maggiore (Cremona), Italy; Flavia Savelli, Anestesia e
Rianimazione - TI 2, Ospedale Maurizio Bufalini (Cesena), Italy; Giuseppe A.
Vulcano, Terapia Intensiva, Ospedale Civile Nicola Giannettasio (Rossano), Italy;
Roberto Fumagalli, Anestesia e Rianimazione 1, Ospedale Niguarda Ca’ Granda
(Milano), Italy; Andrea Marudi, Rianimazione Neurorianimazione, Nuovo
Ospedale Civile Sant Agostino Estense (Modena), Italy; Ugo Lefons, Terapia
intensiva, Ospedale Alta Val d’Elsa (Poggibonsi), Italy; Rita Lembo, Rianimazi-
one generale, Ospedale Castelli di Verbania (Verbania), Italy; Maria Babini,
Servizio Anestesia e Rianimazione, Ospedale Civile Lugo (Lugo), Italy;
Alessandra Paggioro, Struttura Semplice di Rianimazione e Terapia Intensiva,
Ospedale degli Infermi di Biella - ASL BI (Biella), Italy; Vieri Parrini, Anestesia e
Rianimazione, Ospedale del Mugello (Borgo San Lorenzo), Italy; Maria Zaccaria,
Rianimazione e Terapia Intensiva, Ospedale di Ciriè (Torino), Italy; Stefano
Clementi, terapia intensiva polivalente, Ospedale di Sesto San Giovanni (Sesto
San Giovanni), Italy; Carmelo Gigliuto, Rianimazione, Ospedale di Vigevano
- Azienda Ospedaliera della Provincia di Pavia (Vigevano), Italy; Francesca
Facondini, Reparto di Rianimazione e Terapia Intensiva, Ospedale
Infermi(Rimini), Italy; Simonetta Pastorini, Servizio Anestesia-Rianimazione ,
Ospedale P. Cosma-AUSL 15 Alta padovana (Camposampiero), Italy; Susanna
Munaron, Unità di Terapia Intensiva, Ospedale San Giacomo (Castelfranco
Veneto), Italy; Italo Calamai, Rianimazione, Ospedale San Giuseppe (Empoli),
Italy; Anna Bocchi, Terapia Intensiva, Ospedale San Luca (Trecenta), Italy; Adele
Adorni, Unità di Terapia Intensiva Rianimatoria, Ospedale Valduce (Como), Italy;
Maria Grazia Bocci, Centro di Rianimazione, Policlinico Agostino Gemelli
(Roma), Italy; Andrea Cortegiani, Unità di Terapia Intensiva Polivalente,
Policlinico P. Giaccone. University of Palermo, Italy; Tiziana Casalicchio, Terapia
Intensiva, Ospedale San Giovanni Bosco (Torino), Italy; Serena Mellea, Unità di
Terapia Intensiva, Ospedale Santa Maria della Misericordia (Perugia), Italy; Elia
Graziani, Unità Operativa Anestesia e Rianimazione, Santa Maria delle Croci
(Ravenna), Italy; Massimo Barattini, Rianimazione, Ospedale Santa Maria Nuova
(Firenze), Italy; Elisabetta Brizio, Servizio di Rianimazione, Ospedale SS
Annunziata, Italy; Maurizio Rossi, UO Anestesia e Rianimazione, Azienda
Ospedaliera Sant’Anna Como – Presidio di Menaggio, Italy; Michael Hahn, ICU,
Haugesund hospital, Norway; Hans Flaatten, General ICU, Haukeland
University Hospital, Norway; Nicolai Kemmerer, ICU, Kongsberg hospital,
Norway; Hans Frank Strietzel, ICU, Kristiansund Hospital, Norway; Knut Dybwik,
ICU, Nordlandssykehuset Bodo, Norway; Terje Legernaes, ICU , Hamar hospital,
Norway; Pål Klepstad, Dept Intensive Care Medicine, St Olavs University
Hospital, Norway; Even Braut Olaussen, ICU, Stavanger University Hospital,
Norway; Knut Inge Olsen, ICU, Namsos Hospital, Norway; Ole Marius Brresen,
ICU, Telemark Hospital, Skien, Norway; Geir Bjorsvik, ICU , University Hospital
Tromso, Norway; Finn H. Andersen, ICU, Ålesund hospital, Norway; Sameer
Maini, Medical ICU, Aalesund Hospital, Norway; Lutz Fehrle, ICU, Molde
hospital, Norway; Miroslaw Czuczwar, ICU, First Public Teaching Hospital in
Lublin, Poland; Pawel Krawczyk, ICU, University Hospital in Krakow, Poland;
Mirosław Ziętkiewicz, Respiratory and Thoracic Surgical ICU, John Paul II
Hospital in Krakow, Poland; Łukasz R. Nowak, Department of Anaesthesiology
and Intensive Care, Maria Sklodowska-Curie Memorial Institute of Oncology
Krakow Branch, Poland; Katarzyna Kotfis, Department of Anaesthesia, Intensive
Care and Acute Poisonings, Pomeranian Medical University, Teaching Hospital
No.2, Poland; Katarzyna Cwyl, ICU, RCZ in Lublin, Poland; Ryszard Gajdosz,
Department of Anaesthesiology and Intensive Care, Scanmed St. Raphael
Hospital in Kraków, Poland; Jowita Biernawska, Department of Anaesthesiol-
ogy and Intensive Care, Pomeranian Medical University, Teaching Hospital No.
