Www. thecarenet.ca Long-term Outcomes of the Very Elderly Admitted to ICUs in Canada: A Quality Finish? Daren K. Heyland MD, MSc Queen’s University and

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Long-term Outcomes of the Very Elderly Admitted to ICUs in Canada:

A Quality Finish?

Daren K. Heyland MD, MScDaren K. Heyland MD, MScQueen’s University and Kingston General HospitalQueen’s University and Kingston General Hospital

Kingston OntarioKingston Ontario

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

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18%

22%

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


Quality EOL Care

Scare ICU Resources Aging of

Society

(Very) Elderly in the ICU?

Background

A Quality Finish?

CMAJ 2006;174:627



Results from Patient’s Perspective

Areas of Greatest “Importance”Areas of Greatest “Importance” % % “Extremely “Extremely ImportantImportant””

To have trust and confidence in the Doctor looking after youTo have trust and confidence in the Doctor looking after you 55.855.8

Not to be kept alive on life support when there is little hope Not to be kept alive on life support when there is little hope for a meaningful recoveryfor a meaningful recovery

55.755.7

That information about your disease be communicated to you That information about your disease be communicated to you in a honest mannerin a honest manner

44.144.1

To complete things and prepare for life’s end To complete things and prepare for life’s end 43.943.9

To have an adequate plan of care and services available to To have an adequate plan of care and services available to look after you at home upon discharge look after you at home upon discharge

41.8 41.8

To not be a physical or emotional burden on your family To not be a physical or emotional burden on your family 41.8 41.8

N= 440

Heyland CMAJ 2006;174:627

What Matters the Most to Quality of What Matters the Most to Quality of End of Life Care in CanadaEnd of Life Care in Canada

Good Communication and Decision-Making?


Improving EOL Improving EOL communication and decision communication and decision makingmaking

Greatest Improvements in EOL Greatest Improvements in EOL CareCare

Improving EOL Improving EOL communication and communication and decision makingdecision making

Failure to Engage Hospitalized Failure to Engage Hospitalized Elderly Patients and Their Elderly Patients and Their FFamiliesamilies

• Multicenter survey of 283 80+ on hospital Multicenter survey of 283 80+ on hospital wardswards

• Majority had thought of EOL wishes and could Majority had thought of EOL wishes and could express preference for treatment at EOLexpress preference for treatment at EOL

• Less than 1/3 had spoken to health care Less than 1/3 had spoken to health care professionalprofessional

• Fewer than 20% acknowledged a prognostic Fewer than 20% acknowledged a prognostic disclosuredisclosure

• Expressed preferences and documents ‘goals Expressed preferences and documents ‘goals of care’ only agreed 1/3 timeof care’ only agreed 1/3 time

www.thecarenet.cawww.thecarenet.caHeyland JAMA Int Med Heyland JAMA Int Med

20132013

Consequences of Intensification Consequences of Intensification of Care at the End of Life 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

Wright JAMA 2008;300:1665www.thecarenet.cawww.thecarenet.ca

Wright JAMA 2008;300:1665

End of Life Discussions…End of Life Discussions…

…Associated with decreased intensity of care


plauplau

• 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.

Zhang Arch Intern Med 2009;169:480www.thecarenet.cawww.thecarenet.ca

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!


Prognosis

Values+

Good Decision

Purpose of Information Exchange

What do we know about the outcomes of the very elderly critically ill patient?

REALISTIC-80What 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 ImportantMost Important chances of survivingchances of surviving resultant health stateresultant health state

Moderate ImportanceModerate Importance Impact on family’s livesImpact on family’s lives

Least ImportantLeast Important Length of hospital stay,Length of hospital stay, probability of institutionalizationprobability of institutionalization amount of painamount of pain ICUs, ventilators etc.ICUs, ventilators etc.

Heyland Chest 2006;130:419 and Lloyd CCM 200432:649

More important for very elderly


Realities, Expectations and Attitudes to Life

Support Technologies in Intensive Care forOctogenarians

The REALISTIC 80 study

Funded by CIHRFunded by CIHR

Conducted under the auspices of the CCCTG Conducted under the auspices of the CCCTG and and

CARENETCARENET

REALISTIC-80Overall Design

610 EnrolledICU 80+ Patients and their families

3,6,9,12 Month

Outcomes

All 80+ admitted to participating ICU >24 hrs and had a family member present

Heyland Crit Care Med 2015; Palliative Med 2015; Intensive Care Med 2015 (in press)

Inclusion criteria:- >24 hrs in ICU- Family present

REALISTIC-80Research 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-80Research Questions-Family

3) For non-surviving patients, what are the processes of care 3) For non-surviving patients, what are the processes of care (descriptive)?(descriptive)?

