The Cost of Inappropriate Care at the End of life
Content
Original Article
The Cost of Inappropriate Care at the End
of life: Implications for an Aging Population
American Journal of Hospice
& Palliative Medicine®
2015, Vol. 32(7) 703-708
ª The Author(s) 2014
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DOI: 10.1177/1049909114537399
ajhpm.sagepub.com
Paul E. Marik, MD, FCCM, FCCP, FACP1
Abstract
Elderly patients patients (older than 65 years) account for only 11% of the US population yet they account for 34% of health care
expenditure. The disproportionate usage of health care costs by elderly patients is in striking contrast with that of other Western
Nations. It is likely that these differences are largely due to variances in hospitalization and the use of high technology health care
resources at the end of life. The United States has 8 times as many intensive care unit (ICU) beds per capita when compared to
other Western Nations. In the United States, elderly patients currently account for 42% to 52% of ICU admissions and for almost
60% of all ICU days. A disproportionate number of these ICU days are spent by elderly patients before their death. In many
instances, aggressive life supportive measures serve only to prolong the patient’s death. Such treatment inflicts pain and
suffering on the patient (with little prospects of gain) and incurs enormous financial costs to the health care system. We
present the case of an 86-year-old female who spent almost 3 months in our ICU prior to her death. The fully allocated hospital
costs for this patient were estimated to be US$254 945 (US$5100/d). With the increasing age of the population and the projected
increased demand for ICU beds, we review the benefits and burdens of admitting elderly patients to the ICU.
Keywords
ICU, futile care, elderly, surgery, aging
Case Report
An 86-year-old female presented to our hospital with symptoms of abdominal pain and diarrhea. She had undergone
an open abdominal aortic aneurysm repair 15 years previously.
She had a history of hypertension and hypercholesterolemia.
A computed tomography scan demonstrated celiac artery
occlusion, high-grade superior mesenteric artery (SMA)
obstruction, and a right common iliac artery aneurysm.
Cardiac evaluation demonstrated concentric left ventricular
hypertrophy, diastolic dysfunction, and tricuspid regurgitation with moderate pulmonary hypertension. The patient
underwent an open thoracoabdominal aneurysm repair using
a fenestrated graft and SMA stenting. On postoperative day
1, the patient required surgical exploration for hemorrhagic
shock. She was noted to have 2 L blood in the peritoneum with
several small bleeding branches of the left internal iliac and a
splenic laceration which required a splenectomy. On postoperative day 4, she was taken back to the operating room for
abdominal closure. She underwent additional relook abdominal explorations and a tracheotomy. Her hospital course
was further complicated by acute pancreatitis, renal failure
requiring hemodialysis, ventilator-associated pneumonia,
urinary tract infection, progressive respiratory failure, and
neurological decline progressing to coma. By the end of the
second hospital week, the patient was assessed by the critical care team as being in established multisystem organ
failure (MSOF) with a negligible chance of ever leaving the
intensive care unit (ICU) alive. The patient did not have an
advanced directive but had apparently expressed the wish
that ‘‘she would never want to be on a machine.’’ Nevertheless, in consultation with the family, the surgical team
decided to continue all aggressive supportive measures.
Despite aggressive supportive care over the next 6 weeks,
the patient’s condition showed no signs of improvement.
After multiple discussions with our palliative care team and
after spending 8 weeks in the ICU, the family agreed to
‘‘comfort care measures.’’
This case generated a lively and at times heated discussion between the patient’s health care providers as to the
appropriateness of providing extraordinary invasive life supportive measures to a critically ill octogenarian, which many
considered to be inappropriate. In addition, the patient’s
protracted ICU course and ‘‘suffering’’ took a heavy emotional toll on many of the patient’s health care providers.
1
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical
School, Norfolk, VA, USA
Corresponding Author:
Paul E. Marik, MD, FCCM, FCCP, FACP, Eastern Virginia Medical School, 825
Fairfax Av, Suite 410, Norfolk, VA 23507, USA.
Email: [email protected]
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American Journal of Hospice & Palliative Medicine® 32(7)
704
Table 1. Hospital Charges of the Patients.a
100 022
88 423
13 580
5725
(3770)
(749)
(70)
(63)
2808 (24)
8062 (58)
12 826 (53)
5290 (23)
12 438 (94)
41 659 (45)
5419 (29)
21 545 (7)
59 038 (193)
21 472 (32)
16 542 (9)
100 537
116 516
107 358
2769 (39)
6216 (42)
31 856 (176)
49 200 (50)
155 250 (50)
48 480
US$821 721
a
The number in parentheses is the number of units/tests/items or procedures.
