Very Old Americans Less Likely to Get ICU Care

Very Old Americans Less Likely to Get ICU Care

By Bruce Sylvester

ORLANDO—Intensive care unit (ICU) treatment in the United States during the course of a serious disease declines significantly with age, researchers reported at the American Thoracic Society International Conference.

Analysis of data from >1 million Medicare beneficiaries nationwide showed that a person >90 years old was about one third as likely as someone aged 68 to 70 years—in the same illness category and of the same race, gender, and income level—to receive care in an intensive or critical care unit.

“For patients, this reemphasizes the point that they need to take the hard step of rethinking in advance their preferences for critical care once they become seriously ill,” lead investigator Theodore Iwashyna, MD, PhD, of the University of Pennsylvania, Philadelphia, told IMWR. “If patients do not clearly express their own preferences, assumptions may be made that are incorrect.”

For example, among patients with lung cancer, 47.6% of those aged between 68 and 70 years received critical care, compared with 25% of those between ages 86 and 90, and only 20.7% of those >90 years old. Similar patterns were found of ICU care for other diseases, including myocardial infarction (MI), stroke, hip fracture, congestive heart failure, leukemia, and lymphoma.

Among MI patients, those aged 86 to 90 years were 75% less likely to be cared for in an ICU compared with those aged 68 to 70 years, and those aged >90 years were 85% less likely to go to an ICU than those aged 68 to 70 years. Also, stroke patients aged 86 to 90 were 57% less likely to use critical care than those aged 68 to 70, and stroke patients aged >90 years were 72.5% less likely to be cared for in an ICU than those aged 68 to 70 years.

Dr Iwashyna said that this study raises the question of whether some older people are receiving optimal care. He noted that although previous research indicates that the very elderly are more likely to have “do not resuscitate” orders, physicians or family members may be assuming wrongly that these patients do not want aggressive care in general. He also noted that ICU treatment for an 85-year-old is generally just as effective as for a 65-year-old.

During the 5-year data-collection period of the study, 54.9% of the 1.1 million Medicare beneficiaries received some type of critical care. “For patients, this reemphasizes the point that they need to take the hard step of rethinking their preferences for critical care if they become seriously ill,” said Dr Iwashyna.

“For physicians, it brings up 2 issues: critical care is common among patients with serious illness…and we as physicians may make strong assumptions about patient preferences—assumptions with very real implications for patient outcomes—that may not be accurate reflections of the patient’s values.”

Randall Curtis, MD, of the University of Washington, Seattle, told IMWR, “This study underlines the fact that it is extremely important that older people express their wishes in advance of needs. We can’t really tell if these data are consistent with the expressed wishes of the older elderly. It does tell us that these patients are less likely to get ICU service, but it does not tell us exactly why.”