Survival and disposition of patients 75 years or older following mechanical ventilation of 7 or more daysPRINCIPAL INVESTIGATORS: THOMAS MILLER, MD, KRISTINA NEWPORT MD, FAAHPM

PALLIATIVE MEDICINE CONSULTANTS OF HOSPICE & COMMUNITY CARE, LANCASTER PACOLLABORATORS: SHANTHI SIVENDRAN MD, MSCR, LISA ESTRELLA, MS, MICHAEL HORST PHD, ROBIN HICKS, DO

LANCASTER GENERAL HEALTH AND HEART OF LANCASTER REGIONAL MEDICAL CENTER

CORRESPONDENCE: KNEWPORT@SUPPORTIVECARE.ORG

INVESTIGATORS HAVE NO CONFLICTS OF INTEREST TO DISCLOSE

Objective:

Describe mortality and disposition of patients 75 years or older who require mechanical ventilation 7 or more days

Background: Mechanical ventilation ≥7days more decisions

PEG/Tracheostomy/cardiac resuscitation Patient/family base decisions on expectations of recovery But, providers often present only ‘life or death’, not quality of life

Inpatient palliative care consultation often requested Goals of care for elderly patients Loss of independence and caregiver burden cited as major factors in

decisions Frail patients may be one acute illness away from dependence or death

Literature Review: Outcomes for elderly survivors of mechanical ventilation/ICU care

• ICU care that includes mechanical ventilation(MV) leads to:• ↑ Mortality: 43% of ≥65 years died within 2 months of MV ≥ 2days4

• ↑ Health care costs6

• ↑ Caregiving needs & Disability1,2

• ↑ Care transitions: Adults requiring MV ≥21days had median of 4 transitions in the next yr6

• ↓ Decreased Quality of Life3

• More than 50% of patients ≥70 years who experience critical illness died within 1 month of intensive care unit(ICU) admission

• 28.8% (3098/10,743) of adults hospitalized in 25 Scottish hospitals died within one year of hospitalization in 2013, 32.3% died during index hospitalization, pts ≥ 85y mortality was three times higher than ≤60. (45.6% vs 13.1%; p < 0.001). 5

1 Barnato, A et al.‘Disability among Elderly Survivors of Mechanical Ventilation’, American Journal of Respiratory and Critical Care Medicine, 183 (2011), 1037–42 2 Ferrante, L etal ‘Functional Trajectories among Older Persons before and after Critical Illness’, JAMA Internal Medicine, 175 (2015), 523–29

3Chatila, W., D. T. Kreimer, and G. J. Criner, ‘Quality of Life in Survivors of Prolonged Mechanical Ventilatory Support’, Critical Care Medicine, 29 (2001), 737–424QOLAfter Mechanized Ventilation in the Elderly Study Investigators, ‘2-Month Mortality and Functional Status of Critically Ill Adult Patients Receiving Prolonged MV’, Chest, 121 (2002), 549–

585Clark, D et al., ‘Imminence of Death among Hospital Inpatients: Prevalent Cohort Study’, Palliative Medicine, 28 (2014), 474–79

6Unroe, M et al One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study’, Annals of Internal Medicine, 153 (2010), 167–75

Research Objectives & Methods:Objective:

Determine mortality and disposition of patients 75 or older who require ≥7 days of mechanical ventilation compared to patients in ICU ≥7 days or hospitalized ≥7 days but intubated <7 days via retrospective chart review.

Methods: Study Population:

Patients age ≥ 75 years who were hospitalized between 5/1/11 to 4/30/15 and did not have pre-existing tracheostomy

Source of Data: Electronic medical records (EMR) from one large suburban community hospital (590

beds)and one large non-profit community hospice (daily census 450) were reviewed, retrospectively, for outcomes and covariates.

Public internet searches were performed to determine date and location of death if not available in EMR.

TABLE 1

All Patients(N=6,724)

≥7d Hospitalization (N=6290)

≥7 d ICU care (N=346)

≥7d intubation (N=88)

AGE (years) Mean83.3(StDev 5.5) 83.4(StDev 5.5) 81.5(StDev 4.75) 81.3(StDev 5.2)

Median 83 (75-108) 83(75-108) 81(75-95) 79(75-96)

RACE Asian 31 29 2 0Black 127 120 6 1Other 75 71 2 2Unknown 47 40 6 1White 6444 6030 330 84

LOS Mean10.56 (StDev 5.0) 10.13(StDev 4.4) 16.84(StDev 8.1) 16.22(StDev 7.7)

Median 9 (7-68) 9(7-68) 15(7-52) 14(7-39)

Characteristics of Sample

Death in hospital Death with 30 days of Discharge

Death within 1 year of Discharge

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

0.0307

16.18%

37.86%

52.02%46.59%

73.86%

80.68%

Mortality Rates of Patients ≥75 YearsPe

rcen

tage

of P

atie

nts w

ho D

ied

Home In-depen-dently

Home with services

Palliative Based plan of

care

Facility based care

Readmission within 30 days

Readmission within 1 year

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

12.97%

25.14%

6.14%

57.55%

4.14%

21.72%18.28%

74.14%

25.17%

48.62%

0.00%3.41%

15.91%

50.00%

21.28%

31.91%

Disposition of Patients ≥75 Years

≥7d Hospitalization (6290) ≥7 d ICU care (290) ≥7d intubation (88)

Results: 88 patients aged 75 or older required mechanical ventilation for ≥7 days from 5/1/11 to 4/30/15. 54.5% of patients survived hospitalization Only 19.32% of patients were alive 1 year later 87.5% of patients died or were re-hospitalized within 1 year. Of those discharged alive, the vast majority (93.6%) required care in a

facility. 3.4% of patients returned home after discharge and 2/3 of them had hospice services. 0 (None) of the patients returned home completely independent. 47.6% of surviving patients were re-hospitalized within 1 year.

Conclusion:

Life after prolonged intubation (≥7days) for patients ≥75y is likely to require skilled nursing care (93%) with poor chance of

survival >1 year(19%)

Study Weaknesses These findings are correlations, not proof of causation Pre-hospital functional status or level of care was not available We cannot account for patients who decided against mechanical ventilation or who

pursued palliative vent withdrawal before 7 days EMR identification of death is unreliable, limiting the ability to compare groups’ 30 d

and 1 y mortality Chart review did not allow for disposition status at 30 days or 1 year Assumptions about Quality of life, physical and psychosocial distress may be made

but not confirmed without inclusion of patient reported outcomes

TakeawaysIf “Life or Death” decisions are on the table, be sure “Life” is accurately

described

Mechanical ventilation( ≥7 days) for patients 75 years or older, is associated with high in-hospital and 1-year mortality and universal need

for post-hospital medical services

Retrospective studies such as this one can yield valuable information with low utilization of resources

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References & Questions