Are polymorphonuclear leukocytes an abnormal finding in cerebrospinal fluid? Results from 225 normal cerebrospinal fluid specimens.

Although it is often claimed that the presence of a single polymorphonuclear leukocyte (PMN) in the cerebrospinal fluid (CSF) is abnormal, recently some have suggested that a few PMNs are occasionally present in cytocentrifuged differential cell counts of normal CSF. We examined 225 consecutive normal CSF specimens to determine how frequently PMNs occur in normal CSF and to identify factors associated with the presence of PMNs. One or more PMNs were present in 73 cases (32%). The number of CSF PMNs was strongly correlated with the degree of CSF blood contamination and the hematologic PMN count. Of the 163 specimens having 25 red blood cells or less per cubic millimeter, only eight (5%) had three or more PMNs, and these outliers had abnormally high hematologic PMN counts. Of the 36 specimens having 100 red blood cells or more per cubic millimeter, 17 (47%) had six or more PMNs. We conclude that the number of PMNs found on cytocentrifuged differential cell counts is highly dependent on the degree of CSF blood contamination and the patient's hematologic PMN count and that even minimal blood contamination can result in the presence of one to two PMNs in normal CSF.

Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: During serious illness, patient preferences regarding life-sustaining treatments play an important role in medical decisions. However, little is known about life-sustaining preference stability in this population or about factors associated with preference change. METHODS: We evaluated 2-month cardiopulmonary resuscitation (CPR) preference stability in a cohort of 1590 seriously ill hospitalized patients at 5 acute care teaching hospitals. Using multiple logistic regression, we measured the association of patient demographic and health-related factors (quality of life, function, depression, prognosis, and diagnostic group) with change in CPR preference between interviews. RESULTS: Of 1590 patients analyzed, 73% of patients preferred CPR at baseline interview and 70% chose CPR at follow-up. Preference stability was 80% overall-85% in patients initially preferring CPR and 69% in those initially choosing do not resuscitate (DNR). For patients initially preferring CPR, older age, non-African American race, and greater depression at baseline were independently associated with a change to preferring DNR at follow-up. For patients initially preferring DNR, younger age, male gender, less depression at baseline, improvement in depression between interviews, and an initial admission diagnosis of acute respiratory failure or multiorgan system failure were associated with a change to preferring CPR at follow-up. For patients initially preferring DNR, patients with substantial improvements in depression score between interviews were more than 5 times as likely to change preference to CPR than were patients with substantial worsening in depression score. CONCLUSIONS: More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments.

Functional status among survivors of in-hospital cardiopulmonary resuscitation. SUPPORT Investigators Study to Understand Progress and Preferences for Outcomes and Risks of Treatment.

OBJECTIVES: To describe functional outcomes of seriously III patients who survived 2 months after in-hospital cardiopulmonary resuscitation (CPR) and to identify patient and clinical characteristics associated with worse functional status after CPR. METHODS: Multicenter prospective observational analysis of 162 seriously ill hospitalized patients who survived 2 months after CPR. Analysis of clinical characteristics associated with worse functional outcome. RESULTS: Among 162 survivors of in-hospital CPR, 56% had the same or improved function and 44% had worse function at 2 months compared with functional status before CPR. Patients with worse function deteriorated by a mean of 3.9 activities of daily living and were less likely to survive to hospital discharge (P < .001) or to 6 months after study entry (P < .001). Worse functional outcome was associated with greater age and longer hospital stay before CPR. CONCLUSIONS: More than half of CPR survivors had preserved functional status 2 months after CPR. However, patients with worse function are profoundly disabled. In anticipation of possible severe disability after CPR, preferences for care in such health states should be discussed with patients before the need for CPR, particularly among older patients and those with long hospital stays.

Attitudes of hospitalized patients toward life support: a survey of 200 medical inpatients.

