Is there some more center to collect data. Indeed, we're very interested in this kind of project.

Sincerely Yours

Since i think France now have a Nationwide accetance, you can probably register your ICU at www.VIP1study.com. You can also contact national P for France:I professor Bertrand Guidet in Paris about it ([email protected])

Kind regards

Hans Flaatten

Regarding the frail and elderly on ICU, the end of life decisions are probably the most pressing question posed brought up by nurses and doctors to the ethics commissions. The elder patient needs early intensified and more holistic treatment, but may not bear either complexity/overload or failure of more complicated treatment.

If dementia or unability to speak for themselves are present, this may complicate therapeutic cooperation further, especially if relatives do not speak with one voice. To answer the question, what future are we trying to save the patient for, may be  impossible by then.  

Try to consensuate the limitation of therapy with relatives and identify previous patient decisions

Regarding the elderly patients there are some kind of problems in my opinion:

Among European nation there are some different ethical problem regarding end-of-life decision, religious and economic issue. Therefore there is an organizational problem, it is different when patient is admitted to ICU in an University Hospital or in a Community one. Then there are clinical issues elderly patients admitted to ICU after elective surgery have a better early and long term outcome than elderly admitted for unplanned surgery or medical problems. So, maybe, would be necessary a sort of score which can help physicians to chose for admitting elderly patients in ICU.

in my UN published experiences in our tertiary respiratory hospital ,we need more rapid early tracheostomy for these patients,as we doing PDT here ,I'm doing it sooner than younger people and its facilitate early mobilizations and weaning in compare with the standard group.

if you like I will send our data analysis .

Early discussion of diagnosis and prognosis with relatives is very important. Religious concerns and counselling are very important. Prolongation of life in the presence of terminal illness may be inappropriate. 

Fascinating & interesting project.... As a nurse this topic hits home as many of us in the Healthcare field struggle with the decision making regarding prolonging life of this age group and how that effects the individual, their family, community & whole society.... good luck & please keep us posted on its outcome or learnings

In modern medicine, very important ethical aspects have been raised that until a decade ago were not considered in the strategy of health personnel when it was necessary to deal with relatives: Desire of the patient to end his suffering, moral and religious implications of the family, Even when these are not to the patient's liking or when it is decided to continue with life support. I think that we must be more inclusive, more human in deciding what will happen to the elderly patient, is a critically ill human being, with difficulties in vital and important decisions and most importantly, pain and suffering.

Many questions than answers:

1- Understanding how geriatric physiology is different - Despite we understand the pediatric side we do not understand the geriatric one. Nutrition, management of delirium and drug doses should be different - Is Geriatric ICU should be a new ICU sub-specialty - Specialized Geriatric ICUs??

2- Triaging: We face commonly those patients and we are not sure of their physiologic reserve (and tolerance to heavy ICU management) and not sure of their wishes. I think it is of utmost importance to introduce an early discussion by the family physicians with the patients and relatives about "in case" scenario -e.g. If the 85 years old develops severe pneumonia, stroke, cardiogenic shock or a fall - what they want? and the family should understand. Such advanced directive should be available as a reference "in case".

3- Long term post-ICU management: As they have more limited reserve they will need continuous different level of care post-ICU. Some become chronic critically ill and needs a more specific management and may be units.

We need data to direct decision making. Many RCT's have an upper age cut off, so we really don't know how well our choice therapies work in this age group and many epidemiological studies treat >65 as a single age group, albeit somewhat improved in recent years. We don't know expectations in this age group, and we don't have enough epidemiological data focusing on this age group to help us predict the likely ICU run an individual patient will have.

Thanks for your hardworking,

The issue here lies to be able to understand the physiologic and also pathological changes that extremes of ages(over 80 yo) encounters. Irrespective of the admission of ICU, these patients are fragile and also facing multiorgan failure. Because any organ within human body has eternal life, it is time limited even though some are showing excellent regeneration and recovery. 

These patients have issues related to cognitive dysfunction, heart-lung problems, systemic illnesses related to dm,ht or equivalent disorders, nutritional disorders, also these patients are more flail to demans or delirium related to admitting to ICU itself. If they are aware of what is going on around there, the emotion of dying is frustrating so these patient needs a lot of morale support of parents.

To sum up, we do need specialized ICU teams comprising of many specialists related to overcome problems related to aging process, treatment and also rehabilitation process,

Best regards

for ''improved prognostications & triage''

Elderly abuse should not be forgotten in this work. Usually, a good triage with a diagnosis can be effective. 

Thank you for your very important work.

I would be interested in ethical issues regarding the very old in the ICU. Example: recurrent malignancy, now with septic shock, how far should we go, considering that the primary diagnosis (metastatic/recurrent malignancy) will likely be fatal in the next 12 months?

Best regards,

Alice Gallo

It's not a question of age....but rather a question of quality of life and prognosis of illness.  Both variables should be considered and are when physician is honest, open, and willing to explain choices. 

Thank you all for valuable comments. I would however like you to propose one or two studies you would like to see performed within the next 1-2 year in this group, and how it can be done. We will discuss in the ESICM/HSRO section this year the launch of another study in the very old ICU patients, so any suggestion will bes most welcome. Maybe we will choose yours?

Excellent work Dr Fllaatten: Is very interesting this group of "master survivors" ( we have seen two cases near 100 years old that survived in ICU). One question could be about the targets (blood pressure, renal function, Sat O2, Hb, etc) of management, are the same as for those under 65 or for those under 80 years old?, I supose that no are the same exactly.

Best regards 

Hans,

I find that the very old "80 +" patient arrive in the ICU for many reasons, and all too often (in the United States) it is end of live care related to advanced disease. The trauma population (80+") is a real interesting one. Many of these patients are generally "healthier" than medical admission patients of the same age. Their survivability is quite amazing. I would propose a retrospective comparison of trauma versus medical admissions (multicenter would be helpful) to explore comorbity and survivability.( QALY after discharge should be determined as well @Stefani Daniels). Let those finding inform further questions and study developments. 

Regards,

Chris

Dear Dr Flaaten,

I would suggest that the general physical fitness and activity intensity is important.

This group comprises the people that are soon to die and in overtime as well as those well on the way to 100.

I would think the person in a scootmobile with an oxygen tank is another than our 90 year old competitive swimmer. So I would include a physical fitness score.

Regards

Christiaan

New machine learning models for using physiological parameters to improve prognostication may be particularly important in this group - probably for admission as well as predicting outcome / length of stay. There's a recent and very interesting review:

Johnson AE, Ghassemi MM et al. Machine Learning and Decision Support in Critical Care. Proc IEEE Inst Electr Electron Eng. 2016 Feb;104(2):444-466. Epub 2016 Jan 25.