Long-term Outcomes of the Very Elderly
Admitted to ICUs in Canada:
A Quality Finish?
Daren K. Heyland MD, MSc
Queen’s University and Kingston General Hospital
Kingston Ontario
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Background
• Globally, population is ageing
• In US, the number of persons aged 85 years or older is likely to
grow from about 4 million in 2000 to 19 million by 2050
• In Canada
– Currently 55-64 fast growing age group
– >80 second fast growing age group (25% increase from 2001-2005)
– Rate of growth projected to continue till 2031 when seniors would account
for 25% of population (currently 13%)
– As the population ages, the proportion of patients with advanced medical
diseases will rise and our health care system needs to adapt to this changing
demographic
Current ICU Utilization of Very
Elderly in Ontario
18%
22%
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Biomedicalization of Aging
• Society views ageing negatively, as a disease for which medical
intervention is normalized, necessary, and appropriate.
• The more high tech medicine one consumes; the more one
forestalls aging.
• In this paradigm, use of life sustaining technology becomes the
norm
• From Family’s perspective, caring is associated with everything
being done
• Consequence is that we have a crisis where demand for critical
resources outstrips supply and problem will only get worse
Background
Quality EOL Care
Scare ICU
Resources
Aging of Society
(Very) Elderly in the ICU?
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A Quality Finish?
CMAJ 2006;174:627
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What Matters the Most to Quality of End of
Life Care in Canada
N= 440
Results from Patient’s Perspective
Areas of Greatest “Importance”
% “Extremely
Important”
To have trust and confidence in the Doctor looking after you
55.8
Not to be kept alive on life support when there is little hope for a
meaningful recovery
55.7
That information about your disease be communicated to you in a
honest manner
44.1
To complete things and prepare for life’s end
43.9
To have an adequate plan of care and services available to look after
you at home upon discharge
41.8
To not be a physical or emotional burden on your family
41.8
Good Communication and Decision-Making?
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Heyland CMAJ 2006;174:627
Improving EOL communication
and decision making
Greatest Improvements in EOL Care
Improving EOL communication
and decision making
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Failure to Engage Hospitalized
Elderly Patients and Their Families
• Multicenter survey of 283 80+ on hospital wards
• Majority had thought of EOL wishes and could
•
•
•
express preference for treatment at EOL
Less than 1/3 had spoken to health care
professional
Fewer than 20% acknowledged a prognostic
disclosure
Expressed preferences and documents ‘goals of
care’ only agreed 1/3 time
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Heyland JAMA Int Med 2013
Consequences of Intensification of
Care at the End of Life
• 7 academic centers from US
• 332 patients with advanced cancer who died and their
•
•
•
family caregivers
Patients asked, “have you and your doctor discussed
any particular wishes you have about the care you
would want to receive if you were dying?”
123 (37%) reported have end of life discussion
at baseline
median follow up 4.4 months after baseline
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Wright JAMA 2008;300:1665
End of Life Discussions…
…Associated with decreased intensity of care
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Wright JAMA 2008;300:1665
plau
• Background:
– 30% of medical care is attributable to 5% of those who die in
a year
– About 1/3 of annual expenditures of those who die occurs in
the last month
– Most of these final costs are secondary to aggressive medical
care in the last 30 days.
• Patients with no EOL conversation much more likely to
•
•
die in ICU, less likely to go to hospice
Last week of life medical expenses $2917 vs $1876 for
those who did have a EOL conversation
Based on number of cancer deaths each year, if could
increase ACP to 50% levels, would result in $76 million
savings/year.
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Zhang Arch Intern Med 2009;169:480
Summary
• Very elderly- it is plausible that poor
communication and decision-making
leads to overutilization of ICU resources
and poor quality EOL care.
• To the extent that admission to ICU for
an elderly patient requires a decision to
be made, let’s improve clinical decision
making!
Purpose of Information Exchange
Prognosis
+
Values
Good Decision
What do we know about the outcomes of the
very elderly critically ill patient?