PURPOSE: Life-support decisions have profound medical, ethical, and economic implications; yet little is known about inpatients' preferences for life-sustaining treatments. We therefore conducted a prospective survey of medical inpatients to determine attitudes toward life support under differing medical outcomes, and the extent of physician communication about these issues. PATIENTS AND METHODS: The study population consisted of 200 adult patients admitted to the general medical services at UCLA Medical Center during August and September 1987. Each patient completed a standardized 13-item questionnaire. Patients rated their agreement with life-support treatment in the context of four outcome scenarios. A five-point Lickert scale for each question was used, and an overall life-support scale was created by summing the four items. Patients were also asked about previous life-support discussions with their physicians. RESULTS: Life support was desired in 90 percent of the patients if their health could be restored to its usual level, in 30 percent if they would be unable to care for themselves after discharge, in 16 percent if their chance for recovery was hopeless, and in only 6 percent if they would remain in a vegetative state. Patients who desired less aggressive care were older, female, and more likely to have terminal illnesses. Only 16 percent reported having discussed life support with their physicians; however, an additional 47 percent desired such discussions. CONCLUSION: Hospitalized medical patients base their preferences for life support upon perceived outcomes. Lack of communication creates the potential for patients to be subjected to burdensome and expensive treatments they may not desire. We encourage physicians to offer their patients discussions about prognosis and the efficacy of life support so that disproportionate treatments can be avoided.

Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: For patients hospitalized with serious illnesses, we identified factors associated with a stated preference to forgo cardiopulmonary resuscitation (CPR), examined physician-patient communication about these issues, and determined the relationship of patients' preferences to intensity of care and survival. PATIENTS AND METHODS: The study was a cross-sectional evaluation of patient preferences. The setting was five geographically diverse academic acute-care medical centers participating in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project. Study participants were hospitalized patients > or = 18 years of age with 1 of 9 serious illnesses who were interviewed between days 3 and 6 after qualifying for the study. Using standardized interviews, patients provided information on demographics, preferences for CPR and other treatments, quality of life, functional status, perceptions of prognosis, and whether the patient had discussed CPR preferences with his or her physician. Data abstracted from the medical record included physiologic measures, therapeutic intensity, whether CPR was provided, and whether there was a do-not-resuscitate order. RESULTS: Of 1,995 eligible patients, 84% were interviewed (mean age 62 years, 58% men, inhospital mortality 7%, 6-month mortality 33%). Of the respondents, 28% did not want CPR. Factors associated independently with not wanting CPR included: hospital site; diagnosis; being older; being more functionally impaired; and patient perception of a worse prognosis. Only 29% of patients had discussed their preferences with their physician; 48% of those who did not want CPR reported such discussions. After adjusting for illness severity and factors associated with CPR preferences, patients not wanting CPR had lower intensity of care; similar inhospital mortality; and higher mortality at 2 and 6 months following study entry. CONCLUSIONS: The diagnosis, patients' perception of the prognosis, and hospital site were significantly associated with patients' resuscitation preferences after adjusting for patient demographics, severity of illness, and functional status. The rate of discussing CPR was low even for patients who did not want CPR. Patient preferences not to receive CPR were associated with a small decrease in intensity of care but no difference in hospital survival.

Patterns of resource consumption in medical intensive care.

Intensive care is being scrutinized as a major factor in increasing health care costs. We examined 404 consecutive admissions to the medical ICUs at a university medical center to study patterns of consumption of ICU resources and the proportion of resources used by patients admitted for monitoring only. We found a skewed distribution of ICU resource consumption, with the "high-cost" 8 percent using as many ICU resources as the "low-cost" 92 percent. Forty-one percent of admissions did not receive acute ICU treatments, but these admissions consumed less than 10 percent of ICU resources. Reducing the number of patients admitted for monitoring will have a relatively small impact on hospital charges. Since over 70 percent of the high-cost patients died, improved understanding of prognosis and better physician-patient communication may substantially reduce the proportion of critical care resources expended on futile treatment.

Predictors of mortality in older patients following medical intensive care: the importance of functional status.

OBJECTIVE: We examined predictors of hospital and 6-month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age-related changes. These age-related changes may be approximated by changes in functional status (FS). DESIGN: We conducted a retrospective chart review and collected severity of illness data using the Acute Physiology Score (APS), pre-hospitalization FS dichotomized as limited or not limited, and hospital mortality. County death records were reviewed for 6-month mortality. SETTING: Three community hospital MICUs. PATIENTS: Four-hundred MICU patients aged 50 and older admitted during the study period. RESULTS: Limited FS was found in 42% of the 227 patients who had FS data in the chart. Mortality was significantly associated with APS, age, FS, immunocompromise state, comorbidity, and nursing home residence. In logistic regression analyses, while controlling for important variables, APS (P less than 0.001) and age greater than or equal to 75 with limited FS (P less than 0.05) were associated with hospital mortality. Six-month mortality predictors were APS (P less than 0.001), hospital (P less than 0.05), immunocompromised state (P less than 0.05) and age greater than or equal to 75 with limited FS (P less than 0.05). CONCLUSIONS: We found that among patients without functional limitations, the oldest group was no more likely to die than the youngest group. Age and functional status had a significant interaction: patients older than 75 years with functional limitations were almost six times more likely to die in hospital compared to the reference group of patients between 50-64 years old without functional limitations. We conclude that functional status is an important predictor of outcome in older MICU patients.

Physician understanding of patient resuscitation preferences: insights and clinical implications.

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in-hospital CPR. DESIGN: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician-patient communication with physician understanding of patient CPR preferences. Among patients preferring to forego CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician. PATIENTS/SETTING: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments. GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forego CPR. Younger patient age, higher physician-estimated quality of life, and higher physician prediction of 6-month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forego CPR. Physicians who spoke with patients about resuscitation and had longer physician-patient relationships understood patients' preferences to forego CPR more often. Patients whose physicians understood their preference to forego CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation. CONCLUSIONS: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forego CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forego CPR but whose wishes are not understood by their physician may receive unwanted treatment.

A prospective study of patient-physician communication about resuscitation.

OBJECTIVE: To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians. DESIGN: Prospective cohort. SETTING: Five academic medical centers. PARTICIPANTS: Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life-threatening illness (n = 1288). MEASUREMENTS: Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow-up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators. RESULTS: Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month-period following hospital admission. Patients whose preference was to forego CPR (odds ratio (OR) 2.9;(95% CI, 1.9-4.2)) and whose preference had changed from desiring to foregoing CPR (OR 1.6; (95% CI, 1.1-2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forego CPR communicated this over a 2-month period. Having an advance directive and remaining in the hospital at 2-month follow-up were also independently associated with communication, whereas patients' preference for participation in decision-making, health status, and prognostic estimate were not. CONCLUSIONS: Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forego resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician-patient discussions about resuscitation.

Surrogate and physician understanding of patients' preferences for living permanently in a nursing home.

OBJECTIVE: To evaluate patients' willingness to live permanently in a nursing home and surrogate and physician understanding of that preference. DESIGN: Evaluation of cross-sectional interview data from a cohort study. SETTING: Five academic medical centers. PARTICIPANTS: Seriously ill hospitalized adults enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASUREMENTS: Patients' willingness to live permanently in a nursing home was measured on a 5-point scale ranging from "very willing" to "rather die." Ordinal logistic regression was used to identify patient demographic and clinical characteristics associated with this preference. Surrogate and physician perceptions of patient preferences were compared with patients' responses, and factors associated independently with surrogate and physician understanding of patient preference were identified. RESULTS: Of 9105 patients, 3262 (36%) provided responses to the study question: 7% were "very willing" to live permanently in a nursing home, 19% "somewhat willing," 11% "somewhat unwilling," 26% "very unwilling," and 30% would "rather die." Older age was associated independently with less willingness to live permanently in a nursing home (odds ratio [OR] = .90 per decade; 95% confidence interval [CI]: 0.85, 0.96). Patients with more education (OR = 1.03 per year; 95% CI: 1.00, 1.05) and more disabilities (OR = 1.05 per disability; 95% CI: 1.01, 1.09), and black patients (OR = 1.46 compared with white patients; 95% CI: 1.20, 1.76) were more willing to live in a nursing home. Surrogates understood 61% of patients' nursing home preferences but identified only 35% of patients who were willing to live permanently in a nursing home. Physicians identified 18% of patients willing to live permanently in a nursing home. CONCLUSION: Patient attitudes about living permanently in a nursing home can be elicited, cannot be reliably predicted from demographic and clinical variables, and are frequently misunderstood by surrogates and physicians. Elicitation of patient preferences regarding permanent nursing home placement should be explored before patients become unable to participate in decision making in order to enhance the concordance of patient preference with the way they spend the end of their lives.