1, Poland; Romuald Bohatyrewicz, Department of Anaesthesiology and
Intensive Care, Pomeranian Medical University, Teaching Hospital No. 1,
Poland; Ryszard Gawda, Department of Anaesthesiology and Intensive Care,
University Hospital in Opole, Poland; Paweł Grudzień, ICU, Edward Szczeklik
Specialist Hospital in Tarnów, Poland; Paweł Nasiłowski, Department of
Anaesthesiology and Intensive Care, Gabriel Narutowicz Specialist Hospital in
Kraków, Poland; Natalia Popek, Department of Anaesthesiology and Intensive
Care, Stefan Żeromski Specialist Hospital in Kraków, Poland; Waldemar
Cyrankiewicz, Department of Anaesthesiology and Intensive Care, Antoni
Jurasz University Hospital No. 1 in Bydgoszcz, Poland; Katarzyna Wawrzyniak,
Department of Anaesthesiology and Intensive Care, Antoni Jurasz University
Hospital No. 1 in Bydgoszcz, Poland; Marek Wnuk, Department of Anaesthesi-
ology and Intensive Care, John Paul II Memorial Hospital in Bełchatów, Poland;
Dariusz Maciejewski, Department of Anaesthesiology and Intensive Care,
Provincial hospital in Bielsko-Biała, Poland; Dorota Studzińska, Department of
Anaesthesiology and Intensive Care, St. John Grande Hospital, Poland; Maciej
Żukowski, Department of Anaesthesiology, Intensive Care and Acute
Poisoning, Pomeranian Medical University, Teaching Hospital No. 2 in Szczecin,
Poland; Szymon Bernas, Department of Anaesthesiology and Intensive
Therapy Centre for Artificial Extracorporeal Kidney and Liver Support, Dr
Władysław Biegański Regional Specialist Hospital in Łódź, Poland; Mariusz
Piechota, Department of Anaesthesiology and Intensive Therapy Centre for
Artificial Extracorporeal Kidney and Liver Support, Dr Władysław Biegański
Regional Specialist Hospital in Łódź, Poland; Centre for Artificial Extracorporeal
Kidney and Liver Support, Poland; Wojciech Szczeklik, Department of Intensive
Care and Perioperative Medicine, University Hospital in Kraków, Poland; Ilona
Nowak, Department of Intensive Care and Perioperative Medicine, University
Hospital in Kraków, Poland; Jakub Fronczek, Department of Intensive Care and
Perioperative Medicine, University Hospital in Kraków, Poland; Marta Serwa,
Department of Anaesthesiology and Intensive Care, University Hospital and
Educational Centre of the Medical University of Łódź, Poland; Waldemar
Machała, Department of Anaesthesiology and Intensive Care, University
Hospital and Educational Centre of the Medical University of Łódź, Poland; Jan
Stefaniak, Department of Anaesthesiology and Intensive Care, University
Clinical Centre in Gdańsk, Poland; Maria Wujtewicz, Department of Anaesthesi-
ology and Intensive Care, University Clinical Centre in Gdańsk, Poland; Paweł
Maciejewski, Department of Anaesthesiology and Intensive Care, Orthopedic-
Rehabilitation University Hospital in Zakopane, Poland; Małgorzata Szymkow-
iak, Department of Anaesthesiology and Intensive Care, Józef Struś Hospital in
Poznan, Poland; Barbara Adamik, Department of Anaesthesiology and
Intensive Care, Wrocław University Hospital, Poland; Nuno Catorze, UCIP, C. H.
Médio TEJO, Portugal; Miguel Castelo Branco, Unidade de Cuidados Intensivos,
Centro Hospitalar Cova da Beira, EPE, Portugal; Inês Barros, Unidade de
Cuidados Intensivos Polivalente, Centro Hospitalar Tondela-Viseu, Portugal;
Nelson Barros, Serviço Medicina Intensiva, Centro Hospitalar Trás-os-Montes e
Alto Douro, Portugal; Andriy Krystopchuk, Intensive Care and Emergency
Department, Centro Hospitalar do Algarve-Hospital de Faro, Portugal; Teresa
Honrado, Unidade Cuidados INtensivos Polivalente, Hospital de São João,
Portugal; Cristina Sousa, UCI, Hospital da Luz, Portugal; Francisco Munoz, UMI,
