Intensive care medicine in an ageing population

Abstract

The Dutch population is ageing, and this has an impact on our healthcare. Although currently less than 5% of our population is aged 80 years and older, they are responsible for more than 10% of the hospital admissions and 15% of the ICU admissions. This thesis illustrates that, despite significantly decreased mortality rates for both younger and very old patients over time, the mortality risks of the patients aged 80 years and older are still twice as high as that of younger patients. In addition, their remaining life expectancy is lower, ICU treatment often is burdensome and expensive and many patients who do survive, will suffer from functional and/or cognitive decline. The balance between potential benefits and burden of ICU treatment may therefore be more negative than in younger patients. This stresses the need to weigh the proportionality of ICU treatment carefully. Although older patients often have less to gain from an ICU admission than younger patients, ICU treatment certainly can be beneficial, even for patients over 90 years. Nearly 3 out of 4 ICU patients aged 90 years and older survived until hospital discharge and half of the patients were still alive one year after ICU-admission. Of the very old patients admitted with sepsis, about half died during hospitalization and more than two-thirds had died after one year. However, not sepsis, but frailty, age and disease severity (SOFA) were identified as predictors for mortality. The simple qSOFA showed to be a poorly sensitive predictive score for mortality. Under normal circumstances, age is, together with other risk factors, weighed as a risk factor for poor outcome. This may lead to the shared decision to forego ICU treatment, but it cannot be justified to withhold ICU admission for all patients above a certain age. However, in times of scarcity, not only the proportionality of treatment and autonomy of the patient but also the shortage of resources may play a role in ICU admission decisions. Therefore, it could be justified to prioritize the younger patients in circumstances of a pandemic, according to the utilitarian approach, which aims to maximize the benefits for the largest number of people and prioritize care based on the (estimated) greatest advantage of ICU treatment, the so-called incremental probability of survival. The use of age as a selection criterion in case of scarcity can also be justified by pointing at the "fair innings" that a patient has had, meaning that older patients have already had their opportunity to reach a certain "mature" age, which has given them a fair equality of opportunity. This strategy does not amount to age discrimination as all people are treated alike: everyone will become older, and thereby their claim on life-sustaining treatment decreases.

In conclusion, decision-making in very old patients requiring ICU treatment remains complex. Physicians should carefully address the prognosis and risk factors and explore the preferences, treatment goals, expectations and personal values of the very old patients.