Differences in Directives to Limit Treatment and Discontinue Mechanical Ventilation Between Elderly and Very Elderly Patients: A Multinational Observational Study

Purpose: To characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65 - 80 years) and very elderly (> 80 years) intensive care unit (ICU) patients. Measurements: We prospectively described new orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), NIV use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States). Results: We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p=0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2-8) vs. 7 (4-13) days, p=0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5.0%) vs. 40 (6.8%)], initial SBT [105 (52.0%) vs. 302 (51.5%)] and initial successful SBT [84 (80.0%) vs. 245 (81.1%)]. Very elderly patients experienced similar outcomes, but had higher hospital mortality. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission. Conclusions: Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.