Considering age when making treatment decisions in the ICU: too little, too much, or just right?

There are a number of studies providing evidence that age is associated with treatment decisions for critically ill adults, although most of these studies have been unable to fully account for both prehospital health status and severity of acute illness. In the previous issue of Critical Care, Turnbull and colleagues present a well-executed study analyzing data from a prospective cohort study of critically ill patients with acute respiratory distress syndrome to investigate the association between age and new limitations in life-sustaining therapy. They report a strong association between age and new limitations in life support in this cohort, even after adjusting for comorbidities, prehospital functional status, and severity of illness including daily organ dysfunction scores. Their results demonstrate that decisions about the goals of care and the ongoing use of life-sustaining treatments should be viewed as dynamic and responsive to events occurring during critical illness. This study raises the important question about the contributors to this association, and the authors raise the possibility that physician or surrogate bias may be contributing to decisions for older patients. While this is unlikely to be the only contributor to the association between age and end-of-life decisions, the mere possibility should prompt reflection on the part of clinicians caring for critically ill patients.