Hospital do SAMS, Portugal; Marta Rebelo, UCIP, Hospital de Egas Moniz,
Portugal; Rui Gomes, UCI, Hospital Garcia de Orta, Portugal; Jorge Nunes,
Unidade de Cuidados Intensivos, Hospital Lusiadas Lisboa, Portugal; celeste
dias, Neurocritical ICU, Hospital de São João, Portugal; Ana Margarida
Fernandes, UCI Neurocríticos, Hospital S. José - CHLC EPE, Portugal; Cristina
Petrisor, Anaesthesia and Intensive Care 1, Clinical Emergency County Hospital
Cluj, Portugal; Bodolea Constantin, ATI, Municipal Hospital, Portugal; Vladislav
Belskiy, Department of Anesthesiology and Intensive Care, Privolzhskiy District
Medical Center, Russia; Boris Boskholov, Dept of intensive care, Zhadkevich
Clinical Hospital, Russia; Enver Rodriguez, UCI , General Universitario de
Castellón, Spain; Sergio Rebollo, ICU, HGU Santa Lucia,Cartagena, Murcia,
Spain; Gerardo Aguilar, Unidad de Reanimación - Surgical ICU, Hospital Clínico
Universitario de Valencia, Spain; Gaspar Masdeu, Servei Medicina Intensiva,
Hospital de Tortosa Verge de la Cinta, Spain; Marián Irazábal Jaimes, Critical
Care Unit, Hospital General de Catalunya, Spain; Ángela Prado Mira, Medicina
Intensiva, Hospital General Universitario de Albacete, Spain; Maria A. Bodi,
General ICU, Hospital Universitari de Tarragona Joan XXIII, Spain; Jesus A. Barea
Mendoza, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre,
Spain; Sonia López-Cuenca, Servicio de Medicina Intensiva y Grandes
Quemados, Hospital Universitario de Getafe, Spain; Marcela Homez Guzman,
ICU, Hospital Universitario del Henares, Spain; Jesús Rico-Feijoo, Postoperative
Critical Care Unit and Reanimation, Hospital Universitario Río Hortega de
Valladolid, Spain; Mercedes Ibarz , ICU Hospital Universitario Sagrado Corazon,
Hospital Universitario Sagrado Corazon. Barcelona, Spain; Josep Trenado
Alvarez , Intensive Care Department. UCI-Semicritics, Hospital Universitario
Mutua Terassa, Spain; Rafael Kawati, central ICU, Akademiska sjukhuset,
Sweeden; Joakim Sivik, IVA Alingsås Lasarett, Alingsås Lasarett, Sweeden;
Jessica Nauska, Intensivvårdsavdelning 31, Blekingesjukhuset Karlsk rona,
Sweeden; Daniel Smole, IVA, Centralsjukhuset i Karlstad, Sweeden; Fredric
Parenmark, IVA, Gävle sjukhus, Sweeden; Johanna Lyrén, Intensivvårdsavdeln-
ing, Hudiksvalls sjukhus, Gävleborg, Hudiksvalls sjukhus, Sweeden; Katalin
Rockstroh, IVA, Kalmar Länssjukhus, Sweeden; Sara Rydén, Karolinska ICU
Huddinge, Karolinska University Hospital Huddinge, Sweeden; Martin
Spångfors, Intensiven, Kristianstad, Sweeden; Morten Strinnholm, ICU
Kungälvs Hospital, Kungälvs hospital, Sweeden; Sten Walther, Cardiothoracic
ICU, Linköping University Hospital, Sweeden; Lina De Geer, ICU, Linköping
University Hospital, Sweeden; Peter Nordlund, OP/IVA Kliniken, Länssjukhuset
Ryhov, Sweeden; Staffan Pålsson, Intensivvårdsavdelningen, Norrtälje,
Sweeden; Harald Zetterquist, IVA, Nykopings lasarett, Sweeden; Annika
Nilsson, IVA, Ornskoldsvik, Ornskoldsviks hospital, Sweeden; Karin Thiringer,
avdelning 227, IVA, Sahlgrenska University Hospital Mölndal, Sweeden; Mårten
Jungner, ICU SUS Malmö, Skane University Hospital, Sweeden; Björn Bark, IVA
Lund, Skåne University Hospital, Sweeden; Berit Nordling, IVA Sundsvall,
Sundsvall, Sweeden; Hans Sköld, ICU, Torsby Sjukhus, Sweeden; Camilla
Brorsson, CIP, University Hospital Northern Sweden, Sweeden; Stefan Persson,
Intensivvårsdavdelningen USÖ, University hospital Örebro, Sweeden; Anna
Bergström, IVA Vrinnevisjukhuset, Vrinnevi hospital, Sweeden; Johan Berkius,
IVA Västervikssjukhus,Västervikssjukhus, Sweeden; Johanna Holmström,
Intensivvårdsavdelningen Västerås, Västmanlands sjukhus, Västerås, Sweeden; I.