Table 2. Physician Charges.
Anesthesia (7)
General surgery (7)
Critical care (49)
Infectious diseases (37)
Nephrology (48)
Cardiology (33)
Palliative care(3)
Total
Charges
Medicare
Payments
24 435 (est)
12 700
12 645
5215
10 638 (est)
4965 (est)
577
71 175
4050
7630
8685
3834
8177
3430
400
35 206
3000 (est)
5111
6260
2665
5587 (est)
2470 (est)
288
25 381
Abbreviation: est, estimated.
This led us to explore the appropriateness of providing critical care to elderly patients (discussed subsequently).
Furthermore, as we are currently in the midst of a health
care financing crisis, we were curious as to the economic
costs of such care. To this end, we obtained a detailed
breakdown of the patient’s hospital bill. The aggregate hospital charge was US$821 721 (summarized in Table 1). The
fully allocated hospital costs were estimated to be US$254
945 (US$5100/d). Total physician charges (US$71 175),
total Medicare charges (US$35 206), and total payment
(US$25 381) we obtained from our billing office; as not all
the physicians involved in the care of this patient were part
of our practice plan, the charges and payments for these services were estimated using the Medicare rates. The physician charges and payments are summarized in Table 2.
Annual per capita healthcare costs ($)
50000
Medications
Laboratory tests
Basic metabolic panel (BMP)
Complete blood count (CBC)
and differential count
Lactic acid
Magnesium
Arterial blood gasses (ABGs)
Troponins
Microbiology
Radiology
Chest X-ray
CT scans
Blood, blood products, and testing
Red blood cells
Platelets
Surgery and surgical supplies
Anesthesia
Respiratory therapy
ABG collection
Patient assessment
Suctioning
Ventilator
Room and board
Miscellaneous charges
Total hospital Charges
UK
Germany
Sweden
Spain
US
40000
30000
20000
10000
0
0
20
40
60
80
Age
Figure 1. Annual per capita health care costs by age. Adapted from
Paul Fischbeck, Carnegie Melon University, James Hilston, Pittsburgh
Post-Gazette, December 13, 2009.
Discussion
The United States is in the midst of a health care crisis; health
care expenditure currently accounts for 17.7% of the Gross
National Product when compared to 6% to 11% for other
Western Nations.1,2 Hospitalizations rather than physician and
other services are the major contributor to health care spending
in the United States.1 Elderly patients (older than 65 years)
account for 11% of the US population yet they account for
34% of health care expenditure.1 The disproportionate usage
of health care costs by the elderly patients is in striking contrast
with that of other Western Nations (see Figure 1). It is likely
that these differences are largely due to variances in hospitalization and the use of high technology health care resources at
the end of life. The United States has 8 times as many ICU beds
per capita when compared to other Western Nations.3 In the
United States, elderly patients currently account for 42% to
52% of ICU admissions and for almost 60% of all ICU
days.4-7 People who are older than 65 years of age are the fastest growing segment of the US population.8,9 By 2030, the population older than 65 years will double to approximately
70 million6,9,10 The aging of the population with the projected
increased demand for ICU beds requires us to examine the current pattern of ICU bed utilization in order to limit this costly
resource to those who are most likely to derive benefit and to
utilize our health care resources in a more cost-effective
manner.
A disproportionate number of ICU days are spent by elderly
patients before their death. Of the Medicare expenditures, 30%
is attributable to the 5% of beneficiaries who die each year,
resulting in per-capita spending on patients who died, that is,
6 times as great as for nondecedents.11 Kwok and colleagues
analyzed the use of in-patient surgical services among Medicare beneficiaries.12 They reported that in 2008, 18.3% of
patients who died underwent a surgical procedure in their last
month of life and 8% underwent a procedure during their last
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Marik
705
week of life. Teno and colleagues investigated ICU utilization
and site of death and of Medicare beneficiaries from 2000 to
2009.13 During this time period, ICU utilization during the last
month of life increased, with 29.2% of patients who died being
admitted to the ICU in the last month of life. Similarly, Unroe
and colleagues studied resource use in the last 6 months of
life among Medicare beneficiaries with heart failure between
2000 and 2007.14 Approximately 80% of patients were hospitalized in the last 6 months of life, with the use of ICU during
the terminal hospitalization increasing from 42% to 50% during this period. Wunsch and colleagues compared the use of
ICU services during terminal hospitalization in England and
the United States.15 Although the overall population mortality
statistics were similar between England and the United States,
5.1% of all deaths in England involved the ICU compared to
17.2% in the United States, representing 10.1% of hospital
deaths in England versus 47% in the United States. Greater ICU
use in the United States was most notable with older age;
among patients who died who were 85 years and older, ICU
care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9% and 8.5% of deaths
in England.
