ICU Use for the Elderly

Intensive care unit use is very expensive.  End-of-life care can be very expensive.  Using ICUs for the very elderly may be questionable.  These subjects are explored in a new study from France regarding ICU use for patients over 75.   (JAMA Article)   The study involved 3036 patients at 24 hospitals which had ICUs.  The hospitals were randomized to either continue using their current practices for ICU use or to adopt a systematic triaging for whether patients over 75 got admitted to an ICU.  The most common diagnoses for the patients being evaluated were septic shock, acute pneumonia, cardiac insufficiency and acute respiratory failure.  While there were more deaths in the 6 months following the hospital admissions in the group using a triage system for ICU use, after adjustment for patient characteristics these differences were not significant.  ICU use was actually higher, at 61% of the patients, for the triage system hospitals than for the ones using standard practice, at 34%, and was significant after adjustment.  The mortality rate while the patients were in the ICU was not significantly different between the two sets of hospitals, but the in-hospital mortality was higher in the systematic triage hospitals.  Independence in activities of daily living and quality of life did not appear to be materially different after 6 months between the group of patients in the hospitals using their standard approach to ICU admissions and those using the systematic triage approach.  Interpretation of the results is ambiguous.  Taking a more rigorous approach to who gets into an ICU appeared to actually increase ICU use, which raises costs.  At the same time, being in an ICU did not appear to either increase quality outcomes or decrease them.  So, given that it likely costs something to implement the systematic triage, hospitals almost might be better off doing what they have been doing.  And it is not clear that the study answers more fundamental questions about whether ICU care is necessary at all, does it provide any benefits for any patients?