February 15, 2015

Is the ICU Good for Your Health?

Your goals of care determine what kind of medical treatment makes sense for you—or they should. If you want any treatment, however painful or debilitating, as long as it has a reasonable prospect of prolonging your life, then you would accept high risk surgery or attempted CPR. If you want treatment that offers a good possibility of making your daily life better by helping you with every day activities such as seeing or walking or hearing, then you’d be all for cataract surgery or a hip replacement or a hearing aid. And if you want treatment provided that it makes you more comfortable, by helping you breathe more easily or diminishing nausea or lessening pain, then you’d opt for oxygen, anti-emetics, or opioid medications, depending on your symptoms. The challenge for patients and doctors has been figuring out what kinds of medical treatment don’t make sense, given your goals, because they are unlikely to produce the effect you want—and may even produce the opposite effect. A new article in JAMA Internal Medicine helps clarify when one particular treatment, ICU care, is apt to achieve various discrete goals of medical care.

The authors of this important new study wanted to know what happens to older people after an ICU stay. They wanted to know not only whether they would survive, but also what their lives would be like in the months following ICU treatment. They also wanted to know how the person’s level of functioning before the hospitalization would affect what happened after the hospitalization.

This remarkable study involved prospectively following individuals over the age of 70 who, at the time of enrollment, were non-disabled in four basic activities of daily living. A total of 754 people were followed with home assessments at baseline and every year and a half from 1998 through 2012. When patients or their surrogates reported a hospitalization, the details of that stay were gleaned from medical record review and from claims data. 

Of the 754 patients followed, 291 (or just under 40%) at some point were admitted to an ICU, which in itself is impressive. For the 241 who lived to be discharged (17% died in the hospital), the researchers found 3 distinct trajectories. Fully half (51.1%) experienced severe disability over the year after discharge; slightly over one-quarter (28.1%) had mild to moderate disability; and just over one-fifth (20.8%) had minimal disability. Most of the patients (except the 7% who died during the first 30 days after discharge) got slightly better in the first three months after leaving the hospital—that is, they experienced fewer disabilities than at the time of discharge—but in all 3 groups, the level of disability stabilized after 3 months rather than continuing to improve.

How well people did after an ICU stay was closely related to how well they were functioning before the hospitalization. Not surprisingly, those with severe disability before the acute illness (77 people) had severe disability afterwards as well, and one-third of them died. Among those who had mild to moderate disability before the hospitalization (128 people) , 32% had roughly the same level of disability afterwards, 40% had severe disability, and 26% died. Finally, among those who had only minimal disability before the ICU stay (86 people), half still had minimal disability afterwards, about one quarter had mild to moderate disability, and the remaining quarter were evenly distributed between those who died and those who had developed severe disability.

How does this study help align treatment with the patient’s goals? For older people whose primary goal is comfort, ICU care is not likely to help. Patients in the ICU were placed on ventilators (30%) and underwent all the other invasive treatments commonly associate with the ICU. For older individuals whose primary goal is maximizing function, ICU care is likely to lead to a deterioration of function, unless the patient was already suffering from severe disability (though even these individuals tended to have a larger number of disabilities after the hospitalization than before). Decline in function is particularly striking for those who started out with mild to moderate disability. And for older patients whose primary goal is life-prolongation, ICU care made most sense for those whose baseline status involved minimal disability—81% of such patients survived a year, compared to 56% of those with mild to moderate disability at baseline and only 33% of those with underlying severe disability.

The ICU is a remarkable institution. It represents the pinnacle of American high-tech care. But it comes at a price, even when it succeeds in prolonging life. That price is greater disability, which may or may not be acceptable to older patients. It all depends on your goals of care. 

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