In general severity of illness, comorbidities, premorbid
functional status, and age appear to be the most important
factors determining ICU and hospital survival as well as
long-term functional outcome.16-19 Older patients’ admitted
to the ICU have higher short-term mortality and long-term disability.20-22 Nevertheless, although survival rates are lower in
this population than in younger individuals they are sufficiently
high to justify admission to the ICU.22,23 In addition, long-term
outcomes and quality of life suggest that older patients may
benefit from ICU admission.24-26 However, not all elderly
patients benefit from admission to the ICU. The requirement
for mechanical ventilation and/or the presence of circulatory
failure appear to be important determinants of both short- and
long-term outcome in elderly patients. Ely and colleagues
reported that the 28-day survival of patients with acute lung
injury decreased significantly with increasing age.27 Cheng and
Matthay reported a 72% mortality in patients older than 60
years with acute respiratory distress syndrome compared to
37% in younger patients.28 Using data from the Nationwide
Inpatient Sample, Behrendt demonstrated that both the incidence and the mortality from acute respiratory failure increased
significantly with aging.29 Biston and colleagues evaluated the
outcome of elderly patients (>75 years and >85years compared
with <75 years) with circulatory failure (90% required mechanical ventilation).30 The hospital mortality was 52% for those
<75 years compared to 70% for those >75 years. Furthermore,
the 12-month survival was 34% for those <75 years, 16% for
those between 75 and 84 years, and only 3% for those >85
years. The decreased physiologic reserve with aging may partly
explain the very poor outcome of elderly patients with respiratory and circulatory failure admitted to the ICU.23,31 Circulatory failure is the major risk factor for the development of
MSOF which is associated with an extremely high mortality
in elderly patients.32-37 In addition, diaphragmatic atrophy due
to the ‘‘sarcopenia of the elderly’’ and the accelerated loss of
lean body mass with acute illness likely play a major role in
accounting for the poor prognosis of those elderly patients
requiring mechanical ventilation. An accelerated loss of muscle and diaphragmatic mass occurs in patients requiring
mechanical ventilation; this loss is most severe in elderly
patients.38-42 Patients with diaphragmatic dysfunction are at
a high risk of weaning failures. This sets in motion a vicious
cycle in which ongoing mechanical ventilation results in further diaphragmatic atrophy which further compromises
attempts at weaning. These patients remain ventilator dependent frequently developing multiple complications including
pneumonia, delirium, bedsores, and ultimately succumb to
MSOF (as occurred in our patient).
With the projected exponential increase in the number of
elderly patients and the increasing burden of chronic disease,
how should we select patients who are likely to derive the most
benefit from admission to the ICU? The current guidelines of
the Society of Critical Care Medicine state that ‘‘in general
ICU’s should be reserved for those patients with reversible
medical conditions who have a reasonable prospect of substantial recovery.’’43 Despite this recommendation, almost all
patients with serious and life-threatening illnesses in the United
States regardless of their prognosis or prospect of recovery are
admitted to an ICU, unless the patient or his or her surrogate
specifically declines ICU admission. It is therefore exceedingly
uncommon for intensivists in the United States to refuse ICU
admission; if a bed is not immediately available, one is
‘‘made.’’ This contrasts to the situation in most Western nations
in which not all requests for an ICU bed are honored. Indeed,
refusal of ICU admission is common, with a rate that varies
from 24% to 88%.26,44-49 Advanced age and poor functional
status are reported to be the commonest reasons for ICU
refusal.44,45,48,50 Garrouste-Orgeas and colleagues studied the
ICU admission patterns of patients aged 80 years or older who
presented to the emergency department of 15 hospitals in
France.49 Of the 2646 patients who met one or more predetermined ICU admission criteria, only 329 (12.4%) were admitted
to the ICU. Of the refusals, approximately half of the patients
were considered ‘‘too well’’ to benefit from the ICU, while the
other half were considered ‘‘too sick’’ to benefit from admission to the ICU.