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REALISTIC-80
What do we know about outcomes of Elderly in ICU
• European and US studies:
– ICU mortality 30-35% mortality
– 12 month mortality 60-70% mortality
– Severity of illness strongest predictor of short term survival
– Comorbidities strongest predictor of long term survival
– Significant comorbidities plus prolonged ICU stay=<5% survival
• Limited data on functional outcomes/QOL
– QOL studies in selected survivors
– Of survivors, functional status or QOL seems ‘reasonable’
– Most studies old, single centered, using non-validated instruments of
functional status
• No studies have comprehensively evaluated the determinants of
long-term quality of life or functional recovery after critical
illness in very elderly persons.
Information Most Important to Patients
Facing a Life-threatening Illness
 Most Important
 chances of surviving
 resultant health state
More important for very elderly
 Moderate Importance
 Impact on family’s lives
 Least Important




Length of hospital stay,
probability of institutionalization
amount of pain
ICUs, ventilators etc.
Heyland Chest 2006;130:419 and Lloyd CCM 200432:649
a l C ar e
i als G
ro
i
ad
Tr
a n Cri
t ic
up C an
Realities, Expectations and Attitudes to Life
Support Technologies in Intensive Care for
Octogenarians
The REALISTIC 80 study
Funded by CIHR
Conducted under the auspices of the CCCTG and
CARENET
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REALISTIC-80
Overall Design
All 80+ admitted to participating ICU >24 hrs
and had a family member present
610 Enrolled
ICU 80+
Patients and
their
families
3,6,9,12 Month
Outcomes
Inclusion criteria:
- >24 hrs in ICU
- Family present
Heyland Crit Care Med 2015; Palliative Med 2015; Intensive Care Med 2015 (in press)
REALISTIC-80
Research Questions-Patient
• Primary
1) What are the 12 month survival and HRQOL of patients
admitted to ICU who are 80+ years old?
• Secondary
2) Which patient characteristics are associated with
recovery from critical illness at 12 months?
We defined ‘recovery’ from critical illness as being alive
with SF-36 physical function score of at least 10 points
and not 10 or more points below baseline at 12 months.
REALISTIC-80
Research Questions-Family
3) For non-surviving patients, what are the processes of care
(descriptive)?
4) For non-surviving patients, what is the family satisfaction with
EOL care, as measured using Family Satisfaction with ICU Care
24 (in ICU death) and the CANHELP Satisfaction instrument (in
hospital)?
5) What are the values that influence decisions about goals of care
for this patient population?
6) What is the quality of decision making about the goals of care for
an 80+ patient?
Patient Characteristics
Age
Sex (Male)
Baseline APACHE II
Baseline SOFA score
Admission types
Medical
Surgical elective
Surgical emergency
Primary ICU diagnosis
Cardiovascular/vascular
Respiratory
Gastrointestinal
Sepsis
Other
Baseline Physical Function score
Charlson Co-morbidity Index
Functional Co-morbidity Index
IQCODE
Frailty Index
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All patients
(n=610)
84.4±3.4 (79.9-99.4)
338 (55.4%)
21.6±6.9 (7.0-49.0)
5.4±3.2 (0.0-15.0)
377 (61.8%)
83 (13.6%)
150 (24.6%)
143 (23.4%)
157 (25.7%)
110 (18.0%)
72 (11.8%)
128 (21.0%)
40.3±29.9 (0.0-100.0)
2.1±1.9 (0.0-11.0)
1.9±1.4 (0.0-6.0)
3.3±0.5 (1.0-5.0)
0.3±0.1 (0.0-0.7)
Family Member Characteristics
All Family Members
(n=535)
61.4±13.6 (18.0-100.0)
Family member age *
Family member sex
male
female
162 (30.3%)
373 (69.7%)
Father/Mother
Husband/Wife
Brother/Sister
Other
Missing
Are you the person who provides the
most care for this person?
