One-third of patients over age 65 die in
the hospital after they are put on ventilators. Doctors are beginning to
wonder if the procedure should be used so often.
By Paula Span
 |
| David Plunkert |
Earlier this
year, an ambulance brought a man in his 80s to the emergency room at
Brigham and Women’s Hospital in Boston. He had metastatic lung cancer;
his family had arranged for hospice care at home.
But when he grew less alert and began struggling to breathe, his son tearfully called 911.
“As
soon as I met them, his son said, ‘Put him on a breathing machine,’”
recalled Dr. Kei Ouchi, an emergency physician and researcher at the
hospital.
Hospice patients know that
they’re close to death; they and their families have also been
instructed that most distressing symptoms, like shortness of breath, can
be eased at home.
But the son kept insisting, “Why can’t you put him on a breathing machine?”
Dr.
Ouchi, lead author of a new study of how older people fare after
emergency room intubation, knew this would be no simple decision.
“I went into emergency medicine thinking
I’d be saving lives. I used to be very satisfied putting patients on a
ventilator,” he told me in an interview.
But
he began to realize that while intubation is indeed lifesaving, most
older patients came to the E.R. with serious illnesses. “They sometimes
have values and preferences beyond just prolonging their lives,” he
said.
Often, he’d see the same people he’d
intubated days later, still in the hospital, very ill, even
unresponsive. “Many times, a daughter would say, ‘She would never have
wanted this.’”
Like all emergency
doctors, he’d been trained to perform the procedure — sedating the
patient, putting a plastic tube down his throat and then attaching him
to a ventilator that would breathe for him.
But, he said, “I was never trained to talk to patients or their families about what this means.”
His study, published in the Journal of the American Geriatrics Society, reveals more about that.
Analyzing
35,000 intubations of adults over age 65, data gathered from 262
hospitals between 2008 and 2015, Dr. Ouchi and his colleagues found that a third of those patients die in the hospital despite intubation (also called “mechanical ventilation”).
Of
potentially greater importance to elderly patients — who so often
declare they’d rather die than spend their lives in nursing homes — are
the discharge statistics.
Only a
quarter of intubated patients go home from the hospital. Most survivors,
63 percent, go elsewhere, presumably to nursing facilities. The study doesn’t address whether they face short rehab stays or become permanent residents.
But it does document the crucial role that age plays.
After
intubation, 31 percent of patients ages 65 to 74 survive the
hospitalization and return home. But for 80- to 84-year-olds, that
figure drops to 19 percent; for those over age 90, it slides to 14
percent.
At the same time, the mortality rate climbs sharply, to 50 percent in the eldest cohort from 29 percent in the youngest.
All
intubated patients proceed to intensive care, most remaining sedated
because intubation is uncomfortable. If they were conscious, patients
might try to pull out the tubes or the I.V.’s delivering nutrition and
medications. They cannot speak.
Intubation
“is not a walk in the park,” Dr. Ouchi said. “This is a significant
event for older adults. It can really change your life, if you survive.”
A study at Yale
University in 2015 following older adults before and after an I.C.U.
stay (average age: 83) confirmed what many geriatricians already
understood. Depending on how disabled patients are before a critical
illness, they’re likely to see a decline in their function afterward, or to die within a year.
Those
who underwent intubation had more than twice the mortality risk of
other I.C.U. patients. “You don’t get better, most of the time,” said
Dr. Ouchi. While outcomes remain hard to predict, “a lot of times, you
get worse.”
Intubation rates are projected to increase.
But so has the use of alternatives known as “noninvasive ventilation” —
primarily the bipap device, short for bi-level positive airway
pressure.
A tightfitting mask over
the nose and mouth helps patients with certain conditions breathe nearly
as well as intubation does. But they remain conscious and can have the
mask removed briefly for a sip of water or a short conversation.
When
researchers at the Mayo Clinic undertook an analysis of the technique,
reviewing 27 studies of noninvasive ventilation in patients with
do-not-intubate or comfort-care-only orders, they found that most survived to discharge. Many, treated on ordinary hospital floors, avoided intensive care.
“There
are cases where noninvasive ventilation is comparable or even superior
to mechanical ventilation,” said Dr. Douglas White, a critical care
physician and ethicist at the University of Pittsburgh School of
Medicine.
Dr. Ouchi, for instance,
explained to his patient’s distraught son that intubation would thwart
his father’s desire to remain communicative. The patient, able to see
though not to say much, died four days later in a hospital room with
bipap and morphine to reduce his “air hunger.”
Most patients
in the Mayo review died within a year, too. But bipap may provide an
interim option, giving families and physicians time to decide together
whether to intubate an ailing older patient, who at this point probably
can’t direct his own care.
The
harried emergency room environment, after all, hardly encourages
thoughtful discussions about patients’ prognoses and wishes. Those can
become fraught conversations anyway, as Dr. White’s previous research
has demonstrated.
His
2016 study showed that when physicians and surrogate decision makers
have very different expectations about a critically ill patient’s odds
of recovery, it’s not merely because family members fail to grasp what the physician explained.
“Other
things get in the way of making good decisions,” Dr. White pointed out.
“A lot of this has to do with psychological and emotional factors” —
like “optimism bias” (Most people with this condition will die, but not my mom) or “performative optimism” (If we maintain hope, our mom will get better).
In
their most recent study, he and his colleagues experimented with a
support program for families with relatives in I.C.U.s., nearly all
intubated.
When
a specially-trained nurse checked in daily to explain developments and
answer questions, families rated their communications more highly and felt more satisfied with their loved ones’ care.
The University of Pittsburgh Medical Center’s health system has begun adopting the program in its 40 I.C.U.s.
But discussing
how aggressively an older person wants to be treated remains a
conversation — probably a series of them — best held before a crisis.
Intubation, for instance, is often something a physician can foresee. Older
patients who have cardio-respiratory conditions (emphysema, lung
cancer, heart failure), or who are prone to pneumonia, or who have
entered the later stages of Alzheimer's or Parkinson's disease — any of
them may be nearing this crossroads.
When they do, Dr. Michael Wilson, a critical care physician at the Mayo Clinic, opts for a particularly humane approach.
As
he recently described in JAMA Internal Medicine, before he inserts the
tube, he explains to the patient and family that while he and the staff
will do everything they can, people in this circumstance may die.
“You
may later wake up and do fine,” he tells his patient. “Or this may be
the last time to communicate with your family,” because intubated
patients can’t talk.
Since setting up
intubation generally takes a few minutes, he encourages people to spend
them sharing words of comfort, reassurance and affection. Without that
pause, “I have stolen the last words from patients,” he told me.
His editorial has drawn attention from critical care physicians around the world.
Dr.
Wilson has used this approach about 50 times in his I.C.U., so he has
learned what patients and families, given this opportunity, tell one
another.
Full Article & Source:
Breathing Tubes Fail to Save Many Older Patients
1 comment:
I think medical procedures are used way too often in many areas and not necessary.
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