The operative mortality and incidence of postoperative complications are increased in elderly patients undergoing elective
surgery.51 It is not uncommon for elderly patients who appear
fit and healthy (physiologic age less than chronologic age) to
do poorly following elective surgery. Furthermore, elderly
patients have a high incidence of protracted disabilities following
major surgery.52 The decreased physiologic reserve and increased
incidence of comorbidities probably account for this finding.
Most randomized controlled trials comparing surgical to a more
conservative approach are performed in patients less than 65 years
of age. It is probably not appropriate to extrapolate the results of
these trials to the elderly population. The operative mortality and
rate of postoperative complication are even higher in elderly
patients undergoing emergency surgery, being reported in up to
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American Journal of Hospice & Palliative Medicine® 32(7)
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49% and 68% of cases, respectively.51,53-55 Surgery must be
therefore be considered very carefully in elderly patients.
The case we report is not unique. Huynh and colleagues analyzed the frequency and cost of treatment perceived to be
‘‘futile’’ in 5 ICUs at an academic health care system in the
United States.56 In this study, 20% of patients were considered
to have received care that was ‘‘probably futile.’’ The daily
ICU cost was US$4004. Age was the most important predictor
of futile care. The decision to admit an elderly patient to an ICU
(and provide ongoing care) should be carefully evaluated and
should be based upon the patient’s comorbidities, acuity of illness, and prehospital functional status which includes ‘‘quality
of life.’’ Elderly patients with respiratory failure requiring ventilator support and those with circulatory failure requiring
hemodynamic support have a very poor prognosis, and such
patients are unlikely to benefit from admission to the ICU. A
time-limited trial in the ICU may be appropriate in elderly
patients whose prognosis is uncertain, in those with ‘‘conflicted’’ decision makers and in postoperative patients.57 The
patient’s progress over the next 4 to 6 days should then guide
further goals of care. Patients with nonresolving failure of 2
or more organ systems (multiple organ failure ) have a mortality approximating 100% and limitation of care should be considered at this time.32-37 A palliative care consult should be
obtained as part of the time-limited trial. The patients preferences (or surrogates best estimate of the patient’s wishes) with
regard to mechanical ventilation and other forms of lifesustaining treatment should be considered in all triage decisions. For dying patients with irreversible disease, admission
to the ICU (or ongoing care) is frequently inappropriate and the
care of these patients should be primarily focused on a palliative approach allowing a dignified death. A palliative care consult and an ethics consult should be considered in those
circumstances, where the goals of the patient and/or family
appear unrealistic and when long-term interventions such as
tracheostomy and percutaneous endoscopic gastrostomy tube
placement are being considered. Our case demonstrates the
enormous hospital costs of prolonging a patient’s death with
extraordinary life supportive measures. This money would be
better spent upfront in promoting health and well-being and
thereby preventing admission to the ICU. It is unclear why
Americans are so unaccepting of death and frequently want
‘‘everything to be done’’ in the face of certain death. This may
be due to unrealistic expectations that patients and their families have with regard to what modern medicine can actually
achieve. These unrealistic expectations are perpetuated by misinformation provided by the lay press, television, and the Internet. It is likely that in many instances, physicians contribute to
these unrealistic expectations by failing to provide honest
information regarding the likelihood of a prolonged hospital
course, the need for prolonged rehabilitation in a long-term
acute care facility and about expected 1-year survival, functional status, cognitive status, and alternatives to continuing
aggressive life supportive measures.58
In conclusion, we believe that in the face of critical illness
discussions regarding the patient’s values and preferences,
together with an assessment of his or her baseline functional
status, comorbidities and measures of physiologic reserve
should be sought and integrated into recommendations regarding a realistic treatment plan for patients with advanced age.
These recommendations may include a time-limited trial of
ICU care or a more limited comfort care approach. Americans
have a culture of fierce individualism not given to the better
social good; however, the reality is that although we are the
richest nation on the Earth, we need to ration health care; this
should however be done fairly, justly, and equitably.
Acknowledgment
The author would like to acknowledge Drs Leonard J. Weireter and
Dr Robert Palmer for their thoughtful review of the manuscript and
Dr Joshua Bloomstone for his assistance with the financial data.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
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53. Rigberg D, Cole M, Hiyama D, McFadden D. Surgery in the nineties. Am Surg. 2000;66(9):813-816.
54. Keller SM, Markovitz LJ, Wilder JR, Aufses AH Jr. Emergency
and elective surgery in patients over age 70. Am Surg. 1987;
53(11):636-640.
55. Yilmazlar T, Guner O, Yilmazlar A. Criteria to consider when
assessing the mortality risk in geriatric surgery. Int Surg. 2006;
91(2):72-76.
56. Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost
of treatment perceived to be futile in critical care. JAMA Intern
Med. 2013;173(20):1887-1894.
57. Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B,
Azoulay E. The ICU trial: a new admission policy for cancer
patients requiring mechanical ventilation. Crit Care Med.
2007;35(3):808-814.
58. Nelson JE, Mercado AF, Camhi SL, et al. Communication about
chronic critical illness. Arch Intern Med. 2007;167(22):2509-2515.
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The Cost of Inappropriate Care at the End
of life: Implications for an Aging Population
American Journal of Hospice
& Palliative Medicine®
2015, Vol. 32(7) 703-708
ª The Author(s) 2014
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1049909114537399
ajhpm.sagepub.com
Paul E. Marik, MD, FCCM, FCCP, FACP1
Abstract
Elderly patients patients (older than 65 years) account for only 11% of the US population yet they account for 34% of health care
expenditure. The disproportionate usage of health care costs by elderly patients is in striking contrast with that of other Western
Nations. It is likely that these differences are largely due to variances in hospitalization and the use of high technology health care
resources at the end of life. The United States has 8 times as many intensive care unit (ICU) beds per capita when compared to
other Western Nations. In the United States, elderly patients currently account for 42% to 52% of ICU admissions and for almost
60% of all ICU days. A disproportionate number of these ICU days are spent by elderly patients before their death. In many
instances, aggressive life supportive measures serve only to prolong the patient’s death. Such treatment inflicts pain and
suffering on the patient (with little prospects of gain) and incurs enormous financial costs to the health care system. We
present the case of an 86-year-old female who spent almost 3 months in our ICU prior to her death. The fully allocated hospital
costs for this patient were estimated to be US$254 945 (US$5100/d). With the increasing age of the population and the projected
increased demand for ICU beds, we review the benefits and burdens of admitting elderly patients to the ICU.
Keywords
ICU, futile care, elderly, surgery, aging
Case Report
An 86-year-old female presented to our hospital with symptoms of abdominal pain and diarrhea. She had undergone
an open abdominal aortic aneurysm repair 15 years previously.
She had a history of hypertension and hypercholesterolemia.
A computed tomography scan demonstrated celiac artery
occlusion, high-grade superior mesenteric artery (SMA)
obstruction, and a right common iliac artery aneurysm.
Cardiac evaluation demonstrated concentric left ventricular
hypertrophy, diastolic dysfunction, and tricuspid regurgitation with moderate pulmonary hypertension. The patient
underwent an open thoracoabdominal aneurysm repair using
a fenestrated graft and SMA stenting. On postoperative day
1, the patient required surgical exploration for hemorrhagic
shock. She was noted to have 2 L blood in the peritoneum with
several small bleeding branches of the left internal iliac and a
splenic laceration which required a splenectomy. On postoperative day 4, she was taken back to the operating room for
abdominal closure. She underwent additional relook abdominal explorations and a tracheotomy. Her hospital course
was further complicated by acute pancreatitis, renal failure
requiring hemodialysis, ventilator-associated pneumonia,
urinary tract infection, progressive respiratory failure, and
neurological decline progressing to coma. By the end of the
second hospital week, the patient was assessed by the critical care team as being in established multisystem organ
failure (MSOF) with a negligible chance of ever leaving the
intensive care unit (ICU) alive. The patient did not have an
advanced directive but had apparently expressed the wish
that ‘‘she would never want to be on a machine.’’ Nevertheless, in consultation with the family, the surgical team
decided to continue all aggressive supportive measures.
Despite aggressive supportive care over the next 6 weeks,
the patient’s condition showed no signs of improvement.
After multiple discussions with our palliative care team and
after spending 8 weeks in the ICU, the family agreed to
‘‘comfort care measures.’’
This case generated a lively and at times heated discussion between the patient’s health care providers as to the
appropriateness of providing extraordinary invasive life supportive measures to a critically ill octogenarian, which many
considered to be inappropriate. In addition, the patient’s
protracted ICU course and ‘‘suffering’’ took a heavy emotional toll on many of the patient’s health care providers.
1
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical
School, Norfolk, VA, USA
Corresponding Author:
Paul E. Marik, MD, FCCM, FCCP, FACP, Eastern Virginia Medical School, 825
Fairfax Av, Suite 410, Norfolk, VA 23507, USA.