4) For non-surviving patients, what is the family satisfaction 4) For non-surviving patients, what is the family satisfaction with EOL care, as measured using Family Satisfaction with EOL care, as measured using Family Satisfaction with ICU Care 24 (in ICU death) and the CANHELP with ICU Care 24 (in ICU death) and the CANHELP Satisfaction instrument (in hospital)? Satisfaction instrument (in hospital)?

5) What are the values that influence decisions about goals 5) What are the values that influence decisions about goals of care for this patient population?of care for this patient population?

6) What is the quality of decision making about the goals of 6) What is the quality of decision making about the goals of care for an 80+ patient?care for an 80+ patient?


Patient Characteristics All patients(n=610)

Age 84.4±3.4 (79.9-99.4)Sex (Male) 338 (55.4%)Baseline APACHE II 21.6±6.9 (7.0-49.0)Baseline SOFA score 5.4±3.2 (0.0-15.0)Admission types

Medical 377 (61.8%)Surgical elective 83 (13.6%)

Surgical emergency 150 (24.6%)Primary ICU diagnosis

Cardiovascular/vascular 143 (23.4%)Respiratory 157 (25.7%)

Gastrointestinal 110 (18.0%)Sepsis 72 (11.8%)Other 128 (21.0%)

Baseline Physical Function score 40.3±29.9 (0.0-100.0)

Charlson Co-morbidity Index 2.1±1.9 (0.0-11.0)Functional Co-morbidity Index 1.9±1.4 (0.0-6.0)IQCODE 3.3±0.5 (1.0-5.0)

Frailty Index 0.3±0.1 (0.0-0.7)


Family Member Characteristics All Family Members(n=535)

Family member age * 61.4±13.6 (18.0-100.0)Family member sex

male 162 (30.3%)female 373 (69.7%)

The patient is my… Father/Mother 337 (63.0%)Husband/Wife 153 (28.6%)Brother/Sister 10 (1.9%)

Other 34 (6.4%)Missing 1 (0.2%)

Are you the person who provides the most care for this person?

Yes 430 (80.4%)No 104 (19.4%)

Missing 1 (0.2%)Are you the legal substitute decision maker for the patient?

Yes 395 (73.8%)No 113 (21.1%)

Unsure 26 (4.9%)


Clinical Outcomes All patients(n=610)

Proportion of patients undergoing invasive mechanical ventilation

439 (72.0%)

Average duration of invasive mechanical ventilation (median, IQR, range)

4.0[2.0 to 10.0] (1.0, 116.0)

Index ICU LOS (median, IQR, range) 6.0[ 4.0 to 11.0] (2.0, 96.0)Total Hospital LOS (median, IQR, range)Hospital LOS * 21.1[11.3 to 39.6] (0.4, 201.8)

Percentage of patients have a stay in hospital prior to ICU

554 (90.8%)

ICU mortality 85 (13.9%)Hospital mortality 158 (25.9%)Discharged from Hospital: 452 (74.1%)

Ward in another hospital 132 (21.6%)ICU in another hospital 11 (1.8%)Long term care facility 81 (13.3%)

Home 197 (32.3%)Rehab 25 (4.1%)

Palliative Care 1 (0.2%)Other 5 (0.8%)

Proportion of patient at home prior to hospitalization discharged to home

179 (34.0%)

Kaplan-Meier Survival Curves of Study Population Compared to Age and Sex Matched Community Control Population.


SF-36 Scores Among Survivors: SF-36 Scores Among Survivors: Physical Functioning DomainPhysical Functioning Domain

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Recovery to Baseline Physical Function After Critical Illness Among Patients Aged 80 Years or Older


Pro

po

rtio

n o

f pa

tien

ts

01

03

05

07

09

0

3 months 6 months 9 months 12 months

DeceasedAlive with PF score<10Alive with PF>=10 but 10 or more points below baselineAlive with PF>=10 and not 10 or more points below baseline

n=519 n=508 n=480 n=505

Heyland ICM 2015 (in press)

Logistic Regression Model Predicting Physical Recovery 12 months After ICU Admission

Heyland ICM 2015 (in press)

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) 0.88 (0.57, 1.34) 0.55

APACHE II score (per 10 points) 0.50 (0.27, 0.96) 0.04

Baseline SOFA score (per 5 points) 0.82 (0.57, 1.19) 0.29

Admission type (Medical vs. Surgical) 0.32

Surgical elective vs. Medical 1.71 (0.79, 3.67)

