Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study.

Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions. OBJECTIVES: To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. DESIGN: Interview-based qualitative study using inductive thematic analysis. SETTING AND PARTICIPANTS: Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. RESULTS: Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. CONCLUSIONS AND RELEVANCE: An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Moral Distress in Canadian Intensivists: A Complex Interplay of Contextual and Relational Factors.

BACKGROUND: Health care professionals experience moral distress when they cannot act based on their moral beliefs because of perceived constraints. Moral distress prevalence is high among critical care (ICU) clinicians, but varies significantly between and within professions. RESEARCH QUESTION: How can the interindividual variability in moral distress of Canadian ICU physicians be explained to inform future system-based interventions? STUDY DESIGN AND METHODS: We analyzed 135 free-text comments written by 83 of the 225 ICU physicians who participated in an online cross-sectional wellness survey. An interdisciplinary team of five investigators completed the thematic analysis of anonymized survey comments according to published guidelines. RESULTS: Physicians identified contextual and relational factors that contributed to moral distress and work-related stress. Combined sources of distress created high work-related demands that were not always matched by equally high resources or mitigated by work-related rewards. An imbalance between demands and rewards could lead to undesirable individual and collective consequences. INTERPRETATION: Moral distress is experienced variably by ICU physicians and is linked to contextual and relational factors. Future studies should evaluate modifiable factors such as team interactions and the role of professional rewards as mitigators of distress to bring new insights into strategies to improve ICU clinician wellness and patient care.

New approach to assessing and addressing moral distress in intensive care unit personnel: a case study.

PURPOSE: To test a new approach to address moral distress in intensive care unit (ICU) personnel. METHODS: Using principles of participatory action research, we developed an eight-step moral conflict assessment (MCA) that guides participants in describing the behaviour that they have to implement, the effects this has on them, their current coping strategies, their values in conflict, any other concerns related to the situation, what helps and hinders the situation, new coping strategies, and the effect of the preceding steps on participants. This assessment was tested with eight ICU providers in an 11-bed community ICU. RESULTS: During three one-hour sessions, participants described their moral distress that was caused by the use of ongoing life-support for a patient who the team believed did not prefer this course of care, but whose family was requesting it. Participants experienced frustration and discouragement and coping strategies included speaking to colleagues and exercising. They felt that they were unable to take meaningful action to resolve this conflict. Values that were in conflict in the situation included beneficence and patient autonomy. Based on ranking of helping and hindering factors, the team proposed new strategies including improving consistency of care plans and educating patients' family members and ICU personnel about advance care planning and end-of-life care. After completing this assessment, participants reported less stress and a greater ability to take meaningful action, including some of the proposed new strategies. CONCLUSIONS: We found this new approach to address moral distress in ICU personnel to be feasible and a useful tool for facilitating plans for reducing moral distress.

RéSUMé: OBJECTIF: Nous avons souhaité mettre à l'essai une nouvelle approche pour traiter la détresse morale du personnel des unités de soins intensifs (USI). MéTHODE: En nous fondant sur les principes de la recherche-action participative, nous avons développé une évaluation des conflits moraux (ECM) en huit étapes qui guide les participants dans la description du comportement qu'ils doivent mettre en œuvre, des effets que cela a sur eux, de leurs stratégies d'adaptation actuelles, de leurs valeurs en conflit, de toute autre préoccupation liée à la situation, de ce qui aide et entrave la situation, de nouvelles stratégies d'adaptation, et de l'effet des étapes précédentes sur les participants. Cette évaluation a été testée auprès de huit praticiens de soins intensifs dans une unité de soins intensifs communautaire de 11 lits. RéSULTATS: Au cours de trois séances d'une heure, les participants ont décrit leur détresse morale causée par l'utilisation d'un système de réanimation continu pour un patient qui, selon l'équipe, ne préférait pas ce traitement, mais qui était demandé par la famille. Les participants ont éprouvé de la frustration et du découragement et les stratégies d'adaptation comprenaient le fait d'en parler à des collègues et de faire de l'exercice. Ils se sont sentis incapables de poser des gestes significatifs pour résoudre ce conflit. Les valeurs qui étaient en conflit dans la situation comprenaient la bienfaisance et l'autonomie du patient. Sur la base du classement des facteurs d'aide et d'entrave, l'équipe a proposé de nouvelles stratégies, notamment l'amélioration de l'uniformité des plans de soins et l'éducation des membres de la famille des patients et du personnel des soins intensifs sur la planification de soins avancés et les soins de fin de vie. Après avoir terminé cette évaluation, les participants ont déclaré éprouver moins de stress et une plus grande capacité à poser des gestes significatifs, y compris certaines des nouvelles stratégies proposées. CONCLUSION: Nous avons constaté que cette nouvelle approche visant à traiter la détresse morale chez le personnel des soins intensifs était faisable et qu'elle constituait un outil utile pour faciliter les plans de réduction de la détresse morale.

