The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU

 

by Oded Mousai, Lola Tafoureau, Tamar Yovell, Hans Flaatten, Bertrand Guidet, Michael Beil, Dylan de Lange, Susannah Leaver, Wojciech Szczeklik, Jesper Fjolner, Akiva Nachshon, Peter Vernon van Heerden, Leo Joskowicz, Christian Jung, Gal Hyams and Sigal Sviri 

 

Annals of Intensive Care volume 13, Article number: 40 (2023) 

 

Background

Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU.

Methods

This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST.

Results

The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables.

Conclusions

Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST.