Abstract
Purpose
To assess physician decisions about ICU admission for life-sustaining treatments (LSTs).
Methods
Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV).
Results
The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13–0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10–0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04–3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23–0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively.
Conclusions
Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Bagshaw SM, Webb SA, Delaney A, George C, Pilcher D, Hart GK, Bellomo R (2009) Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care 13:R45
Garrouste-Orgeas M, Montuclard L, Timsit JF, Reignier J, Desmettre T, Karoubi P, Moreau D, Montesino L, Duguet A, Boussat S, Ede C, Monseau Y, Paule T, Misset B, Carlet J (2005) Predictors of intensive care unit refusal in French intensive care units: a multiple-center study. Crit Care Med 33:750–755
Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste-Orgeas M, Cohen Y, Thuong M, Paugam C, Apperre C, De Cagny B, Brun F, Bornstain C, Parrot A, Thamion F, Lacherade JC, Bouffard Y, Le Gall JR, Herve C, Grassin M, Zittoun R, Schlemmer B, Dhainaut JF (2001) Compliance with triage to intensive care recommendations. Crit Care Med 29:2132–2136
Vanhecke TE, Gandhi M, McCullough PA, Lazar MH, Ravikrishnan KP, Kadaj P, Begle RL (2008) Outcomes of patients considered for, but not admitted to, the intensive care unit. Crit Care Med 36:812–817
Garrouste-Orgeas M, Timsit JF, Montuclard L, Colvez A, Gattolliat O, Philippart F, Rigal G, Misset B, Carlet J (2006) Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission. Intensive Care Med 32:1045–1051
Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine (1999) Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27:633–638
Garrouste-Orgeas M, Boumendil A, Pateron D, Aergerter P, Somme D, Simon T, Guidet B (2009) Selection of intensive care unit admission criteria for patients aged 80 years and over and compliance of emergency and intensive care unit physicians with the selected criteria: an observational, multicenter, prospective study. Crit Care Med 37:2919–2928
Frost DW, Cook DJ, Heyland DK, Fowler RA (2011) Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review. Crit Care Med 39:1174–1189
Joynt GM, Gomersall CD, Tan P, Lee A, Cheng CA, Wong EL (2001) Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med 27:1459–1465
Reignier J, Dumont R, Katsahian S, Martin-Lefevre L, Renard B, Fiancette M, Lebert C, Clementi E, Bontemps F (2008) Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal. Crit Care Med 36:2076–2083
Le Conte P, Riochet D, Batard E, Volteau C, Giraudeau B, Arnaudet I, Labastire L, Levraut J, Thys F, Lauque D, Piva C, Schmidt J, Trewick D, Potel G (2010) Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support. Intensive Care Med 36:765–772
Barnato AE, Hsu HE, Bryce CL, Lave JR, Emlet LL, Angus DC, Arnold RM (2008) Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study. Crit Care Med 36:3156–3163
Alemayehu E, Molloy DW, Guyatt GH, Singer J, Penington G, Basile J, Eisemann M, Finucane P, McMurdo ME, Powell C (1991) Variability in physicians’ decisions on caring for chronically ill elderly patients: an international study. CMAJ 144:1133–1138
Philippart F, Vesin A, Bruel C, Kpodji A, Durand-Gassellin B, Garçon P, Levy-Soussan M, Jagot J, Calvo-Verjat N, Timsit JF, Misset B, Garrouste Orgeas M (2013) The ETHICA study (part I): elderly thoughts about intensive care unit admission for life-sustaining treatments: on behalf of the ETHICA group. Intensive Care Med. doi:10.1007/s00134-013-2976-y
Lawton MP, Brody EM (1969) Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9:179–186
Katz S (1983) Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 31:721–727
Skevington SM, Lotfy M, O’Connell KA (2004) The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL Group. Qual Life Res 13:299–310
Power M, Quinn K, Schmidt S (2005) Development of the WHOQOL-old module. Qual Life Res 14:2197–2214
Edbrooke DL, Minelli C, Mills GH, Iapichino G, Pezzi A, Corbella D, Jacobs P, Lippert A, Wiis J, Pesenti A, Patroniti N, Pirracchio R, Payen D, Gurman G, Bakker J, Kesecioglu J, Hargreaves C, Cohen SL, Baras M, Artigas A, Sprung CL (2011) Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis. Crit Care 15:R56