Seriously ill hospitalized adults: do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments.

OBJECTIVE: To determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age-related differences in resource use are explained by patients' severity of illness and preferences for life-extending care. STUDY DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic acute care medical centers participating in the SUPPORT Project. PATIENTS: A total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6-month mortality of 50%. MEASUREMENTS: Resource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs. RESULTS: The median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $ 71.61 lower, respectively. These differences persisted after further adjustment for patients' preferences for life-extending care. CONCLUSIONS: Compared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource-intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life-extending care.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued. RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn. CONCLUSIONS: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

The changing relationship between clinicians and the laboratory medicine specialist in the managed care era.

Largely because of increased health-care costs, a variety of managed-care programs have been developed, and payment plans based on capitation will probably predominate in the future. Capitated, per-case, or per diem payment plans alter the traditional independence of health-care providers from the payment system. In these systems, clinical laboratory use becomes a resource to be managed, rather than a neutral third party or a source of income. Under capitated payment systems, clinicians will be motivated to reevaluate their own clinical laboratory resource use. Successful laboratory medicine specialists will understand these trends as well as the impact of newer payment plans on the relationship between themselves and clinicians, and develop new strategies to work with clinical colleagues to effect change.

Use of specimen turnaround time as a component of laboratory quality. A comparison of clinician expectations with laboratory performance.

Quantitative laboratory quality measures include test accuracy and precision. To be useful, however, tests also must be available in a timely manner. The authors surveyed 757 University of California, Los Angeles, house officers (485-64% responded) regarding their expectations of laboratory test turnaround time for five test groups that are regularly offered both stat and routine. They compared expectations with actual laboratory performance by evaluating turnaround time for 42,414 consecutive laboratory requests received over two weeks. The authors' laboratory performed 45% of studied analytes stat. Median turnaround time was 44 minutes for stat and 119 minutes for routine tests, although variation exists by test group. The percentage of time their laboratory met median stat and routine turnaround time expectations varies by shift and work area. Timeliness of results often may be as important as accuracy and precision in assuring quality of care and cost-effective use of hospital services. Although the laboratory may not meet current housestaff turnaround time expectations, it is unclear whether laboratory performance is inadequate or housestaff expectations are unreasonable. Publicizing actual routine turnaround times may reduce the number of stat requests ordered if routine turnaround times are incorrectly perceived to be too slow. Reduction in stat test ordering may improve overall laboratory performance and turnaround time. The authors recommend that clinical pathologists and clinicians together develop turnaround time goals based on practicality, medical necessity, and clinician expectations.

Evaluation of stat and routine turnaround times as a component of laboratory quality.

Quality assurance has been an essential part of clinical laboratory operations for more than two decades. Analytic precision and accuracy goals have been established, and laboratory performance is monitored periodically. For a laboratory test to be useful, it must be available in a timely manner. Expedience of result reporting has not, however, been routinely included among measures of laboratory quality. The authors evaluated stat and routine turnaround times for 42,414 requests on 24 clinical analytes over a 14-day period with the use of a personal computer. Median turnaround time is 1.70 times faster for stat than for routine tests. When examined by shift, average turnaround time is considerably faster for tests ordered stat than for tests ordered routinely during the day and evening shifts, when the work load is the greatest. The authors are now examining turnaround time as an indicator of quality laboratory performance and efficiency. Computer systems in many clinical laboratories already have the sophistication necessary to perform turnaround time analysis. The authors recommend that clinical laboratories begin to include timeliness of stat and routine result reporting as part of their quality assurance programs. Laboratories may also wish to investigate the usefulness of stat requests during slower shifts because these requests may interrupt the normal flow of specimens without expediting result reporting.

The covariance decomposition of the probability score and its use in evaluating prognostic estimates. SUPPORT Investigators.

