Retrospective Chart review of patients > 75 years intubated for 7 days or more

1. Survival and disposition of
patients 75 years or older
following mechanical
ventilation of 7 or more days
PRINCIPAL INVESTIGATORS: THOMAS MILLER, MD, KRISTINA NEWPORT MD, FAAHPM
PALLIATIVE MEDICINE CONSULTANTS OF HOSPICE & COMMUNITY CARE, LANCASTER PA
COLLABORATORS: SHANTHI SIVENDRAN MD, MSCR, LISA ESTRELLA, MS, MICHAEL HORST PHD, ROBIN HICKS, DO
LANCASTER GENERAL HEALTH AND HEART OF LANCASTER REGIONAL MEDICAL CENTER
CORRESPONDENCE: KNEWPORT@SUPPORTIVECARE.ORG

2. INVESTIGATORS HAVE NO CONFLICTS OF INTEREST
TO DISCLOSE

3. Objective:
Describe mortality and disposition of patients 75
years or older who require mechanical
ventilation 7 or more days

4. Background:
 Mechanical ventilation ≥7days  more decisions
 PEG/Tracheostomy/cardiac resuscitation
 Patient/family base decisions on expectations of recovery
 But, providers often present only ‘life or death’, not quality of life
 Inpatient palliative care consultation often requested
 Goals of care for elderly patients
 Loss of independence and caregiver burden cited as major factors in decisions
 Frail patients may be one acute illness away from dependence or death

5. Literature Review: Outcomes for elderly survivors
of mechanical ventilation/ICU care
• ICU care that includes mechanical ventilation(MV) leads to:
• ↑ Mortality: 43% of ≥65 years died within 2 months of MV ≥ 2days4
• ↑ Health care costs6
• ↑ Caregiving needs & Disability1,2
• ↑ Care transitions: Adults requiring MV ≥21days had median of 4 transitions in the next yr6
• ↓ Decreased Quality of Life3
• More than 50% of patients ≥70 years who experience critical illness died within 1 month of
intensive care unit(ICU) admission
• 28.8% (3098/10,743) of adults hospitalized in 25 Scottish hospitals died within one year of
hospitalization in 2013, 32.3% died during index hospitalization, pts ≥ 85y mortality was three times
higher than ≤60. (45.6% vs 13.1%; p < 0.001). 5
1 Barnato, A et al.‘Disability among Elderly Survivors of Mechanical Ventilation’, American Journal of Respiratory and Critical Care Medicine, 183 (2011), 1037–42
2 Ferrante, L etal ‘Functional Trajectories among Older Persons before and after Critical Illness’, JAMA Internal Medicine, 175 (2015), 523–29
3Chatila, W., D. T. Kreimer, and G. J. Criner, ‘Quality of Life in Survivors of Prolonged Mechanical Ventilatory Support’, Critical Care Medicine, 29 (2001), 737–42
4QOLAfter Mechanized Ventilation in the Elderly Study Investigators, ‘2-Month Mortality and Functional Status of Critically Ill Adult Patients Receiving Prolonged MV’, Chest, 121 (2002), 549–58
5Clark, D et al., ‘Imminence of Death among Hospital Inpatients: Prevalent Cohort Study’, Palliative Medicine, 28 (2014), 474–79
6Unroe, M et al One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study’, Annals of Internal Medicine, 153 (2010), 167–75

6. Research Objectives & Methods:
Objective:
 Determine mortality and disposition of patients 75 or older who require ≥7 days of mechanical
ventilation compared to patients in ICU ≥7 days or hospitalized ≥7 days but intubated <7
days via retrospective chart review.
Methods:
 Study Population:
 Patients age ≥ 75 years who were hospitalized between 5/1/11 to 4/30/15 and did not have
pre-existing tracheostomy
 Source of Data:
 Electronic medical records (EMR) from one large suburban community hospital (590 beds)and
one large non-profit community hospice (daily census 450) were reviewed, retrospectively, for
outcomes and covariates.
 Public internet searches were performed to determine date and location of death if not
available in EMR.