Surgical emergency vs. Medical 1.83 (0.77, 4.34)

Primary ICU diagnosis 0.0001

CABG/Valve vs. Cardiovascular/vascular 4.21 (1.96, 9.03)

Gastrointestinal vs. Cardiovascular/vascular 1.09 (0.53, 2.22)

Neurologic vs. Cardiovascular/vascular 1.30 (0.53, 3.18)

Other vs. Cardiovascular/vascular 0.77 (0.26, 2.25)

Respiratory vs. Cardiovascular/vascular 1.24 (0.48, 3.24)

Sepsis vs. Cardiovascular/vascular 1.38 (0.54, 3.51)

Stroke vs. Cardiovascular/vascular 0.11 (0.01, 0.91)

Trauma vs. Cardiovascular/vascular 0.47 (0.15, 1.47)

Baseline PF score (per 50 points) 0.32 (0.22, 0.45) <0.0001

Charlson Comorbidity Index (per 2 units) 0.76 (0.59, 0.98) 0.03

IQCODE at baseline (per 0.5 point) 0.96 (0.71, 1.30) 0.77

Frailty Index (per 0.2 point) 0.32 (0.19, 0.56) <0.0001

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.

REALISTIC-80Research Questions-Family

3) For non-surviving patients, what are the processes of care 3) For non-surviving patients, what are the processes of care (descriptive)?(descriptive)?

4) For non-surviving patients, what is the family satisfaction 4) For non-surviving patients, what is the family satisfaction with EOL care, as measured using Family Satisfaction with EOL care, as measured using Family Satisfaction with ICU Care 24 (in ICU death) and the CANHELP with ICU Care 24 (in ICU death) and the CANHELP Satisfaction instrument (in hospital)? Satisfaction instrument (in hospital)?

5) What are the values that influence decisions about goals 5) What are the values that influence decisions about goals of care for this patient population?of care for this patient population?

6) What is the quality of decision making about the goals of 6) What is the quality of decision making about the goals of care for an 80+ patient?care for an 80+ patient?

The Very Elderly Admitted to The Very Elderly Admitted to Intensive Care Unit: A quality Intensive Care Unit: A quality finish ?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).

www.thecarenet.cawww.thecarenet.caHeyland CCM

2015

Additional Family Additional Family Member PerspectivesMember 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.

www.thecarenet.cawww.thecarenet.caHeyland Palliative Medicine 2015

Family Member Family Member PreferencesPreferences


• 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

Additional Family Additional Family Member PerspectivesMember 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 life-sustaining treatments group; p=0.06).

www.thecarenet.cawww.thecarenet.caHeyland Palliative Medicine 2015

Family Family Satisfaction Satisfaction with with Critical Critical CareCare(FS-ICU 24)(FS-ICU 24)


Conclusions (1)

If admitted to ICUIf admitted to ICU Stay in ICU for a week or moreStay in ICU for a week or more Remain in hospital for a month or moreRemain in hospital for a month or more 1/3 will die in hospital after a prolonged dying 1/3 will die in hospital after a prolonged dying

experienceexperience 1/3 will be discharged home1/3 will be discharged home 1/3 will be discharged to alternative location1/3 will be discharged to alternative location At 1 yearAt 1 year

Half patients will be deadHalf patients will be dead 25% will have a good outcome (recovery to baseline)25% will have a good outcome (recovery to baseline)

Narrative can be adapted to individuals with Narrative can be adapted to individuals with clinical prediction toolclinical 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 Where do we go from here?here?


Effectivenss of Multi-faceted Decision Support Intervention

Elements to includeElements to include Information leaflet on ‘how decisions are made’ and Information leaflet on ‘how decisions are made’ and

‘your role’ and ‘how others cope’‘your role’ and ‘how others cope’ Systematically eliciting patient/family values, Systematically eliciting patient/family values,

preferences (including ACP/AD)preferences (including ACP/AD) Systematically offering non-curative, palliative care as a Systematically offering non-curative, palliative care as a

treatment optiontreatment option Systematically obtain information on key determinants Systematically obtain information on key determinants

to recovery (baseline PF, Frailty, comorbidities, etc.)to recovery (baseline PF, Frailty, comorbidities, etc.)

Provide this information to clinical team early in stay

www.myicuguide.com

A Quality Finsih?A Quality Finsih?More needs to be done urgently to improve EOL

care for very elderly (in Canada)!


Documents

Www. thecarenet.ca Long-term Outcomes of the Very Elderly Admitted to ICUs in Canada: A Quality Finish? Daren K. Heyland MD, MSc Queen’s University and