10 minutes on ‘very elderly’ admissions to ICU…and cost

I read an interesting editorial this evening on how the critical care community is attempting to rationalise decision making with respect to who is admitted to intensive care or what they are offered once they get there. You can find the editorial by Bassford here:

As an intensive care registrar I find myself constantly trying to figure out “should I admit this patient?”. If you do not work for intensive care, you probably often ask yourself “should I refer this patient?” As Bassford points out the potential factors that can contribute to this sort of decision making process include not just patient preference and a consideration of the burden versus potential benefit of invasive treatments, but also a mind to the fact that critical care resources are not infinite.

This month also in Critical Care Medicine, Chin-Yee et al., published a paper which attempts to cost-analyse admissions to critical care in the ‘very elderly’ (that is patients 80 years or older).

The paper is available by open access here.

The most interesting, though perhaps not surprising part of this paper for me was the fact that a while more than 80% of patients received more than one ‘life-sustaining’ treatment, just 51% had a clear preference for this avenue of care. I was also surprised that such a large proportion of the admissions (almost half) had an advance directive. This seems much more than what I see in practice in the UK and although outside the scope of their project, it is a shame that the team didn’t capture what these directives covered.

The most obvious question thought is probably; can we minimise cost of critical care in this group of patients who have particularly low scope of benefit, without adversely affecting clinical outcome?

The authors suggest their work may add fuel to the idea that we should be focusing on early goal directed conversations in this cohort of patients. They suggest that a commitment to finding out early what a ‘very elderly’ patient or their relative wants and importantly, doesn’t want, not only give us an opportunity to make the care we offer patients as patient-centered as it should be but perhaps also to reduce the cost of critical care admissions in this cohort.

The five minute summary of their findings is below:

Interested to discuss around this one, so let me know your thoughts!

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Author:

I am a single speciality Intensive care Medicine trainee and member of the Intensive Care Society Council... originally from Ireland but trained and working in West Mids, UK. You say my name like ee-fa My notes are not medical advice. Please enjoy, comment, share and let me know your thoughts. Disclaimers: All my opinions are generally a work in progress and therefore subject to change - but then why would it be any other way? Views expressed on Whistlingdixie and Scribblingdixie blogs are not medical advice. My opinions and the content on either of these sites do not constitute the opinion of any of my employers, The Intensive Care Society or any other organisation I may be affiliated with.

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