“The relationship between physicians and their patients has changed over the last decades and patients’ empowerment has led to a greater self autonomy in medical decisions,” but apparently not when it comes to moving elderly patients into an intensive care unit, said lead author Dr. Julien Le Guen of Universite Paris Descartes in France.
Legally, no medical decision should be made without the patient’s consent, Le Guen told Reuters Health by email. But based on the results of his team’s study, there seems to be a discrepancy between what doctors say is important, like the patient’s opinion, and what they actually do.
The researchers used data from a previous study of patients over age 80 who came to emergency rooms at 15 hospitals in the Paris region between 2004 and 2006. All had conditions potentially requiring intensive care, and all were conscious and capable of expressing an opinion if asked.
The emergency room physicians filled out a questionnaire on each patient’s status and treatments, the number of available intensive care beds, the physician’s years of experience, and whether or not relatives were consulted.
They also indicated if they sought the opinion of the patient or relatives regarding referral to the intensive care unit (ICU) and if so what their opinions were.
More than 2,000 patients were included in the study and only 270 were asked for their opinion, ranging by medical center from 1 percent of the time to 54 percent of the time.
Patients with a history of dementia were less often asked, and those with more functional autonomy or a relative who had been questioned were more often asked.
Older ER doctors were less likely than younger doctors to ask a patient’s opinion, the researchers reported in the journal Age and Ageing.
“Intensive care techniques in these extreme ages of life raise the question of an artificial prolongation of life and can be perceived by some as therapeutic relentlessness,” Le Guen said.
“Therapeutics used in the ICU are uncomfortable,” he said. And for the oldest old, he added, rates of death in the ICU, in the hospital, and afterward are high, “and survivors frequently face a loss of autonomy in the following months.”
Individual wishes can be hard to predict for the very old, he said.
An elderly person may not want aggressive treatment like intensive care, use of ventilators or feeding tubes, said Dr. Walter E. Limehouse of the Medical University of South Carolina.
When patients arriving in the emergency room lack the ability to make decisions, U.S. emergency physicians are increasingly asking whether they have an advance directive or treatment plan, Limehouse told Reuters Health by email.
“ICU admission policies and process are different between countries,” Le Guen said. “In France, the final decision is always under the intensivist’s responsibility, normally after a global evaluation taking into account patient wishes.”
A history of dementia does not always mean a patient can’t express an opinion, Le Guen said.
“In my opinion, patients suffering from dementia should always be asked, and physicians should always try to receive consent when a medical decision has to be made for these patients, even if a full understanding seems illusory,” he said.
SOURCE: bit.ly/20qXMpU Age and Ageing, online January 11, 2016.
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Elderly patients rarely included in decision to use intensive care
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