Yes
No
Missing
Are you the legal substitute decision
maker for the patient?
Yes
No
Unsure
337 (63.0%)
153 (28.6%)
10 (1.9%)
34 (6.4%)
1 (0.2%)
The patient is my…
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430 (80.4%)
104 (19.4%)
1 (0.2%)
395 (73.8%)
113 (21.1%)
26 (4.9%)
Clinical Outcomes
Proportion of patients undergoing invasive mechanical
ventilation
Average duration of invasive mechanical ventilation
(median, IQR, range)
Index ICU LOS (median, IQR, range)
Total Hospital LOS (median, IQR, range)
Hospital LOS *
Percentage of patients have a stay in hospital prior to ICU
ICU mortality
Hospital mortality
Discharged from Hospital:
Ward in another hospital
ICU in another hospital
Long term care facility
Home
Rehab
Palliative Care
Other
Proportion of patient at home prior to hospitalization
discharged to home
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All patients
(n=610)
439 (72.0%)
4.0[2.0 to 10.0] (1.0, 116.0)
6.0[ 4.0 to 11.0] (2.0, 96.0)
21.1[11.3 to 39.6] (0.4, 201.8)
554 (90.8%)
85 (13.9%)
158 (25.9%)
452 (74.1%)
132 (21.6%)
11 (1.8%)
81 (13.3%)
197 (32.3%)
25 (4.1%)
1 (0.2%)
5 (0.8%)
179 (34.0%)
Kaplan-Meier Survival Curves of Study Population
Compared to Age and Sex Matched Community
Control Population.
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SF-36 Scores Among Survivors: Physical
Functioning Domain
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Heyland ICM 2015 (in press)
Recovery to Baseline Physical Function After
Critical Illness Among Patients Aged 80 Years or
Older
Deceased
Alive with PF score<10
Alive with PF>=10 but 10 or more points below baseline
Alive with PF>=10 and not 10 or more points below baseline
n=480
n=505
50
70
90
n=508
0
10
30
Proportion of patients
n=519
3 months
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6 months
9 months
12 months
Heyland ICM 2015 (in press)
Logistic Regression Model Predicting Physical
Recovery 12 months After ICU Admission
Multivariable Predictor Model
Variables
OR (95% CI)
P-value
Age (per 5 years)
0.73 (0.57, 0.93)
0.01
Sex (Male vs. Female)
APACHE II score (per 10 points)
Baseline SOFA score (per 5 points)
Admission type (Medical vs. Surgical)
Surgical elective vs. Medical
Surgical emergency vs. Medical
Primary ICU diagnosis
CABG/Valve vs. Cardiovascular/vascular
Gastrointestinal vs. Cardiovascular/vascular
Neurologic vs. Cardiovascular/vascular
Other vs. Cardiovascular/vascular
Respiratory vs. Cardiovascular/vascular
Sepsis vs. Cardiovascular/vascular
Stroke vs. Cardiovascular/vascular
Trauma vs. Cardiovascular/vascular
Baseline PF score (per 50 points)
Charlson Comorbidity Index (per 2 units)
IQCODE at baseline (per 0.5 point)
Frailty Index (per 0.2 point)
0.88 (0.57, 1.34)
0.50 (0.27, 0.96)
0.82 (0.57, 1.19)
0.55
0.04
0.29
0.32
1.71 (0.79, 3.67)
1.83 (0.77, 4.34)
0.0001
4.21 (1.96, 9.03)
1.09 (0.53, 2.22)
1.30 (0.53, 3.18)
0.77 (0.26, 2.25)
1.24 (0.48, 3.24)
1.38 (0.54, 3.51)
0.11 (0.01, 0.91)
0.47 (0.15, 1.47)
0.32 (0.22, 0.45)
0.76 (0.59, 0.98)
0.96 (0.71, 1.30)
0.32 (0.19, 0.56)
<0.0001
0.03
0.77
<0.0001
Heyland ICM 2015 (in press)
Clinical Prediction Rule
Table 1: Calculation of recovery scale
Characteristics
Recovery Points
Age<90
1
Apache2 <20
1
Surgical Admission (elective or emergency)
1
Frailty Index <.15
2
Frailty Index .15 to <.25
1
Baseline SF36 PF domain <35
2
Baseline SF36 PF domain 35 to <65
1
Sum points for possible range of 0 to 7.