Garrouste-Orgeas M, Montuclard L, Timsit JF, Misset B, Christias M, Carlet J (2003) Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes. Intensive Care Med 29:774–781
Sprung CL, Artigas A, Kesecioglu J, Pezzi A, Wiis J, Pirracchio R, Baras M, Edbrooke DL, Pesenti A, Bakker J, Hargreaves C, Gurman G, Cohen SL, Lippert A, Payen D, Corbella D, Iapichino G (2012) The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly. Crit Care Med 40:132–138
Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, Oppenheim A, Epstein L, Cotev S (1999) Evaluation of triage decisions for intensive care admission. Crit Care Med 27:1073–1079
Boumendil A, Angus DC, Guitonneau AL, Menn AM, Ginsburg C, Takun K, Davido A, Masmoudi R, Doumenc B, Pateron D, Garrouste-Orgeas M, Somme D, Simon T, Aegerter P, Guidet B (2012) Variability of intensive care admission decisions for the very elderly. PLoS One 7:e34387
Sprung CL, Baras M, Iapichino G, Kesecioglu J, Lippert A, Hargreaves C, Pezzi A, Pirracchio R, Edbrooke DL, Pesenti A, Bakker J, Gurman G, Cohen SL, Wiis J, Payen D, Artigas A (2012) The Eldicus prospective, observational study of triage decision making in European intensive care units: part I-European Intensive Care Admission Triage Scores. Crit Care Med 40:125–131
Boumendil A, Latouche A, Guidet B (2011) On the benefit of intensive care for very old patients. Arch Intern Med 171:1116–1117
De Rooij SE, Govers AC, Korevaar JC, Giesbers AW, Levi M, De Jonge E (2008) Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment. J Am Geriatr Soc 56:816–822
Somme D, Maillet JM, Gisselbrecht M, Novara A, Ract C, Fagon JY (2003) Critically ill old and the oldest-old patients in intensive care: short- and long-term outcomes. Intensive Care Med 29:2137–2143
Martin GS, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34:15–21
Loewy EH (2005) Age discrimination at its best: should chronological age be a prime factor in medical decision making? Health Care Anal 13:101–117
Mick DJ, Ackerman MH (1997) Neutralizing ageism in critical care via outcomes research. AACN Clin Issues 8:597–608
Iapichino G, Corbella D, Minelli C, Mills GH, Artigas A, Edbooke DL, Pezzi A, Kesecioglu J, Patroniti N, Baras M, Sprung CL (2010) Reasons for refusal of admission to intensive care and impact on mortality. Intensive Care Med 36:1772–1779
Escher M, Perneger TV, Chevrolet JC (2004) National questionnaire survey on what influences doctors’ decisions about admission to intensive care. BMJ 329:425
Quill TE, Holloway RG (2012) Evidence, preferences, recommendations–finding the right balance in patient care. N Engl J Med 366:1653–1655
Azoulay E, Pochard F, Chevret S, Adrie C, Annane D, Bleichner G, Bornstain C, Bouffard Y, Cohen Y, Feissel M, Goldgran-Toledano D, Guitton C, Hayon J, Iglesias E, Joly LM, Jourdain M, Laplace C, Lebert C, Pingat J, Poisson C, Renault A, Sanchez O, Selcer D, Timsit JF, Le Gall JR, Schlemmer B (2004) Half the family members of intensive care unit patients do not want to share in the decision-making process: a study in 78 French intensive care units. Crit Care Med 32:1832–1838
Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J (2005) Risk of posttraumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994
Acknowledgments
We thank A. Wolfe, MD, for her assistance in preparing the manuscript and Alexis Tabah for building and managing the study website. We thank all ICU physicians of the ETHICA group who participated in the study. This study was supported by the French Society for Critical Care (SRLF) and the Fondation de France. These organisations had no role in the design or conducting of the study; in data collection, management, or interpretation; or in the writing of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Additional information
Part I of the ETHICA study can be found at: doi:10.1007/s00134-013-2976-y; an editorial discussing both parts of the ETHICA study can be found at: doi:10.1007/s00134-013-2968-y.
On behalf of the ETHICA group; the members of the ETHICA group who acted as co-investigators are listed in the Appendix.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Appendix
Appendix
ETHICA Group List of physicians who participated in the study (all in France).
Allou Nicolas, Surgical ICU, University Bichat Hospital, Paris.
Allyn Jérome, Surgical ICU, University Bichat Hospital, Paris.