van Dijk, Intensive Care , Alrijne Ziekenhuis, The Netherlands; L.E.M. van
Lelyveld-Haas, Intensive Care, Diakonessenhuis Utrecht, The Netherlands;
D.Ramnarain, Intensive Care, Elisabeth Tweesteden Hospital Tilburg, The
Netherlands; Tim Jansen, Intensive Care , HagaZiekenhuis, The Netherlands;
Fleur Nooteboom, IC LZR, Laurentius Ziekenhuis, The Netherlands; Peter HJ
van der Voort, ICU OLVG, OLVG, The Netherlands; Dylan de Lange, Department
of Intensive Care Medicine, UMC Utrecht, The Netherlands; Willem Dieperink,
Department of Critical Care, University Medical Center Groningen, The
Netherlands; Monique C. de Waard, Intensive Care Adults, VU University
Medical Center Amsterdam, The Netherlands; Annemarie GE de Smet,
Intensive Care Unit, University Medical Centre, University of Groningen, The
Netherlands; Laura Bormans, Intensive Care, Zuyderland Medical Centrer,
Heerlen, The Netherlands; Tom Dormans, Intensive Care, Zuyderland Medical
Center, Heerlen, The Netherlands; Ged Dempsey, Critical Care Unit, Aintree
University Hospital NHS Foundation Trust, UK; Shiju J Mathew, ICU, Alexandra
Hospital, UK; Ashok S Raj, ICU, Barts Health NHS Trust, Whipps Cross Hospital,
UK; Irina Grecu, ITU/HDU, Basingstoke and North Hampshire Hospital, UK;
Jason Cupitt, Critical Care Unit, Blackpool Teaching Hospitals NHS Foundation
Trust, UK; Tom Lawton, Critical Care Unit, Bradford Royal Infirmary, UK; Richard
Clark, ICU, Central Manchester Foundation Trust, UK; Monica Popescu, ICU,
Chelsea and Westminster Foundation Trust, West Middlesex University
Hospital, UK; Nick Spittle, ICU, Chesterfield Royal Hospital, UK; Maria Faulkner,
ICU, Countess of Chester Hospital NHS Foundation Trust, UK; Amanda Cowton,
ICU, Darlington memorial Hospital (CDDFT), UK; Esme Elloway, ICU, Derriford
Hospital, UK; Patricia Williams, Critical Care Unit, Dorset County Hospital, UK;
Michael Reay, Critical Care Unit , Dudley Group of Hospitals NHSFT, Russells
Hall Hospital, UK; Srikanth Chukkambotla, Critical Care Unit, East Lancashire
Hospitals NHS Trust, UK; Ravi Kumar , CCU, East Surrey Hospital , UK; Nawaf
Al-Subaie, ICU, Espsom and St Helier University Hospitals, UK; Linda Kent,
Critical Care Unit, Fairfield General Hospital, UK; Tiina Tamm, ICU, Frimley
Health, Wexham Park Hospital, UK; Istvan Kajtor, ICU, Frimley Park Hospital, UK;
Karen Burns, ICU, Furness General, UK; Richard Pugh, Critical Care Unit, Glan
Clwyd Hospital, UK; Marlies Ostermann, ICU, Guys and St Thomas Hospital, UK;
Elisa Kam, ICU, Hillingdon Hospital, UK; Helen Bowyer, Critical Care Centre,
Hinchingbrooke Healthcare NHS Trust, UK; Neil Smith, HICU 1&2, Hull Royal
Infirmary, UK; Maie Templeton, Critical Care UNIT, Imperial College Healthcare
NHS Trust, UK; Jeremy Henning, ICU2&3, James Cook Univeristy Hospital, UK;
Kelly Goffin, ICU, James Paget University Hospital, UK; Ritoo Kapoor, K&C ITU,
Kent and Canterbury Hospital, UK; Shondipon Laha, CrCU, Lancashire Teaching
Hospitals NHS Foundation Trust, UK; Phil Chilton, Critical Care Unit, Leighton
Hospital, UK; Waqas Khaliq, ITU/HDU, Lewisham and Greenwich NHS Trust, UK;
Alison Crayford, ITU/HDU, Maidstone, UK; Samantha Coetzee, ICU, Medway
NHS Foundation Trust, UK; Moira Tait, Adult ICU, Musgrove Park, UK; Wendy
Stoker, ICU, Northumbria Specialist Emergency Care Hospital, UK; Marc
Gimenez, ICU, Papworth Hospital NHS Foundation Trust, UK; Alan Pope, Critical
Care Unit, Peterborough City Hospital, UK; Julie Camsooksai, Critical Care Unit ,
Poole Hospital NHS Trust, UK; David Pogson, Department of Critical Care,
Queen Alexandra Hospital Portsmouth, UK; Kate Quigley, ICU, Queen Elizabeth
Hospital, UK; Jenny Ritzema, Critical Care Department, Queen Elizabeth
Hospital, Gateshead, UK; Anil Hormis, Critical Care Unit, Rotherham NHS
Foundation Trust, UK; Carole Boulanger , ICU, Royal Devon and Exeter NHS
Foundation Trust, UK; M. Balasubramaniam , ICU and HCU, Royal Bolton NHS
hospital trust, UK; Luke Vamplew, Critical Care Unit, Royal Bournemouth
Hospital, UK; Karen Burt, Critical Care Unit, Royal Cornwall Hospital NHS Trust,
UK; Daniel Martin, ICU, Royal Free London NHS Foundation Trust, UK; Irina
Grecu, ICU, Royal Hampshire County Hospital, UK; Jayne Craig, ICU, Royal
Lancaster Infirmary, UK; John Prowle, Adult Critical Care Unit, Royal London
Hospital, UK; Nanci Doyle, ICU, Royal Surrey County Hospital, UK; Jonathon
Shelton , Ward 38 ICU, Royal Victoria Infirmary, UK; Carmen Scott, Ward 18 ICU,
Royal Victoria Infirmary, UK; Phil Donnison, ICU, Salisbury District Hospital, UK;
Sarah Shelton , ICU, Sherwood Forest Hospitals NHS Foundation Trust, UK;
Christian Frey, ITU/HDU, South Tyneside District Hospital, UK; Christine Ryan,
GICU, St Georges Hospital, UK; Dominic Spray, Cardiothoracic ICU, St Georges
Hospital, UK; Christine Ryan, Acute Dependency Unit, St Georges Hospital NHS
Trust London, UK; Veronica Barnes, Neuro ICU, St Georges University Hospital
NHS Foundation Trust, UK; Kerry Barnes, ITU, st helier hospital, UK; Stephanie
Ridgway, Critical Care Unit, NHS Foundation Trust, Tameside General Hospital,
UK; Rajnish Saha, Critical Care Unit, The Princess Alexandra NHS Hospital, UK;
Linda Kent, ICU, The Royal Oldham Hospital, UK; Thomas Clark, ICU, Torbay
Hospital, UK; James Wood, ICU, Tunbridge Wells Hospital, UK; Clare Bolger,
General Intensive Care, Univeristy Hospital Southampton NHS Foundation
Trust, UK; Christopher Bassford, General Critical Care, University Hospital
Coventry, UK; Amanda Cowton, ICU, University hospital of North Durham, UK;
john lewandowski, Critical Care Unit, University Hospital of North Tees, UK;
Xiaobei Zhao, ICU (Level 6), Watford General Hospital / West Hertfortshire NHS
trust, UK; Sally Humphreys, Critical Care, West Suffolk NHS Foundation Trust,
UK; Susan Dowling, Ward 4E Critical Care unit, Whiston, UK; Neil Richardson,
ICU, William Harvey Hospital, Ashford, UK; Andrew Burtenshaw, Critical Care
Unit, Worcestershire Royal Hospital, UK; Carl Stevenson, ICU, Wye Valley NHS
Trust, UK; Danielle Wilcock, Critical Care Unit, York Teaching Hospital NHS
Foundation Trust, UK; Yuiry Nalapko, Anaesthesia and Intensive Care, Lugansk
State Medical University, Ukraine.