The probability score (PS) or Brier score has been used in a large number of studies in which physician judgment performance was assessed. However, the covariance decomposition of the PS has not previously been used to evaluate medical judgment. The authors introduce the technique and demonstrate it by analyzing prognostic estimates of three groups: physicians, their patients, and the patients' decision-making surrogates. The major components of the covariance decomposition--bias, slope, and scatter--are displayed in covariance graphs for each of the three groups. The decomposition reveals that whereas the physicians have the best overall estimation performance, their bias and their scatter are not always superior to those of the other two groups. This is primarily due to two factors. First, the physicians' prognostic estimates are pessimistic. Second, the patients place the large majority of their estimates in the most optimistic category, thereby achieving low scatter. The authors suggest that the calculational simplicity of this decomposition, its informativeness, and the intuitive nature of its components make it a useful tool with which to analyze medical judgment.

Effect of do-not-resuscitate orders on the nursing care of critically ill patients.

BACKGROUND: The effect of a do-not-resuscitate order on the standard of care of critically ill patients is of concern to practitioners, patients, and their families. Because "do not resuscitate" may be misconstrued to include more than "no cardiopulmonary resuscitation," it may influence the aggressiveness with which some patients are managed. Nurses play a central role in determining standards of care. Hence, confusion on their part as to the meaning of this term can have a significant impact on patient care. OBJECTIVES: To compare nurses' attitudes about standards of care for critically ill patients with and without a do-not-resuscitate order. METHOD: A quasi-experimental design using simulation measurement was used for this study. RESULTS: Nurses reported that they would be significantly less likely to perform a variety of physiologic monitoring modalities and interventions for patients with a do-not-resuscitate order than for patients without such an order. Patients with a do-not-resuscitate order were more likely to receive psychosocial interventions including assessment of their spiritual needs and more flexible visiting practices. CONCLUSIONS: Our findings suggest that "do-not-resuscitate" may be misinterpreted to include more than "no cardiopulmonary resuscitation" even if the patient is receiving aggressive medical management. Misinterpretation of orders not to resuscitate may be related to a variety of factors including lack of understanding about hospital policy and ethical and moral values of the staff. We suggest replacing orders such as "Do not resuscitate" with clearly defined resuscitation plans that are jointly determined by the multidisciplinary team, patient, and family.

Nasopharyngeal mass: a manifestation of inflammatory otologic disease.

A nasopharyngeal mass with cranial neuropathies usually indicates an advanced neoplastic process. We present three patients with these findings and concurrent invasive Pseudomonas otitis in whom repeated nasopharyngeal biopsies were negative for tumor. All of the nasopharyngeal masses resolved following treatment of the otitis. Mechanisms of disease spread from the temporal bone to the nasopharynx are discussed. Clinicians may choose to modify diagnostic and therapeutic approaches to the nasopharyngeal mass in patients with concurrent invasive otologic disease.

Assessing illness severity and outcome in critically ill patients.

Severity of illness scores have great potential to improve use of scarce resources and to help monitor quality of care. Injury severity scores can reliably separate trauma patients into high- and low-mortality groups, but have limitations when applied in triage decision making. Specific predictive models for chest pain patients have improved admitting practices in some emergency departments. Univariate predictors of survival include age, severity of illness, and presence of chronic illnesses, especially cancer. General multivariate models for intensive care patients have correctly categorized hospital outcome in approximately 85 per cent of cases when applied in a retrospective fashion. These models are insufficiently precise for application to individual patients; but they may be helpful in assessing quality of care in the intensive care unit, in assessing efficacy of new technologies, and in utilization review audits.

Admitting elderly patients to the ICU: dilemmas and solutions.

Since intensive care is expensive and has limited efficacy, its use should be reserved primarily for patients with acute, reversible illnesses. Although age is related to ICU mortality, more important predictors of ICU outcome are severity of the acute illness, the admitting diagnosis, and previous health status. Thus, age should not be the sole factor considered prior to ICU transfer or the initiation or denial of resuscitative efforts. Geriatric physicians should prospectively develop individualized plans for each of their patients based upon the patients' wishes after a discussion of diagnosis, prognosis, and the likely efficacy and side effects of the available treatments.