Email: [email protected]
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American Journal of Hospice & Palliative Medicine® 32(7)
704
Table 1. Hospital Charges of the Patients.a
100 022
88 423
13 580
5725
(3770)
(749)
(70)
(63)
2808 (24)
8062 (58)
12 826 (53)
5290 (23)
12 438 (94)
41 659 (45)
5419 (29)
21 545 (7)
59 038 (193)
21 472 (32)
16 542 (9)
100 537
116 516
107 358
2769 (39)
6216 (42)
31 856 (176)
49 200 (50)
155 250 (50)
48 480
US$821 721
a
The number in parentheses is the number of units/tests/items or procedures.
Table 2. Physician Charges.
Anesthesia (7)
General surgery (7)
Critical care (49)
Infectious diseases (37)
Nephrology (48)
Cardiology (33)
Palliative care(3)
Total
Charges
Medicare
Payments
24 435 (est)
12 700
12 645
5215
10 638 (est)
4965 (est)
577
71 175
4050
7630
8685
3834
8177
3430
400
35 206
3000 (est)
5111
6260
2665
5587 (est)
2470 (est)
288
25 381
Abbreviation: est, estimated.
This led us to explore the appropriateness of providing critical care to elderly patients (discussed subsequently).
Furthermore, as we are currently in the midst of a health
care financing crisis, we were curious as to the economic
costs of such care. To this end, we obtained a detailed
breakdown of the patient’s hospital bill. The aggregate hospital charge was US$821 721 (summarized in Table 1). The
fully allocated hospital costs were estimated to be US$254
945 (US$5100/d). Total physician charges (US$71 175),
total Medicare charges (US$35 206), and total payment
(US$25 381) we obtained from our billing office; as not all
the physicians involved in the care of this patient were part
of our practice plan, the charges and payments for these services were estimated using the Medicare rates. The physician charges and payments are summarized in Table 2.
Annual per capita healthcare costs ($)
50000
Medications
Laboratory tests
Basic metabolic panel (BMP)
Complete blood count (CBC)
and differential count
Lactic acid
Magnesium
Arterial blood gasses (ABGs)
Troponins
Microbiology
Radiology
Chest X-ray
CT scans
Blood, blood products, and testing
Red blood cells
Platelets
Surgery and surgical supplies
Anesthesia
Respiratory therapy
ABG collection
Patient assessment
Suctioning
Ventilator
Room and board
Miscellaneous charges
Total hospital Charges
UK
Germany
Sweden
Spain
US
40000
30000
20000
10000
0
0
20
40
60
80
Age
Figure 1. Annual per capita health care costs by age. Adapted from
Paul Fischbeck, Carnegie Melon University, James Hilston, Pittsburgh
Post-Gazette, December 13, 2009.
Discussion
The United States is in the midst of a health care crisis; health
care expenditure currently accounts for 17.7% of the Gross
National Product when compared to 6% to 11% for other
Western Nations.1,2 Hospitalizations rather than physician and
other services are the major contributor to health care spending
in the United States.1 Elderly patients (older than 65 years)
account for 11% of the US population yet they account for
34% of health care expenditure.1 The disproportionate usage
of health care costs by the elderly patients is in striking contrast
with that of other Western Nations (see Figure 1). It is likely
that these differences are largely due to variances in hospitalization and the use of high technology health care resources at
the end of life. The United States has 8 times as many ICU beds
per capita when compared to other Western Nations.3 In the
United States, elderly patients currently account for 42% to
52% of ICU admissions and for almost 60% of all ICU
days.4-7 People who are older than 65 years of age are the fastest growing segment of the US population.8,9 By 2030, the population older than 65 years will double to approximately
70 million6,9,10 The aging of the population with the projected
increased demand for ICU beds requires us to examine the current pattern of ICU bed utilization in order to limit this costly
resource to those who are most likely to derive benefit and to
utilize our health care resources in a more cost-effective
manner.