Author contributions
All listed authors have (1) made substantial contributions to conception and
design, acquisition of data, or analysis and interpretation of data; (2) drafted
the article or revised it critically for important intellectual content; and (3)
given final approval of the version submitted for publication.
Compliance with ethical standards
Conflicts of interest
None of the authors have any conflict of interest related to this article.
Received: 28 February 2018 Accepted: 25 April 2018
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... Seventy-eight studies were included in the pooled analysis of the prevalence of frailty, stratified by the mean age of the study sample. Six of the included studies had a mean age between 5-74 years (Courtney-Brooks et al., 2012;Jacobs et al., 2017;Kang et al., 2015;Khan, Ö ztürk et al., 2019Khan, Ö ztürk et al., , 2017Pollack et al., 2017); 58 between 75-84 years (Alonso Salinas et al., 2018;Attisano et al., 2017;Baldwin et al., 2014;Bo et al., 2015;Bo et al., 2016;Cheung et al., 2017;Chew et al., 2017;Chia et al., 2016;Coleman et al., 2012;Dal Moro et al., 2017;Dorner et al., 2014;Drudi et al., 2018;Dutzi et al., 2017;Eamer et al., 2018;Eeles et al., 2012;Engelhardt et al., 2018;Ga et al., 2018;Gleason et al., 2017;Goldfarb et al., 2018;Guidet et al., 2018;Heppenstall et al., 2011;Hewitt et al., 2015;Hii et al., 2014;Hilmer et al., 2011;Jokar et al., 2016;Joseph et al., 2014;Joseph et al., 2016;Juma et al., 2016;Karlekar et al., 2017;Kenig et al., 2015;Kobe et al., 2016;Koyama et al., 2018;Kusunose et al., 2018;Lee et al., 2018;Le Maguet et al., 2014;Lin et al., 2017;Llaó et al., 2018;Madni et al., 2018;Mason et al., 2018;Maxwell et al., 2018;McGuckin et al., 2018;Morton et al., 2018;Nolan et al., 2016;Oliveira et al., 2013;Papageorgiou et al., 2018;Parmar et al., 2019;Pasqualetti et al., 2018;Perera et al., 2009;Poudel et al., 2016;Purser et al., 2006;Sánchez et al., 2011;Sanchis et al., 2015;Sikder et al., 2019;Sündermann et al., 2014;Ticinesi et al., 2016;Timmons et al., 2015;Valentini et al., 2018;Vidán et al., 2014); and 14 ≥ 85 years (Amblàs-Novellas et al., 2018;Blanco et al., 2017;Chong et al., 2017;Gullón et al., 2018;Hartley et al., 2017;Induruwa et al., 2017;Martín et al., 2018;Muessig et al., 2018;Nguyen et al., 2016;Papakonstantinou et al., 2018;Peel et al., 2017;Pelavski et al., 2017;Rose et al., 2014;Wallis et al., 2015). The pooled prevalence of frailty was 52.1% (95% CI 35.1-69%) among studies with a mean age between 65-74 years; 46.1% (95% CI 41.0-51.0%) ...
... Fifty-three studies were included in pooled analysis of the prevalence of frailty stratified by ward type (Amblàs-Novellas et al., 2018;Andela et al., 2010;Baldwin et al., 2014;Bo et al., 2016;Cheung et al., 2017;Chew et al., 2017;Chia et al., 2016;Chong et al., 2017;Coleman et al., 2012;Dent et al., 2014;Dutzi et al., 2017;Eeles et al., 2012;Guidet et al., 2018;Gullón et al., 2018;Hartley et al., 2017;Heppenstall et al., 2011;Hewitt et al., 2015;Hewitt et al., 2016;Hii et al., 2014;Ibrahim et al., 2019;Induruwa et al., 2017;Jokar et al., 2016;Joosten et al., 2014;Joseph et al., 2014;Joseph et al., 2016;Juma et al., 2016;Karlekar et al., 2017;Khan et al., 2019;Kobe et al., 2016;Koyama et al., 2018;Lee et al., 2018;Le Maguet et al., 2014;Martín et al., 2018;Muessig et al., 2018;Müller et al., 2017;Myint et al., 2018;Nolan, Ö ztürk et al., 2016Nolan, Ö ztürk et al., , 2017Papageorgiou et al., 2018;Papakonstantinou et al., 2018;Pasqualetti et al., 2018;Peel et al., 2017;Pollack et al., 2017;Poudel et al., 2016;Purser et al., 2006;Ritt et al., 2015;Rose et * =Data not initially reported, or possible to derive from available data. Obtained, or derived, from correspondence with study authors. ...
