Characteristics and outcomes of mechanically ventilated elderly patients in the absence of an end-of-life care policy: a retrospective study from Bahrain

Abstract

BACKGROUND: Globally, the percentage of elderly patients has been increasing, leading to a higher demand for healthcare resources and intensive care. Bahrain has a majority Muslim population and Islam governs most policies, including end-of-life care. All patients at our institute receive full resuscitative measures regardless of the prognosis, leading to a high number of mechanically ventilated patients. OBJECTIVES: Assess characteristics, outcomes, theoretical costs, and use of antibiotics in critically ill elderly patients requiring mechanical ventilation. DESIGN: Retrospective. SETTING: Intensive care unit and general ward of a tertiary medical care center. PATIENTS AND METHODS: We studied all elderly patients (≥60 years old) admitted under general medicine in the period of January to June 2018 who needed intensive care and were intubated. MAIN OUTCOME MEASURES: The duration of mechanical ventilation, theoretical costs, antibiotic usage. SAMPLE SIZE: 140 patients. RESULTS: Of 140 patients, 136 died (97%) and half of the deaths (n=69, 50.7%) occurred within the first 24 hours of intubation. Sixty-nine (79.3%) of the patients on short-term ventilation (≤96 hours) died within 24 hours of intubation, while the four survivors were on long-term ventilation (>96 hours) ( P <.001). All the nonsurviving patients (n=136) were on antimicrobial therapy, mostly for hospital-acquired infections. The median (interquartile range) APACHE II score was relatively high at 28.0 (8.0) with significantly higher scores in the early mortality group compared to the late mortality group (30 [10] vs 26 [7], P =.013) and higher scores in the short-term vs long-term ventilation group (29 [10] vs 26 [7], P =.029). The median theoretical cost per patient in the early and late mortality groups was USD 10 731 and USD 30 660, respectively ( P <.001). CONCLUSIONS: Given that less than 3% of patients had a favorable outcome, 50% of the cases died within 24 hours after intubation, hospital costs and antimicrobial use were high, the current policy of “full resuscitative measures for all” should be revised. We suggest implementing an end-of-life care policy, since the goal of resuscitation is to reverse premature death, not prolong the dying process. LIMITATIONS: Small sample size and absence of long-term follow-up. Theoretical costs were used as no direct calculated costs were available in our hospital. CONFLICT OF INTEREST: None