The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments.

PURPOSE: To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. METHODS: Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. RESULTS: The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. CONCLUSIONS: Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over.

PURPOSE: To assess physician decisions about ICU admission for life-sustaining treatments (LSTs). METHODS: Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV). RESULTS: The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13-0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10-0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04-3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23-0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively. CONCLUSIONS: Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.