... 2014; Ticinesi et al., 2016;Vidán et al., 2014;Wou et al., 2013). Fifteen of the included studies were specifically conducted on geriatric wards (Amblàs-Novellas et al., 2018;Andela et al., 2010;Bo et al., 2016;Chew et al., 2017;Chong et al., 2017;Dent et al., 2014;Hartley et al., 2017;Joosten et al., 2014;Martín et al., 2018;Müller et al., 2017;Pasqualetti et al., 2018;Peel et al., 2017;Ritt et al., 2015;Ticinesi et al., 2016;Vidán et al., 2014); twelve on general internal medicine wards (Andela et al., 2010;Eeles et al., 2012;Gullón et al., 2018;Heppenstall et al., 2011;Induruwa et al., 2017;Juma et al., 2016;Koyama, Ö ztürk et al., 2018Koyama, Ö ztürk et al., , 2017Papakonstantinou et al., 2018;Peel et al., 2017;Rose et al., 2014;Vidán et al., 2014); seven acute wards (Amblàs-Novellas et al., 2018;Bo et al., 2016;Ibrahim et al., 2019;Joosten et al., 2014;Poudel et al., 2016;Ticinesi et al., 2016;Wou et al., 2013), seven cardiology wards (Hii et al., 2014;Kobe et al., 2016;Purser et al., 2006;Sánchez et al., 2011;Sanchis et al., 2015;Sündermann et al., 2014;Vidán et al., 2014); seven surgical wards (Andela et al., 2010;Cheung et al., 2017;Chia et al., 2016;Hewitt et al., 2015;Hewitt et al., 2016;Jokar et al., 2016;Myint et al., 2018); six intensive care wards (Baldwin et al., 2014;Guidet et al., 2018;Le Maguet et al., 2014;Muessig et al., 2018;Papageorgiou et al., 2018;Pollack et al., 2017); six traumatology wards (Andela et al., 2010;Joseph et al., 2014;Joseph et al., 2016;Karlekar et al., 2017;Khan et al., 2019;Lee et al., 2018); and, three on rehabilitation wards (Coleman et al., 2012;Dutzi et al., 2017;Nolan et al., 2016). The overall pooled prevalence of frailty was 93% (95% CI 81.8-100%) among geriatric hospital inpatients on rehabilitation wards; 66.5% (95% CI 54.3-78.7%) on geriatric wards; 59.3% (95% CI 50.5-68.1%) ...
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Background Frailty is a common and clinically significant condition among geriatric populations. Although well-evidenced pooled estimates of the prevalence of frailty exist within various settings and populations, presently there are none assessing the overall prevalence of frailty among geriatric hospital inpatients. The purpose of this review was to systematically search and analyse the prevalence of frailty among geriatric hospital inpatients within the literature and examine its associations with national economic indicators. Methods Systematic searches were conducted on Ovid, Web of Science, Scopus, CINAHL Plus, and the Cochrane Library, encompassing all literature published prior to 22 November 2018, supplemented with manual reference searches. Included studies utilised a validated operational definition of frailty, reported the prevalence of frailty, had a minimum age ≥ 65 years, attempted to assess the whole ward/clinical population, and occurred among hospital inpatients. Two reviewers independently extracted data and assessed study quality. Results Ninety-six studies with a pooled sample of 467,779 geriatric hospital inpatients were included. The median critical appraisal score was 8/9 (range 7–9). The pooled prevalence of frailty, and pre-frailty, among geriatric hospital inpatients was 47.4% (95% CI 43.7–51.1%), and 25.8% (95% CI 22.0–29.6%), respectively. Significant differences were observed in the prevalence of frailty stratified by age, prevalent morbidity, ward type, clinical population, and operational definition. No significant differences were observed in stratified analyses by sex or continent, or significant associations between the prevalence of frailty and economic indicators. Conclusions Frailty is highly prevalent among geriatric hospital inpatients. High heterogeneity exists within this setting based on various clinical and demographic characteristics. Pooled estimates reported in this review place the prevalence of frailty among geriatric hospital inpatients between that reported for community-dwelling older adults and older adults in nursing homes, outlining an increase in the relative prevalence of frailty with progression through the healthcare system.
... Sources of data, methods of measurement, and results of analyses performed previously on these data were described in detail elsewhere. 8,10 Patients with complete data on variables of interest were included in statistical analyses. The distribution of missing data across countries is shown in Supplementary Table S1. ...
... step-down units, palliative care wards, or dedicated healthcare facilities) depending on their prognosis, with less economically developed countries having both a lower propensity to deescalate therapy and availability of intermediate care units. 10,25,26 Previous studies suggest that decisions on limiting life-sustaining treatment are made more frequently in countries with higher gross domestic product, with an early focus on comfort measures instead of life support leading to reduced costs of care without adversely affecting clinical outcomes. 1,10 Another possible explanation for not finding the evidence for a strong relationship between healthcare expenditures and short-term mortality described in previous studies is that a ceiling effect has been reached in participating countries regarding survival. ...
