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Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study

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Abstract

Purpose

The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65–80 years) and very elderly (> 80 years) intensive care unit (ICU) patients.

Methods

We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States).

Results

We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2–8) vs. 7 (4–13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission.

Conclusions

Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.

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Data availability

Written requests for de-identified data can be made to Dr. Burns.

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Acknowledgements

We thank the members of the Canadian Critical Care Trials Group (CCCTG) for their contributions to the study design and guidance during study implementation. We thank the site investigators and research personnel who participated in the Ventilator Weaning and Discontinuation Practices for Critically Ill Patients study.

Funding

This study was funded by a peer-reviewed grant from the Canadian Frailty Network. The parent study was investigator-initiated and peer-review funded [CIHR-industry partnered grant (CIHR, Fisher & Paykel, Covidien, and GE Healthcare Ltd)]. KEAB currently holds a Mid-Career Physician Services Incorporated Award. DJC holds a Canada Research Chair in Knowledge Translation. JV received grants from CIBER de Enfermedades Respiratorias, Madrid, Spain (CB06/06/1088), and from Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Spain (PIFIISC21-36).

Author information

Authors and Affiliations

  1. Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada

    Karen E. A. Burns

  2. Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael’s Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada

    Karen E. A. Burns & Leena Rizvi

  3. Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Canada

    Karen E. A. Burns & Keying Xu

  4. Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada

    Karen E. A. Burns, Deborah J. Cook & Maureen O. Meade

  5. Division of Critical Care Medicine, St Joseph’s Hospital, Hamilton, Canada

    Deborah J. Cook

  6. Applied Health Research Centre, St Michael’s Hospital, Toronto, Canada

    Keying Xu

  7. Division of Critical Care Medicine, Centre for Health Evaluation and Outcome Sciences, St Paul’s Hospital, Vancouver, BC, Canada

    Peter Dodek

  8. University of British Columbia, Vancouver, BC, Canada

    Peter Dodek

  9. CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain

    Jesús Villar

  10. Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain

    Jesús Villar

  11. Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

    Andrew Jones

  12. Department of Intensive Care, Hinduja National Hospital, Bombay, India

    Farhad N. Kapadia

  13. Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia

    David J. Gattas

  14. The George Institute for Global Health, Sydney, Australia

    David J. Gattas

  15. Tufts University School of Medicine, Boston, MA, USA

    Scott K. Epstein

  16. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy

    Paolo Pelosi

  17. San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy

    Paolo Pelosi

  18. Anaesthesia, Critical Care and Pain Medicine, Edinburgh Royal Infirmary, Edinburgh, Scotland, UK

    Kallirroi Kefala

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  1. Karen E. A. Burns
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on behalf of the Canadian Critical Care Trials Group

Contributions

Concept and design: KEAB, DJC, PD, JV, SKE, PP and MOM. Acquisition, analysis, or interpretation of data: KEAB, DJC, KX, JV, AJ, FNK, DJG, SKE, KK and MOM. Drafting of the manuscript: KEAB and JV. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: KX. Obtained funding: KEAB and MOM. Administrative, technical, or material support: KEAB, DJC, AJ and SKE. Supervision: KEAB, JV and PP. Other—coordinated UK contribution: AJ and KK. Other—coordinated India contribution: FNK. Other—coordinated Europe contribution: JV and PP. Other—coordinated Aus/NZ contribution: DJG. Other – coordinated USA contribution: SKE.

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Correspondence to Karen E. A. Burns.

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KEAB and KX had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Burns, K.E.A., Cook, D.J., Xu, K. et al. Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study. Intensive Care Med 49, 1181–1190 (2023). https://doi.org/10.1007/s00134-023-07188-4

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