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REALISTIC-80
Research Questions-Family
3) For non-surviving patients, what are the processes of care
(descriptive)?
4) For non-surviving patients, what is the family satisfaction with
EOL care, as measured using Family Satisfaction with ICU Care
24 (in ICU death) and the CANHELP Satisfaction instrument (in
hospital)?
5) What are the values that influence decisions about goals of care
for this patient population?
6) What is the quality of decision making about the goals of care for
an 80+ patient?
The Very Elderly Admitted to
Intensive Care Unit: A quality finish ?
• Of enrolled patients, 240 (39%) remained in ICU for 7
•
days or more; of these, 99 (41%) died in hospital.
Neither frailty nor advance directives had significant
impact on processes of care (use or withhold/withdraw
of life-sustaining treatments).
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Heyland CCM 2015
Additional Family Member
Perspectives
• On average, interviews occurred 3 days after ICU
•
admission
Family members reported that the “patient be
comfortable and suffer as little as possible” was the most
important value and “the belief that life should be
preserved at all costs” was the least important value
considered in making their treatment decisions.
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Heyland Palliative Medicine 2015
Family Member
Preferences
• 57% reported that the doctor talked to them about being able to
choose between treatment options for your family member in ICU.
• 30.7% of family members had decisional conflict related to their
treatment preference.
• Decisional conflict was lower in family members who had talked to a
doctor than those who had not.
Heyland Palliative Medicine 2015
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Additional Family Member
Perspectives
• If family members’ stated preferred comfort measures
– 83.7% of related patients received life-sustaining treatments;
– 20.2% received one or more for more than 7 days
– the time from ICU admission to death was on average 10.0 days
amongst non-survivors.
• Among non-survivors, time from ICU admission to death
was longest in patients whose family members were
‘unsure’ of their treatment preferences (16.0 days vs.
10.0 days in comfort group vs. 12.0 days in lifesustaining treatments group; p=0.06).
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Heyland Palliative Medicine 2015
Family
Satisfaction
with Critical
Care
(FS-ICU 24)
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Conclusions (1)
 If admitted to ICU






Stay in ICU for a week or more
Remain in hospital for a month or more
1/3 will die in hospital after a prolonged dying experience
1/3 will be discharged home
1/3 will be discharged to alternative location
At 1 year
 Half patients will be dead
 25% will have a good outcome (recovery to baseline)
 Narrative can be adapted to individuals with clinical
prediction tool
Conclusions (2)
 Baseline PF and Frailty Index are significant risk factors and
consideration should be given to routinely measuring them in older
patients admitted to ICU in addition to traditional measure
describing the acute illness.
 There is incongruity between family members’ values and
preferences for end of life care of their very elderly relatives, and
the actual care received.
 Deficiencies in communication and decision-making may be
associated with non-beneficial and prolonged use of life-sustaining
treatments in very elderly critically ill patients, many of whom
ultimately die.
Where do we go from here?
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Effectivenss of Multi-faceted Decision
Support Intervention
 Elements to include
 Information leaflet on ‘how decisions are made’ and ‘your role’
and ‘how others cope’
 Systematically eliciting patient/family values, preferences
(including ACP/AD)
 Systematically offering non-curative, palliative care as a
treatment option
 Systematically obtain information on key determinants to
recovery (baseline PF, Frailty, comorbidities, etc.)
Provide this
information to clinical
team early in stay
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A Quality Finsih?
More needs to be done urgently to improve EOL
care for very elderly (in Canada)!
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