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The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over

M. Garrouste-Orgeas| A. Tabah| A. Vesin| F. Philippart| A. Kpodji| C. Bruel| C. Grégoire| A. Max| J. F. Timsit| B. Misset
Original
Volume 39, Issue 9 / September , 2013

Pages 1574 - 1583

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.

Keywords

References

  1. 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
    • View reference on PubMed
    • View reference on publisher's website
  2. 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
    • View reference on PubMed
    • View reference on publisher's website
  3. 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
    • View reference on PubMed
    • View reference on publisher's website
  4. 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
    • View reference on PubMed
    • View reference on publisher's website
  5. 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
  6. 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
  7. 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
    • View reference on PubMed
    • View reference on publisher's website
  8. 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
    • View reference on PubMed
    • View reference on publisher's website
  9. 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
  10. 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
    • View reference on PubMed
    • View reference on publisher's website
  11. 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
  12. 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
    • View reference on PubMed
    • View reference on publisher's website
  13. 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
    • View reference on PubMed
  14. 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
  15. Lawton MP, Brody EM (1969) Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9:179–186
    • View reference on PubMed
    • View reference on publisher's website
  16. Katz S (1983) Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 31:721–727
    • View reference on PubMed
  17. 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
    • View reference on PubMed
    • View reference on publisher's website
  18. Power M, Quinn K, Schmidt S (2005) Development of the WHOQOL-old module. Qual Life Res 14:2197–2214
    • View reference on PubMed
    • View reference on publisher's website
  19. 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
    • View reference on PubMed
    • View reference on publisher's website
  20. 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
    • View reference on PubMed
  21. 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
    • View reference on PubMed
    • View reference on publisher's website
  22. 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
    • View reference on PubMed
    • View reference on publisher's website
  23. 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
    • View reference on PubMed
    • View reference on publisher's website
  24. 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
    • View reference on PubMed
    • View reference on publisher's website
  25. Boumendil A, Latouche A, Guidet B (2011) On the benefit of intensive care for very old patients. Arch Intern Med 171:1116–1117
    • View reference on PubMed
    • View reference on publisher's website
  26. 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
    • View reference on PubMed
    • View reference on publisher's website
  27. 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
  28. 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
    • View reference on PubMed
    • View reference on publisher's website
  29. 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
    • View reference on PubMed
    • View reference on publisher's website
  30. Mick DJ, Ackerman MH (1997) Neutralizing ageism in critical care via outcomes research. AACN Clin Issues 8:597–608
    • View reference on PubMed
    • View reference on publisher's website
  31. 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
  32. Escher M, Perneger TV, Chevrolet JC (2004) National questionnaire survey on what influences doctors’ decisions about admission to intensive care. BMJ 329:425
    • View reference on PubMed
    • View reference on publisher's website
  33. Quill TE, Holloway RG (2012) Evidence, preferences, recommendations–finding the right balance in patient care. N Engl J Med 366:1653–1655
    • View reference on PubMed
    • View reference on publisher's website
  34. 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
    • View reference on PubMed
    • View reference on publisher's website
  35. 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
    • View reference on PubMed
    • View reference on publisher's website

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