The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: Intensive care benefit for the elderly*

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Abstract

Rationale:

Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly.

Objective:

To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients.

Design:

Prospective, observational study of triage decisions from September 2003 until March 2005.

Setting:

Eleven intensive care units in seven European countries.

Patients:

All patients >18 yrs with an explicit request for intensive care unit admission.

Interventions:

Admission or rejection to intensive care unit.

Measurements and Main Results:

Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥65 yrs. Refusal rate increased with increasing patient age (18–44: 11%; 45–64: 15%; 65–74: 18%; 75–84: 23%; >84: 36%). Mortality was higher for older patients (18–44: 11%; 45–64: 21%; 65–74: 29%; 75–84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18–44: 10.2% vs. 12.5%; 45–64: 21.2% vs. 22.3%; 65–74: 27.9% vs. 34.6%; 75–84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.55–0.78, p < .0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57–0.97, p = .01]).

Conclusions:

Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly. (Crit Care Med 2012; 40:132–138)

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