According to a study of 15 emergency departments, patients over age 80 who are admitted to intensive care are often not asked their opinion about admission. “The relationship between physicians and their patients has changed over the last decades and patients’ empowerment has led to a greater self autonomy in medical decisions,” but apparently not when it comes to moving elderly patients into an intensive care unit,” said lead author Dr Julien Le Guen of Universite Paris Descartes in France.
Legally, no medical decision should be made without the patient’s consent, Le Guen is quoted as saying. But based on the results of his team’s study, there seems to be a discrepancy between what doctors say is important, like the patient’s opinion, and what they actually do.
The researchers used data from a previous study of patients over age 80 who came to emergency rooms at 15 hospitals in the Paris region between 2004 and 2006. All had conditions potentially requiring intensive care, and all were conscious and capable of expressing an opinion if asked.
The emergency room physicians filled out a questionnaire on each patient’s status a, the number of available intensive care beds, the physician’s years of experience, and whether or not relatives were consulted. They also indicated if they sought the opinion of the patient or relatives regarding referral to the intensive care unit (ICU) and if so what their opinions were.
More than 2,000 patients were included in the study and only 270 were asked for their opinion, ranging by medical centre from 1% of the time to 54% of the time. Patients with a history of dementia were less often asked, and those with more functional autonomy or a relative who had been questioned were more often asked.
Older ER doctors were less likely than younger doctors to ask a patient’s opinion, the researchers reported. “Intensive care techniques in these extreme ages of life raise the question of an artificial prolongation of life and can be perceived by some as therapeutic relentlessness,” Le Guen said. “Therapeutics used in the ICU are uncomfortable,” he said. And for the oldest old, he added, rates of death in the ICU, in the hospital, and afterward are high, “and survivors frequently face a loss of autonomy in the following months.2 Individual wishes can be hard to predict for the very old, he said.
“ICU admission policies and process are different between countries,” Le Guen said. “In France, the final decision is always under the intensivist’s responsibility, normally after a global evaluation taking into account patient wishes.”
A history of dementia does not always mean a patient can’t express an opinion, Le Guen said. “In my opinion, patients suffering from dementia should always be asked, and physicians should always try to receive consent when a medical decision has to be made for these patients, even if a full understanding seems illusory,” he said.
Background: demand for intensive care of the very elderly is growing, but few studies report inclusion of their opinions in the admission decision-making process. Whether or not to refer a very elderly patient to intensive care unit is a difficult decision that should take into account individual wishes, out of respect for the patient’s decision-making autonomy.
Methods: in 15 emergency departments, patients over 80 years old who had a potential indication for admission to intensive care, and that were capable of expressing their opinion were included. Frequency of opinions sought before referral decision and individual and organisational factors associated were recorded and analysed.
Results: a total of 2,115 patients were included. Only 270 (12.7%) of them were asked for their opinion, and there were marked variations between study centres (minimum: 1.1% and maximum: 53.6%). A history of dementia reduced the probability of a patient being asked for his or her opinion (OR 0.47, 95% CI: 0.25–0.83). Patients’ opinion was most often sought when their functional autonomy was conserved (OR 2.10, 95% CI: 1.39–3.21) and when a relative had been questioned (OR 5.46, 95% CI: 3.8–7.88). Older attending physicians were less likely to ask for the patient’s opinion (older physician versus younger physician, OR 0.48, 95% CI: 0.35–0.66).
Conclusions: elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.