• BurnsKaren E AKEA0000-0002-9967-5424Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. karen.burns@unityhealth.to.Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St , Deborah J Cook, Keying Xu, Peter Dodek, Jesús Villar, Andrew Jones, Farhad N Kapadia, David J Gattas, Scott K Epstein, Paolo Pelosi, Kallirroi Kefala, Maureen O Meade, Leena Rizvi, and Canadian Critical Care Trials Group.
• Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. karen.burns@unityhealth.to.
• Intensive Care Med. 2023 Oct 1; 49 (10): 118111901181-1190.

PurposeThe aim of this study was 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.MethodsWe prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (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).ResultsWe 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%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. 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.ConclusionsVery 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.© 2023. Springer-Verlag GmbH Germany, part of Springer Nature.

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