7. TABLE 1
All Patients
(N=6,724)
≥7d Hospitalization
(N=6290)
≥7 d ICU care
(N=346)
≥7d intubation
(N=88)
AGE (years) Mean
83.3(StDev 5.5) 83.4(StDev 5.5) 81.5(StDev 4.75) 81.3(StDev 5.2)
Median 83 (75-108) 83(75-108) 81(75-95) 79(75-96)
RACE Asian 31 29 2 0
Black 127 120 6 1
Other 75 71 2 2
Unknown 47 40 6 1
White 6444 6030 330 84
LOS Mean
10.56 (StDev 5.0) 10.13(StDev 4.4) 16.84(StDev 8.1) 16.22(StDev 7.7)
Median 9 (7-68) 9(7-68) 15(7-52) 14(7-39)
Characteristics of Sample

8. 3.07%
16.18%
37.86%
52.02%
46.59%
73.86%
80.68%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Death in hospital Death with 30 days of Discharge Death within 1 year of Discharge
PERCENTAGEOFPATIENTSWHODIED
MORTALITY RATES OF PATIENTS ≥75 YEARS
≥7d Hospitalization ≥7 d ICU care ≥7d intubation

9. 12.97%
25.14%
6.14%
57.55%
4.14%
21.72%
18.28%
74.14%
25.17%
48.62%
0.00% 3.41%
15.91%
50.00%
21.28%
31.91%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Home
Independently
Home with
services
Palliative Based
plan of care
Facility based
care
Readmission
within 30 days
Readmission
within 1 year
DISPOSITION OF PATIENTS ≥75 YEARS
≥7d Hospitalization (6290) ≥7 d ICU care (290) ≥7d intubation (88)

10. Results:
88 patients aged 75 or older required mechanical ventilation for ≥7 days from 5/1/11 to 4/30/15.
 54.5% of patients survived hospitalization
 Only 19.32% of patients were alive 1 year later
 87.5% of patients died or were re-hospitalized within 1 year.
 Of those discharged alive, the vast majority (93.6%) required care in a facility.
 3.4% of patients returned home after discharge and 2/3 of them had hospice services.
 0 (None) of the patients returned home completely independent.
 47.6% of surviving patients were re-hospitalized within 1 year.

11. Conclusion:
Life after prolonged intubation (≥7days) for patients
≥75y is likely to require skilled nursing care (93%)
with poor chance of survival >1 year(19%)

12. Study Weaknesses
 These findings are correlations, not proof of causation
 Pre-hospital functional status or level of care was not available
 We cannot account for patients who decided against mechanical ventilation or who pursued
palliative vent withdrawal before 7 days
 EMR identification of death is unreliable, limiting the ability to compare groups’ 30 d and 1 y
mortality
 Chart review did not allow for disposition status at 30 days or 1 year
 Assumptions about Quality of life, physical and psychosocial distress may be made but not
confirmed without inclusion of patient reported outcomes

13. Takeaways
If “Life or Death” decisions are on the table, be sure “Life” is accurately described
Mechanical ventilation( ≥7 days) for patients 75 years or older, is associated with
high in-hospital and 1-year mortality and universal need for post-hospital medical
services
Retrospective studies such as this one can yield valuable information with low
utilization of resources

