Chief Editor’s note: Prof Reinikainen’s paper truthfully reflects the physician’s dilemma regarding the indication for transferring a critically ill patient to an intensive care unit (ICU). I have no doubt that his presentation will be followed by our readers’ comments. The Newsletter will be glad to publish your opinion on this very sensitive subject.
My phone rang twice within a short time frame. In each case, a colleague was referring an old patient for admission to the intensive care unit (ICU).
The first call came from the coronary angiography room. A patient with an acute inferior myocardial infarction had developed severe bradycardia and hypotension and had become pulseless. A brief period of cardiopulmonary resuscitation had restored spontaneous circulation, but the haemodynamic situation was still unstable, and respiratory support was needed. Despite being well over 80 years old, the patient had been in rather good shape before this cardiac event and had been able to independently manage both basic and instrumental activities of daily living.
After a successful percutaneous cardiological intervention (opening the occluded right coronary artery), we transferred the patient to the ICU for ventilator treatment and medications to support the failing heart. We suspected that the life-threatening situation would probably be transient and that the chance of a good recovery was reasonably high.
The second call came from the emergency department. A patient over 80 years old had been sent to the acute care hospital from a nursing home, his permanent residence. He had been previously diagnosed with chronic heart failure, generalized atherosclerosis, and moderate cognitive impairment. He was able to walk indoors with the aid of a walking frame, but in recent months his walking distance had gradually shortened to only a few steps. He needed help to dress and bathe. Now his general condition had deteriorated. He could hardly be awakened and was not able to communicate.
A chest X-ray revealed an enlarged cardiac silhouette and partial pulmonary shadowing consistent with pneumonia. Lactic acidosis was found by blood gas analysis. Bedside echocardiography revealed a dilated left ventricle with extremely poor systolic function.
There were no doubts about the situation being life-threatening. Pneumonia and sepsis had probably led to an acute worsening of the already-poor cardiac function, and the lactic acidosis signalled tissue hypoxia caused by circulatory failure. But should this patient be admitted to the ICU? The danger to life was obviously caused not only by acute infection, but also by chronic comorbidities and frailty. There was no way for ICU care to improve the frailty and low functional capacity. At best, intensive care might help to cure the pneumonia and restore the preceding status, but probably only for a rather short time, given the decline in functional capacity observed in recent months. At worst, intensive care, with its aggressive interventions, would cause pain and suffering with no better result than prolongation of the dying process.
I had a discussion with the patient’s next of kin, his son. I explained the situation, and we talked about treatment options and probable outcomes as well as less likely outcomes. The son stated that his father would definitely not want to spend his last days connected to life-sustaining machinery. After the discussion, we agreed that ICU admission would not be in the patient’s best interests. Fluid resuscitation was given, and antibiotics were administered, but an order was set not to intubate or attempt resuscitation.
An intensive care physician often plays the role of a gatekeeper. Unfortunately, triage decisions are sometimes affected by the availability of ICU beds. Even when there are resources, each decision to initiate or withhold intensive care must be weighed carefully, because care involving invasive interventions may cause harm. We must also respect the patient’s and family’s preferences and make sure that they are adequately informed about the situation and about the possibilities and limitations of intensive care.
Age alone is not a contraindication for ICU care. If a critical condition is assessed as probably reversible and the patient is estimated to have the capacity to benefit from active intensive care, then ICU admission is indicated. However, old age is often associated with frailty and poor functional status, which imply low recovery potential and, especially, a worse long-term prognosis. A combination of poor premorbid functional capacity, severe chronic comorbidities, and a critical acute illness may mean that not much can be gained from intensive care, and the best option may be to withhold aggressive interventions.
There is something more to remember: right now, somewhere in your hospital or your community, there may be some elderly people whom nobody has taken to the ICU door but who might still benefit from ICU care. Even many physicians may not be aware of what modern intensive care can offer. They may consider an acutely and seriously ill old patient to be predestined to die, even in situations where the acute illness could possibly be cured. Therefore, hospital staff must be educated to refer, without delay, patients with life-threatening but treatable and reversible acute conditions for intensive care. A medical emergency team (rapid response team) service within the hospital is helpful in preventing fatal delays.