A disproportionate number of ICU days are spent by elderly
patients before their death. Of the Medicare expenditures, 30%
is attributable to the 5% of beneficiaries who die each year,
resulting in per-capita spending on patients who died, that is,
6 times as great as for nondecedents.11 Kwok and colleagues
analyzed the use of in-patient surgical services among Medicare beneficiaries.12 They reported that in 2008, 18.3% of
patients who died underwent a surgical procedure in their last
month of life and 8% underwent a procedure during their last
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Marik
705
week of life. Teno and colleagues investigated ICU utilization
and site of death and of Medicare beneficiaries from 2000 to
2009.13 During this time period, ICU utilization during the last
month of life increased, with 29.2% of patients who died being
admitted to the ICU in the last month of life. Similarly, Unroe
and colleagues studied resource use in the last 6 months of
life among Medicare beneficiaries with heart failure between
2000 and 2007.14 Approximately 80% of patients were hospitalized in the last 6 months of life, with the use of ICU during
the terminal hospitalization increasing from 42% to 50% during this period. Wunsch and colleagues compared the use of
ICU services during terminal hospitalization in England and
the United States.15 Although the overall population mortality
statistics were similar between England and the United States,
5.1% of all deaths in England involved the ICU compared to
17.2% in the United States, representing 10.1% of hospital
deaths in England versus 47% in the United States. Greater ICU
use in the United States was most notable with older age;
among patients who died who were 85 years and older, ICU
care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9% and 8.5% of deaths
in England.
In general severity of illness, comorbidities, premorbid
functional status, and age appear to be the most important
factors determining ICU and hospital survival as well as
long-term functional outcome.16-19 Older patients’ admitted
to the ICU have higher short-term mortality and long-term disability.20-22 Nevertheless, although survival rates are lower in
this population than in younger individuals they are sufficiently
high to justify admission to the ICU.22,23 In addition, long-term
outcomes and quality of life suggest that older patients may
benefit from ICU admission.24-26 However, not all elderly
patients benefit from admission to the ICU. The requirement
for mechanical ventilation and/or the presence of circulatory
failure appear to be important determinants of both short- and
long-term outcome in elderly patients. Ely and colleagues
reported that the 28-day survival of patients with acute lung
injury decreased significantly with increasing age.27 Cheng and
Matthay reported a 72% mortality in patients older than 60
years with acute respiratory distress syndrome compared to
37% in younger patients.28 Using data from the Nationwide
Inpatient Sample, Behrendt demonstrated that both the incidence and the mortality from acute respiratory failure increased
significantly with aging.29 Biston and colleagues evaluated the
outcome of elderly patients (>75 years and >85years compared
with <75 years) with circulatory failure (90% required mechanical ventilation).30 The hospital mortality was 52% for those
<75 years compared to 70% for those >75 years. Furthermore,
the 12-month survival was 34% for those <75 years, 16% for
those between 75 and 84 years, and only 3% for those >85
years. The decreased physiologic reserve with aging may partly
explain the very poor outcome of elderly patients with respiratory and circulatory failure admitted to the ICU.23,31 Circulatory failure is the major risk factor for the development of
MSOF which is associated with an extremely high mortality
in elderly patients.32-37 In addition, diaphragmatic atrophy due
to the ‘‘sarcopenia of the elderly’’ and the accelerated loss of
lean body mass with acute illness likely play a major role in
accounting for the poor prognosis of those elderly patients
requiring mechanical ventilation. An accelerated loss of muscle and diaphragmatic mass occurs in patients requiring
mechanical ventilation; this loss is most severe in elderly
patients.38-42 Patients with diaphragmatic dysfunction are at
a high risk of weaning failures. This sets in motion a vicious
cycle in which ongoing mechanical ventilation results in further diaphragmatic atrophy which further compromises
attempts at weaning. These patients remain ventilator dependent frequently developing multiple complications including
pneumonia, delirium, bedsores, and ultimately succumb to
MSOF (as occurred in our patient).
With the projected exponential increase in the number of
elderly patients and the increasing burden of chronic disease,
how should we select patients who are likely to derive the most
benefit from admission to the ICU? The current guidelines of
the Society of Critical Care Medicine state that ‘‘in general
ICU’s should be reserved for those patients with reversible
medical conditions who have a reasonable prospect of substantial recovery.’’43 Despite this recommendation, almost all
patients with serious and life-threatening illnesses in the United
States regardless of their prognosis or prospect of recovery are
admitted to an ICU, unless the patient or his or her surrogate
specifically declines ICU admission. It is therefore exceedingly
uncommon for intensivists in the United States to refuse ICU
admission; if a bed is not immediately available, one is
‘‘made.’’ This contrasts to the situation in most Western nations
in which not all requests for an ICU bed are honored. Indeed,
refusal of ICU admission is common, with a rate that varies
from 24% to 88%.26,44-49 Advanced age and poor functional
status are reported to be the commonest reasons for ICU
refusal.44,45,48,50 Garrouste-Orgeas and colleagues studied the
ICU admission patterns of patients aged 80 years or older who
presented to the emergency department of 15 hospitals in
France.49 Of the 2646 patients who met one or more predetermined ICU admission criteria, only 329 (12.4%) were admitted
to the ICU. Of the refusals, approximately half of the patients
were considered ‘‘too well’’ to benefit from the ICU, while the
other half were considered ‘‘too sick’’ to benefit from admission to the ICU.
