End-of-life decision-making in very old critically ill patients

Area of Science:

• Critical Care Medicine
• Geriatrics
• Medical Ethics

Background:

• End-of-life decision-making in intensive care units (ICUs) is ethically challenging, especially for the very old.
• Decisions regarding life-sustaining treatments are influenced by prognosis, patient values, and socioeconomic factors.
• Non-beneficial treatment, offering little benefit and causing suffering, should be avoided in high-quality end-of-life care.

Purpose of the Study:

• To explore the complexities of end-of-life decision-making in very old ICU patients.
• To examine the role of frailty, functional status, and illness severity in treatment choices.
• To highlight challenges in prognostication and shared decision-making.

Main Methods:

• Analysis of large international cohorts (VIP, VIP2, COVIP) focusing on elderly ICU patients.
• Examination of factors influencing decisions to limit life-sustaining treatment.
• Review of ethical considerations in shared decision-making and surrogate decision-making.

Main Results:

• Frailty is strongly linked to mortality, functional decline, and treatment limitation in very old ICU patients.
• Significant regional variations exist in end-of-life care practices.
• Prognostication is often imprecise, potentially leading to prolonged aggressive treatment.

Conclusions:

• Shared decision-making, aligned with patient goals, is crucial but often difficult to achieve.
• Transparent communication, documentation, and time-limited trials can support goal-of-care reassessment.
• Improving end-of-life care requires addressing frailty, prognostication accuracy, and decision-making processes.