Ara-Somohano Claire, University Albert Michallon Hospital, Grenoble.
Asehnoune Karim, Surgical ICU, University Hotel Dieu, Nantes.
Baillat Laetitia, Medical-Surgical ICU, Arbeltier General Hospital, Coulommiers.
Berkelmans Frantz, Medical-Surgical ICU, General Hospital, Dunkerque.
Beuret Pascal, Medical-Surgical ICU, General Hospital, Roanne.
Blanié Antonia, Anesthesiology and ICU Department, University Bicêtre Hospital, Le Kremlin Bicêtre.
Bonadona, Agnés, University Albert Michallon Hospital, Grenoble.
Bonnaire Rémi, Medical-Surgical ICU, Robert Ballanger Hospital, Aulnay Sous-Bois.
Bonneton Benjamin, Medical-Surgical ICU, Arbeltier General Hospital, Couloummiers.
Bornstain Caroline, Medical-Surgical Hospital, Le Raincy Hospital, Montfermeil.
Bougerol François, Medical-Surgical ICU, General Hospital, Dieppe.
Boukantar, Madjid, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Bretsztajn Alain, Medical-Surgical ICU, General Hospital, Salon de Provence.
Brunel Elodie, Medical-Surgical ICU, University Purpan Hospital, Toulouse.
Carr Julie, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Chalumeau-Lemoine Ludivine, Medical-Surgical ICU, Institut Gustave Roussy Hospital, Villejuif.
Chanques Gérald, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Charpentier Julien, Medical ICU, University Cochin Hospital, Paris.
Charron Cyril, Medical-Surgical ICU, University Ambroise Paré Hospital, Boulogne Billancourt.
Ciroldi Magali, Medical-Surgical ICU, General Hospital André Grégoire, Montreuil.
Clec’h Christophe, Medical-Surgical ICU, University Avicenne Hospital, Bobigny.
Combettes Evelyne, Neurology Medical-Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Conia Alexandre, Medical-Surgical ICU, General Victor Jousselin Hospital, Dreux.
Conrad Marie, Medical ICU, University Central Hospital, Nancy.
Coquet Isaline, Medical-Surgical ICU, Foch Hospital, Suresnes.
Coudrot Maud, Medical-Surgical ICU G, University North Hospital, Saint Etienne.
Cravoisy-Popovic Aurélie, Medical ICU, University Central Hospital, Nancy.
Darmon Michael, Medical-Surgical ICU G, University North Hospital, Saint-Priest-en-Jarez.
De Jonghe Bernard, Medical-Surgical ICU, General Hospital, Poissy.
Debarre Matthieu, Neuro-Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Demoule Alexandre, Respiratory and Medical ICU, University La Pitié Salpêtrière Hospital, Paris.
Demory Didier, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Donati Stéphane-Yannis, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Durand-Gasselin Jacques, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Ede Cyrille, Medical-Surgical ICU, General Hospital, Auxerre.
Fassier Thomas, Medical Information, Evaluation and Research, University Hospices Civils, Lyon.
Fieux Fabienne, Surgical ICU, University Saint Louis Hospital, Paris.
Floccard Bernard, Medical-Surgical ICU, University Edouard Herriot Hospital, Lyon.
Galbois Arnaud, Medical ICU, University Saint Antoine Hospital, Paris.
Gamelin Alexandre, Burn ICU, University Roger Salengro Hospital, Lille.
Gauss Tobias, Anesthesiology Department, University Beaujon Hospital, Clichy.
Girault Christophe, Medical ICU, University Charles Nicolle Hospital, Rouen.
Grimaldi David, Medical ICU, University Cochin Hospital, Paris.
Guidet Bertrand, Medical ICU, University Saint Antoine Hospital, Paris.
Hamdi Aïcha, Medical-Surgical ICU, General André Grégoire Hospital, Montreuil.
Hamidfar-Roy Rébecca, Medical ICU, University Albert Michallon Hospital, Grenoble.
Hamzaoui Olfa, Medical ICU, University Antoine Béclère, Hospital, Clamart.
Hérault Marie Christine, Medical-Surgical ICU, University Albert Michallon Hospital, Grenoble.
Holzapfel Laurent, Medical-Surgical ICU, General Hospital Fleyriat, Bourg en Bresse.
Hurel Dominique, Medical-Surgical ICU, General François Quesnay Hospital, Mantes la Jolie.