Moral Distress and Other Wellness Measures in Canadian Critical Care Physicians.

Rationale: Understanding the magnitude of moral distress and its associations may point to solutions. Objectives: To understand the magnitude of moral distress and other measures of wellness in Canadian critical care physicians, to determine any associations among these measures, and to identify potentially modifiable factors. Methods: This was an online survey of Canadian critical care physicians whose e-mail addresses were registered with either the Canadian Critical Care Society or the Canadian Critical Care Trials Group. We used validated measures of moral distress, burnout, compassion fatigue, compassion satisfaction, and resilience. We also measured selected individual, practice, and workload characteristics. Results: Of the 499 physicians surveyed, 239 (48%) responded and there were 225 usable surveys. Respondents reported moderate scores of moral distress (107 ± 59; mean ± standard deviation, maximum 432), one-third of respondents had considered leaving or had previously left a position because of moral distress, about one-third met criteria for burnout syndrome, and a similar proportion reported medium-high scores of compassion fatigue. In contrast, about one-half of respondents reported a high score of compassion satisfaction, and overall, respondents reported a moderate score of resilience. Each of the "negative" wellness measures (moral distress, burnout, and compassion fatigue) were associated directly with each of the other "negative" wellness measures, and inversely with each of the "positive" wellness measures (compassion satisfaction and resilience), but moral distress was not associated with resilience. Moral distress was lower in respondents who were married or partnered compared with those who were not, and the prevalence of burnout was lower in respondents who had been in practice for longer. There were no differences in any of the wellness measures between adult and pediatric critical care physicians. Conclusions: Canadian critical care physicians report moderate scores of moral distress, burnout, and compassionate fatigue, and moderate-high scores of compassion satisfaction and resilience. We found no modifiable factors associated with any wellness measures. Further quantitative and qualitative studies are needed to identify interventions to reduce moral distress, burnout, and compassion fatigue.

Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study.

OBJECTIVES: To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN: Multicenter cohort study. SETTING: Ten adult medical-surgical Canadian ICUs. PATIENTS: Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS: Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.

Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia.

BACKGROUND: Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES: To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS: A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS: All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION: Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.

Outcomes of Critically Ill Patients Who Have Serotype 5 Invasive Pneumococcal Disease.

PURPOSE: To determine whether invasive pneumococcal disease (IPD) due to serotype 5, which occurred as a local outbreak in 2006 to 2007, is associated with intensive care unit (ICU) admission, hospital mortality, or organ supports in those who are critically ill. MATERIALS AND METHODS: Retrospective review of patients who presented with IPD to 2 tertiary hospitals in Vancouver, Canada, from July 2004 to June 2007. We compared patient characteristics, interventions, and outcomes between patients who had serotype 5 and other serotypes using bivariate and multivariate analyses. RESULTS: A total of 149 patients had serotype 5 and 106 had nonserotype 5. Patients with serotype 5 were younger, had lower prevalence of comorbid diseases, and had higher rates of substance use than patients with nonserotype 5. There were no differences in chest tube placement for complications of pneumonia or in ICU admission. Frequency of necrotizing pneumonia and hospital mortality were lower in the serotype 5 group. For the 71 patients with IPD who were admitted to ICU, there was no difference in severity of illness, ICU length of stay, or ICU mortality between the groups. There was also no difference in organ supports except that the serotype 5 group was more likely to receive vasopressors. CONCLUSION: Serotype 5 in patients who have IPD is associated with no difference in ICU admission but with increased use of vasopressors and lower hospital mortality.

Moral distress is associated with general workplace distress in intensive care unit personnel.

PURPOSE: To assess the association between moral distress and general workplace distress in intensive care unit (ICU) personnel. MATERIALS AND METHODS: We administered the Moral Distress Scale Revised and the Job Content Questionnaire to all clinicians (870 nurses, 68 physicians, 452 other health professionals) in 13 ICUs (3 tertiary, 3 large community, 7 small community) in British Columbia, Canada. We used mixed effects regression, treating ICUs as clusters, to examine the association between the Moral Distress Score and each Job Content Questionnaire scale (decision latitude, psychological stressors, social support, psychological strain) after adjusting for age, sex, and years of experience of respondents; separate analyses were done for each profession. RESULTS: Overall response rate was 45%. Nurses and other health professionals had higher moral distress scores than physicians, but there were no differences in general workplace distress scores among professional groups. After adjustment for demographic characteristics, higher moral distress in nurses was associated with lower decision latitude and social support, and with higher psychological stressors and psychological strain. For physicians and other professionals, these relationships were similar. CONCLUSIONS: Moral distress is associated with general workplace distress in ICU personnel. Interventions that ameliorate either type of distress may also ameliorate the other.

Mortality Risk Profiles for Sepsis: A Novel Longitudinal and Multivariable Approach.