14. Barnato, A.E., Albert, S.M., Angus, D.C., Lave, J.R., Degenholtz, H.B., 2011. Disability among elderly survivors of mechanical ventilation. Am. J. Respir. Crit. Care Med. 183, 1037–1042.
doi:10.1164/rccm.201002-0301OC
Boumendil A, Latouche A, Guidet B, ICE-CUB Study Group, 2011. ON the benefit of intensive care for very old patients. Arch Intern Med 171, 1116–1117.
doi:10.1001/archinternmed.2011.102
Chatila, W., Kreimer, D.T., Criner, G.J., 2001. Quality of life in survivors of prolonged mechanical ventilatory support. Crit. Care Med. 29, 737–742.
Ely, E.W., 2003. Optimizing outcomes for older patients treated in the intensive care unit. Intensive Care Med 29, 2112–2115. doi:10.1007/s00134-003-1845-5
Ferrante, L.E., Pisani, M.A., Murphy, T.E., Gahbauer, E.A., Leo-Summers, L.S., Gill, T.M., 2015. Functional trajectories among older persons before and after critical illness. JAMA Intern Med
175, 523–529. doi:10.1001/jamainternmed.2014.7889
Garrouste-Orgeas, M., Timsit, J.-F., Montuclard, L., Colvez, A., Gattolliat, O., Philippart, F., Rigal, G., Misset, B., Carlet, J., 2006. Decision-making process, outcome, and 1-year quality of life of
octogenarians referred for intensive care unit admission. Intensive Care Med 32, 1045–1051. doi:10.1007/s00134-006-0169-7
Greysen, S.R., Stijacic Cenzer, I., Auerbach, A.D., Covinsky, K.E., 2015. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med 175, 559–565.
doi:10.1001/jamainternmed.2014.7756
Herridge, M., Cameron, J.I., 2013. Disability after critical illness. N. Engl. J. Med. 369, 1367–1369. doi:10.1056/NEJMe1309482
Herridge, M.S., Tansey, C.M., Matté, A., Tomlinson, G., Diaz-Granados, N., Cooper, A., Guest, C.B., Mazer, C.D., Mehta, S., Stewart, T.E., Kudlow, P., Cook, D., Slutsky, A.S., Cheung, A.M.,
Canadian Critical Care Trials Group, 2011. Functional disability 5 years after acute respiratory distress syndrome. N. Engl. J. Med. 364, 1293–1304. doi:10.1056/NEJMoa1011802
Heyland, D., Cook, D., Bagshaw, S.M., Garland, A., Stelfox, H.T., Mehta, S., Dodek, P., Kutsogiannis, J., Burns, K., Muscedere, J., Turgeon, A.F., Fowler, R., Jiang, X., Day, A.G., Canadian Critical
Care Trials Group, Canadian Researchers at the End of Life Network, 2015. The Very Elderly Admitted to ICU: A Quality Finish? Crit. Care Med. 43, 1352–1360.
doi:10.1097/CCM.0000000000001024
Hui, D., Bruera, E., 2015. Models of integration of oncology and palliative care. Ann Palliat Med 4, 89–98. doi:10.3978/j.issn.2224-5820.2015.04.01
Iwashyna, T.J., Ely, E.W., Smith, D.M., Langa, K.M., 2010. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 304, 1787–1794.
doi:10.1001/jama.2010.1553
Kress, J.P., Herridge, M.S., 2012. Medical and economic implications of physical disability of survivorship. Semin Respir Crit Care Med 33, 339–347. doi:10.1055/s-0032-1321983
Pandharipande, P.P., Girard, T.D., Jackson, J.C., Morandi, A., Thompson, J.L., Pun, B.T., Brummel, N.E., Hughes, C.G., Vasilevskis, E.E., Shintani, A.K., Moons, K.G., Geevarghese, S.K., Canonico,
A., Hopkins, R.O., Bernard, G.R., Dittus, R.S., Ely, E.W., BRAIN-ICU Study Investigators, 2013. Long-term cognitive impairment after critical illness. N. Engl. J. Med. 369, 1306–1316.
doi:10.1056/NEJMoa1301372
Quality of Life After Mechanized Ventilation in the Elderly Study Investigators, 2002. 2-month mortality and functional status of critically ill adult patients receiving prolonged mechanical
ventilation. Chest 121, 549–558.
Unroe, M., Kahn, J.M., Carson, S.S., Govert, J.A., Martinu, T., Sathy, S.J., Clay, A.S., Chia, J., Gray, A., Tulsky, J.A., Cox, C.E., 2010. One-year trajectories of care and resource utilization for
recipients of prolonged mechanical ventilation: a cohort study. Ann. Intern. Med. 153, 167–175. doi:10.7326/0003-4819-153-3-201008030-00007
Zumtobel, V., Hentsch, S., Kollig, E., 1996. [Long-term prognosis of the critically ill intensive care patient]. Langenbecks Arch Chir Suppl Kongressbd 113, 289–292.
References & Questions