... 10,25,26 Previous studies suggest that decisions on limiting life-sustaining treatment are made more frequently in countries with higher gross domestic product, with an early focus on comfort measures instead of life support leading to reduced costs of care without adversely affecting clinical outcomes. 1,10 Another possible explanation for not finding the evidence for a strong relationship between healthcare expenditures and short-term mortality described in previous studies is that a ceiling effect has been reached in participating countries regarding survival. 27 Systems of intensive care provision are well established across Europe, and it is likely that our findings represent a plateau of the health production function, which would mean that still higher expenses produce relatively small results in terms of mortality. ...
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Background Limited evidence suggests variation in mortality of older critically ill adults across Europe. We aimed to investigate regional differences in mortality among very old ICU patients. Methods Multilevel analysis of two international prospective cohort studies. We included patients ≥80 yr old from 322 ICUs located in 16 European countries. The primary outcome was mortality within 30 days from admission to the ICU. Results are presented as n (%) with 95% confidence intervals and odds ratios (ORs). Results Of 8457 patients, 2944 (36.9% [35.9–38.0%]) died within 30 days. Crude mortality rates varied widely between participating countries (from 10.1% [6.4–15.6%] to 45.1% [41.1–49.2%] in the ICU and from 21.3% [16.3–28.9%] to 55.3% [51.1–59.5%] within 30 days). After adjustment for confounding variables, the variation in 30-day mortality between countries was substantially smaller than between ICUs (median OR 1.14 vs 1.58). Healthcare expenditure per capita (OR=0.84 per $1000 [0.75–0.94]) and social health insurance framework (OR=1.43 [1.01–2.01]) were associated with ICU mortality, but the direction and magnitude of these relationships was uncertain in 30-day follow-up. Volume of admissions was associated with lower mortality both in the ICU (OR=0.81 per 1000 annual ICU admissions [0.71–0.94]) and in 30-day follow-up (OR=0.86 [0.76–0.97]). Conclusion The apparent variation in short-term mortality rates of older adults hospitalised in ICUs across Europe can be largely attributed to differences in the clinical profile of patients admitted. The volume–outcome relationship identified in this population requires further investigation.
... Most studies evaluating short-and long-term mortality are heterogeneous in design and results, and factors associated with mortality vary widely across studies [9]. Outcomes of older patients hospitalised in ICUs are influenced by premorbid conditions, notably frailty and comorbidities, as well as in-ICU events, such as duration of mechanical ventilation and decisions to withdraw life-sustaining therapies [4,5,[9][10][11][12][13]. In addition, among survivors, some may suffer from disabilities, cognitive impairment and decreased quality of life [14,15]. ...
... Specific studies should be designed to confirm our findings. We did not assess frailty nor decisions of withdrawal of life sustaining therapy, which are two important prognostic factors in the older population [10,13]. We did not have information on the type of IMCU the patient was hospitalised (general or specialised high dependency units), thus adding heterogeneity in the IMCU group. ...
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Background Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW). Methods Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed. Results Among 3036 patients, 1675 (55%) were women; median age was 85 [81–99] years; simplified acute physiology score (SAPS-3) 62 [55–69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW ( p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04–1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95–1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5–41.7], p = 0.037 and 44.3 [38.6–48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4–45.3] and 45.5 [40.0–50.0], respectively) and IMCU group (35.7 [29.7–43.8] and 44.5 [39.7–48.4], respectively). Conclusions Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs.
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Chapter
Seasonal or continuous resource constraints are evident in many healthcare systems and necessitate restrictions on admissions to intensive care units (ICUs). When the demand for ICU beds exceeds capacity, patients who are expected to benefit most are prioritised for admission and continuation of intensive care. In addition to survival, the benefit of intensive care in old patients strongly depends on the quality of life that can be achieved after discharge. In this chapter, we will discuss the challenges of predicting outcome for this patient population as well as the medical and ethical issues which may arise during triage.
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What are the limitations of life-sustaining treatment (LLST)?
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Probably the most frequently reported outcome in healthcare in general, and in intensive care in particular, is survival or its counterpart mortality. Obviously, other patient-centered outcomes are very often connected and even dependent on a patient that survives. It makes no meaning to talk about quality of life in patients not surviving the ICU stay, but for survivors post-hospital discharge, other issues than merely survival become more and more important.
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Purpose: Very old critical ill patients are a rapid expanding group in the ICU. Indications for admission, triage criteria and level of care are frequently discussed for such patients. However, most relevant outcome studies in this group frequently find an increased mortality and a reduced quality of life in survivors. The main objective was to study the impact of frailty compared with other variables with regards to short-term outcome in the very old ICU population. Methods: A transnational prospective cohort study from October 2016 to May 2017 with 30 days follow-up was set up by the European Society of Intensive Care Medicine. In total 311 ICUs from 21 European countries participated. The ICUs included the first consecutive 20 very old (≥ 80 years) patients admitted to the ICU within a 3-month inclusion period. Frailty, SOFA score and therapeutic procedures were registered, in addition to limitations of care. For measurement of frailty the Clinical Frailty Scale was used at ICU admission. The main outcomes were ICU and 30-day mortality and survival at 30 days. Results: A total of 5021 patients with a median age of 84 years (IQR 81-86 years) were included in the final analysis, 2404 (47.9%) were women. Admission was classified as acute in 4215 (83.9%) of the patients. Overall ICU and 30-day mortality rates were 22.1% and 32.6%. During ICU stay 23.8% of the patients did not receive specific ICU procedures: ventilation, vasoactive drugs or renal replacement therapy. Frailty (values ≥ 5) was found in 43.1% and was independently related to 30-day survival (HR 1.54; 95% CI 1.38-1.73) for frail versus non-frail. Conclusions: Among very old patients (≥ 80 years) admitted to the ICU, the consecutive classes in Clinical Frailty Scale were inversely associated with short-term survival. The scale had a very low number of missing data. These findings provide support to add frailty to the clinical assessment in this patient group. Trial registration: ClinicalTrials.gov (ID: NCT03134807).