To determine if a set of time-varying biological indicators can be used to: 1) predict the sepsis mortality risk over time and 2) generate mortality risk profiles. DESIGN: Prospective observational study. SETTING: Nine Canadian ICUs. SUBJECTS: Three-hundred fifty-six septic patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical data and plasma levels of biomarkers were collected longitudinally. We used a complementary log-log model to account for the daily mortality risk of each patient until death in ICU/hospital, discharge, or 28 days after admission. The model, which is a versatile version of the Cox model for gaining longitudinal insights, created a composite indicator (the daily hazard of dying) from the "day 1" and "change" variables of six time-varying biological indicators (cell-free DNA, protein C, platelet count, creatinine, Glasgow Coma Scale score, and lactate) and a set of contextual variables (age, presence of chronic lung disease or previous brain injury, and duration of stay), achieving a high predictive power (conventional area under the curve, 0.90; 95% CI, 0.86-0.94). Including change variables avoided misleading inferences about the effects of day 1 variables, signifying the importance of the longitudinal approach. We then generated mortality risk profiles that highlight the relative contributions among the time-varying biological indicators to overall mortality risk. The tool was validated in 28 nonseptic patients from the same ICUs who became septic later and was subject to 10-fold cross-validation, achieving similarly high area under the curve. CONCLUSIONS: Using a novel version of the Cox model, we created a prognostic tool for septic patients that yields not only a predicted probability of dying but also a mortality risk profile that reveals how six time-varying biological indicators differentially and longitudinally account for the patient's overall daily mortality risk.

Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study.

BACKGROUND: Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process. METHODS: We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations. RESULTS: The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider-provider and provider-patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed. INTERPRETATION: Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes.

BACKGROUND: Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. METHODS: This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients. RESULTS: A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority. CONCLUSIONS: Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward.

PURPOSE: To provide a 360-degree description of ICU-to-ward transfers. METHODS: Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer. RESULTS: Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients). CONCLUSIONS: ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study.

BACKGROUND: Moral distress is common among personnel in the intensive care unit, but the consequences of this distress are not well characterized. OBJECTIVE: To examine the consequences of moral distress in personnel in community and tertiary intensive care units in Vancouver, Canada. METHODS: Data for this study were obtained from focus groups and analysis of transcripts by themes and sub-themes in 2 tertiary care intensive care units and 1 community intensive care unit. RESULTS: According to input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported emotion associated with moral distress was frustration. Negative impact on patient care due to moral distress was reported 26 times, whereas positive impact on patient care was reported 11 times and no impact on patient care was reported 10 times. Having thoughts about quitting working in the ICU was reported 16 times, and having no thoughts about quitting was reported 14 times. CONCLUSION: In response to moral distress, health care providers experience negative emotional consequences, patient care is perceived to be negatively affected, and nurses and other health care professionals are prone to consider quitting working in the intensive care unit.

Outcomes of elderly critically ill medical and surgical patients: a multicentre cohort study.

PURPOSE: Very elderly (over 80 yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study is to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers. METHODS: This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge. RESULTS: There were 1,671 patients evaluated in this study. Patient demographics included a mean age of 84.5 yr, baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22.4, baseline Sequential Organ Failure Assessment (SOFA) score of 5.3, overall ICU mortality of 21.8%, and overall hospital mortality of 35.0%. Medical patient median ICU length of stay was 4.1 days, hospital length of stay was 16.2 days, ICU mortality was 26.5%, and hospital mortality was 41.5%. Surgical patient median ICU length of stay was 3.8 days, hospital length of stay was 20.1 days, ICU mortality was 18.7%, and hospital mortality was 31.6%. Only 45.0% of medical patients and 41.6% of surgical emergency patients were able to return home to live. CONCLUSIONS: In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

Causes of moral distress in the intensive care unit: A qualitative study.

PURPOSE: The purpose of the study is to examine the causes of moral distress in diverse members of the intensive care unit (ICU) team in both community and tertiary ICUs. MATERIALS AND METHODS: We used focus groups and coding of transcripts into themes and subthemes in 2 tertiary care ICUs and 1 community ICU. RESULTS: Based on input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported causes of moral distress were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), poor communication, inconsistent care plans, and issues around end of life decision making. CONCLUSIONS: Causes of moral distress vary among ICU professional groups, but all are amenable to improvement.

A clinical prediction tool for hospital mortality in critically ill elderly patients.

BACKGROUND: Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive. OBJECTIVE: The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs. DESIGN: This was a prospective, multicenter cohort study. SETTING: Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed. INTERVENTIONS: A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool. MAIN RESULTS: We included 1033 elderly patients in the analyses. Mean age was 84.6±3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1±7.9, Sequential Organ Failure Assessment score was 5.3±3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; >90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; >300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (<7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60]). CONCLUSION: We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making.