Older patients and intensive care: factors that influence patients decisions on life sustaining measures.

چکیده اصلی

BACKGROUND: Physicians treating older patients are frequently unaware of their patients' personal attitudes towards life-sustaining measures like ventilation, resuscitation, feeding tubes, or ICU admission. In routine clinical practice, there is often little time for reflection prior to deciding in favor or against life sustaining measures in critical medical conditions. Although decisions for or against these measures should ideally be made jointly by the patient and the treating physician, factors like age, disease burden, social inclusion, and affective state may play an important role in the patient's motivation. METHODS: Data from 161 inpatients (mean age 82.0 years) on a geriatric ward were collected and analyzed. Patients were interviewed about their attitudes towards life-sustaining measures like ventilation, resuscitation, tube feeding, ICU admission, and dialysis. Four composite indices were formed by combining sign-aligned component variables: medical burden (age and Charlson Comorbidity Index), functional and cognitive impairment (Barthel Index, iADL, and MoCA), affective distress (Geriatric Depression Scale and Hamilton Depression Scale suicidality item), and social support (living situation, having children, and having friends). These indices with other covariates were then analyzed using a Bayesian Rasch item response model with latent regression. RESULTS: Overall, 14.3% refused all invasive life sustaining measures, whereas 33.8% wished to receive all of the measures listed above. Artificial nutrition was the most refused measure (refused by 53.4%), whereas ICU admission was the most commonly accepted measure (74.4%). Social support had no meaningful association with the decision to accept or refuse life-sustaining measures. Relevant predictors were primarily lower levels of affective distress, and secondarily better functional and cognitive performance and lower medical burden. CONCLUSIONS: Even among older patients, only a minority completely reject life-sustaining measures, even though their life expectancy is often significantly reduced. Patient's attitude towards life-sustaining measures appears to be related more strongly to affective state, functional performance, and medical burden than living situation or social inclusion. As the patient's emotional and functional state can certainly be influenced by medical treatment, practitioners should bear this in mind and, where appropriate, reassess their patients' attitude towards LSM once the aforementioned conditions have improved. CLINICAL TRIAL NUMBER: Registered with the clinical trial registry Deutsches Register Klinischer Studien.

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