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Background: demand for intensive care of the very elderly is growing, but few studies report inclusion of their opinions in the admission decision-making process. Whether or not to refer a very elderly patient to intensive care unit is a difficult decision that should take into account individual wishes, out of respect for the patient's decision-making autonomy. Methods: in 15 emergency departments, patients over 80 years old who had a potential indication for admission to intensive care, and that were capable of expressing their opinion were included. Frequency of opinions sought before referral decision and individual and organisational factors associated were recorded and analysed. Results: a total of 2,115 patients were included. Only 270 (12.7%) of them were asked for their opinion, and there were marked variations between study centres (minimum: 1.1% and maximum: 53.6%). A history of dementia reduced the probability of a patient being asked for his or her opinion (OR 0.47, 95% CI: 0.25-0.83). Patients' opinion was most often sought when their functional autonomy was conserved (OR 2.10, 95% CI: 1.39-3.21) and when a relative had been questioned (OR 5.46, 95% CI: 3.8-7.88). Older attending physicians were less likely to ask for the patient's opinion (older physician versus younger physician, OR 0.48, 95% CI: 0.35-0.66). Conclusions: elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.
Article
Background: Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80. Methods: We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80. Results: We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions. Conclusion: There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.
Article
One of the most important decisions that a physician makes is whether to admit a patient to the intensive care unit (ICU). The modern ICU provides a capacity for advanced monitoring and life support that is typically unavailable elsewhere in the hospital and is lifesaving for patients with a wide array of acute deteriorations in health. However, ICU care is also one of the most expensive, intensive, and intrusive endeavors in health care. Although patients admitted to the ICU account for approximately one-quarter of hospitalized patients, they account for half of total hospital expenditures in the United States, with costs estimated at $110 to $260 billion per year or approximately 1% of the gross domestic product.¹- 3 Furthermore, ICU care can be unnecessary, harmful, or futile. Importantly, the provision of ICU services is increasing. In an era when efforts to contain health care costs have decreased total hospital beds, the number of ICU beds continues to increase.⁴ An important question is whether this growth in ICU services and beds is necessary to meet the demands of an expanding population of critically ill patients or whether ICU beds are being oversupplied and subsequently are being filled with patients who might be cared for in less-intense settings at lower cost with similar or better outcome.
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Importance The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population. Objective To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice. Design, Setting, and Participants Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015. Interventions Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants). Main Outcomes and Measures The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months. Results One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups. Conclusions and Relevance Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU. Trial Registration clinicaltrials.gov Identifier: NCT01508819
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Background: Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts. Methods: An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest). Results: A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths. Conclusions: In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.
Article
The “very old intensive care patients” (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.
Article
Objectives: Withdrawal of life-sustaining therapy may lead to premature limitations of life-saving treatments among patients with intracranial hemorrhage, representing a self-fulfilling prophecy. We aimed to determine whether our algorithm for the withdrawal of life-sustaining therapy decision would accurately identify patients with a high probability of poor outcome, despite aggressive treatment. Design: Retrospective analysis of prospectively collected data. Setting: Tertiary-care Neuro-ICU. Patients: Intraparenchymal, subdural, and subarachnoid hemorrhage patients. Interventions: Baseline demographics, clinical status, and hospital course were assessed to determine the predictors of in-hospital mortality and 12-month death/severe disability among patients receiving maximal therapy. Multivariable logistic regression models developed on maximal therapy patients were applied to patients who underwent withdrawal of life-sustaining therapy to predict their probable outcome had they continued maximal treatment. A validation cohort of propensity score-matched patients was identified from the maximal therapy cohort, and their predicted and actual outcomes compared. Measurements and main results: Of 383 patients enrolled, there were 128 subarachnoid hemorrhage (33.4%), 134 subdural hematoma (35.0%), and 121 intraparenchymal hemorrhage (31.6%). Twenty-six patients (6.8%) underwent withdrawal of life-sustaining therapy and died, 41 (10.7%) continued maximal therapy and died in hospital, and 316 (82.5%) continued maximal therapy and survived to discharge. The median predicted probability of in-hospital death among withdrawal of life-sustaining therapy patients was 35% had they continued maximal therapy, whereas the median predicted probability of 12-month death/severe disability was 98%. In the propensity-matched validation cohort, 16 of 20 patients had greater than or equal to 80% predicted probability of death/severe disability at 12 months, matching the observed outcomes and supporting the strength and validity of our prediction models. Conclusions: The withdrawal of life-sustaining therapy decision may contribute to premature in-hospital death in some patients who may otherwise have been expected to survive to discharge. However, based on probability models, nearly all of the patients who underwent withdrawal of life-sustaining therapy would have died or remained severely disabled at 12 months had maximal therapy been continued. Withdrawal of life-sustaining therapy may not represent a self-fulfilling prophecy.