Jaber Samir, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Kaidomar Michel, Medical-Surgical ICU, General Hospital, Fréjus.
Kallel Hatem, Medical-Surgical ICU, General Andrée Rosemon Hospital, Cayenne.
Lancrin Frédéric, Anesthesiology and ICU Department, Institut Gustave Roussy Hospital, Villejuif.
Laplace Christian, Surgical ICU, Bicêtre University Hospital, Le Kremlin Bicêtre.
Lau Nicolas, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Lebert Christine, Medical-Surgical ICU, Les Oudaries Hospital, La Roche-Sur-Yon.
Lefebvre Aurélie, Medical ICU, University Hôtel Dieu Hospital, Paris.
Legriel Stéphane, Medical-Surgical ICU, Mignot Hospital, Le Chesnay.
Lemiale Virginie, Medical ICU, University Saint Louis Hospital, Paris.
Lenclud Christophe, Medical ICU, University Lariboisière Hospital, Paris.
Lerolle Nicolas, Medical ICU, University Hospital, Angers.
Machado Sonia, Metabolic ICU, University Lapeyronie Hospital, Montpellier.
Max Adeline, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Maxime Virginie, Medical ICU, University Raymond Poincaré Hospital, Garches.
Mayaux Julien, Respiratory and Medical ICU, University La Pitié Salpêtrière Hospital, Paris.
Merceron Sybille, Medical-Surgical ICU, Mignot Hospital, Le Chesnay.
Minet Clémence, Medical ICU, University Albert Michallon Hospital, Grenoble.
Mongardon Nicolas, Medical ICU, University Cochin Hospital, Paris.
Offenstadt Georges, Medical ICU, University Saint Antoine Hospital, Paris.
Parrot Antoine, Respiratory ICU, University Tenon, Hospital, Paris.
Pease Sebastian, Surgical ICU, University Beaujon Hospital, Clichy.
Pene Fréderic, Medical ICU, University Cochin Hospital, Paris.
Percheron Stéphanie, Medical-Surgical ICU, General Sud Essonne Dourdan-Etampes Hospital, Etampes.
Philippon-Jouve Bénédicte, Medical-Surgical ICU, General Hospital, Roanne.
Pradère Pauline, Medical ICU, University Tenon, Hospital, Paris.
Rabbat Antoine, Medical ICU, University Hôtel Dieu Hospital, Paris.
Raux Mathieu, Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Renault Anne, Medical ICU, University La Cavale Blanche Hospital, Brest.
Richard Jean-Christophe, Medical ICU, University La Croix Rousse Hospital, Lyon.
Ricome Sylvie, Medical ICU, University Cochin Hospital, Paris.
Rigaud Jean-Philippe, Medical-Surgical ICU, General Hospital, Dieppe.
Riu Beatrice, Medical-Surgical ICU, University Purpan Hospital, Toulouse.
Rodriguez Luc, Medical ICU, General Pays D’Aix Hospital, Aix en Provence.
Roquilly Antoine, Medical ICU, University Hospital, Nantes.
Roussel Christophe, Medical-Surgical ICU, General Hospital, Fréjus.
Saissi Gilbert, Surgical ICU, University Caremeau Hospital, Nimes.
Schnell David, Medical ICU, University Saint Louis Hospital, Paris.
Schwebel Carole, Medical ICU, University Albert Michallon Hospital, Grenoble.
Seguin Thierry, Medical-Surgical ICU, University Rangueil Hospital, Toulouse.
Serveaux Marianne, Metabolic ICU, University Lapeyronie Hospital, Montpellier.
Siami Shidasp, General Sud Essonne Dourdan-Etampes Hospital, Etampes.
Tamion Fabienne, Medical ICU, University Charles Nicolle Hospital, Rouen.
Theodore Jonathan, Medical-Surgical ICU, General Hospital, Salon de Provence.
Touati Samia, Medical-Surgical ICU, General Hospital, Meaux.
Willems Vincent, Medical-Surgical ICU General Joseph Imbert Hospital, Arles.
Zuber Benjamin, Medical ICU, University Cochin Hospital, Paris.
Rights and permissions
About this article
Cite this article
Garrouste-Orgeas, M., Tabah, A., Vesin, A. et al. The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over. Intensive Care Med 39, 1574–1583 (2013). https://doi.org/10.1007/s00134-013-2977-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-013-2977-x