The operative mortality and incidence of postoperative complications are increased in elderly patients undergoing elective
surgery.51 It is not uncommon for elderly patients who appear
fit and healthy (physiologic age less than chronologic age) to
do poorly following elective surgery. Furthermore, elderly
patients have a high incidence of protracted disabilities following
major surgery.52 The decreased physiologic reserve and increased
incidence of comorbidities probably account for this finding.
Most randomized controlled trials comparing surgical to a more
conservative approach are performed in patients less than 65 years
of age. It is probably not appropriate to extrapolate the results of
these trials to the elderly population. The operative mortality and
rate of postoperative complication are even higher in elderly
patients undergoing emergency surgery, being reported in up to
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American Journal of Hospice & Palliative Medicine® 32(7)
706
49% and 68% of cases, respectively.51,53-55 Surgery must be
therefore be considered very carefully in elderly patients.
The case we report is not unique. Huynh and colleagues analyzed the frequency and cost of treatment perceived to be
‘‘futile’’ in 5 ICUs at an academic health care system in the
United States.56 In this study, 20% of patients were considered
to have received care that was ‘‘probably futile.’’ The daily
ICU cost was US$4004. Age was the most important predictor
of futile care. The decision to admit an elderly patient to an ICU
(and provide ongoing care) should be carefully evaluated and
should be based upon the patient’s comorbidities, acuity of illness, and prehospital functional status which includes ‘‘quality
of life.’’ Elderly patients with respiratory failure requiring ventilator support and those with circulatory failure requiring
hemodynamic support have a very poor prognosis, and such
patients are unlikely to benefit from admission to the ICU. A
time-limited trial in the ICU may be appropriate in elderly
patients whose prognosis is uncertain, in those with ‘‘conflicted’’ decision makers and in postoperative patients.57 The
patient’s progress over the next 4 to 6 days should then guide
further goals of care. Patients with nonresolving failure of 2
or more organ systems (multiple organ failure ) have a mortality approximating 100% and limitation of care should be considered at this time.32-37 A palliative care consult should be
obtained as part of the time-limited trial. The patients preferences (or surrogates best estimate of the patient’s wishes) with
regard to mechanical ventilation and other forms of lifesustaining treatment should be considered in all triage decisions. For dying patients with irreversible disease, admission
to the ICU (or ongoing care) is frequently inappropriate and the
care of these patients should be primarily focused on a palliative approach allowing a dignified death. A palliative care consult and an ethics consult should be considered in those
circumstances, where the goals of the patient and/or family
appear unrealistic and when long-term interventions such as
tracheostomy and percutaneous endoscopic gastrostomy tube
placement are being considered. Our case demonstrates the
enormous hospital costs of prolonging a patient’s death with
extraordinary life supportive measures. This money would be
better spent upfront in promoting health and well-being and
thereby preventing admission to the ICU. It is unclear why
Americans are so unaccepting of death and frequently want
‘‘everything to be done’’ in the face of certain death. This may
be due to unrealistic expectations that patients and their families have with regard to what modern medicine can actually
achieve. These unrealistic expectations are perpetuated by misinformation provided by the lay press, television, and the Internet. It is likely that in many instances, physicians contribute to
these unrealistic expectations by failing to provide honest
information regarding the likelihood of a prolonged hospital
course, the need for prolonged rehabilitation in a long-term
acute care facility and about expected 1-year survival, functional status, cognitive status, and alternatives to continuing
aggressive life supportive measures.58
In conclusion, we believe that in the face of critical illness
discussions regarding the patient’s values and preferences,
together with an assessment of his or her baseline functional
status, comorbidities and measures of physiologic reserve
should be sought and integrated into recommendations regarding a realistic treatment plan for patients with advanced age.
These recommendations may include a time-limited trial of
ICU care or a more limited comfort care approach. Americans
have a culture of fierce individualism not given to the better
social good; however, the reality is that although we are the
richest nation on the Earth, we need to ration health care; this
should however be done fairly, justly, and equitably.
Acknowledgment
The author would like to acknowledge Drs Leonard J. Weireter and
Dr Robert Palmer for their thoughtful review of the manuscript and
Dr Joshua Bloomstone for his assistance with the financial data.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
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