Realities, Expectations and Attitudes Related to Life Support Technologies in Intensive

R ealities, E xpectations and A ttitudes to LI fe S upport T echnologies in Intensive Care for Octogenarians: The R E A L I S T I C 8 0 Study

Seriously ill hospitalized elderly patients rate ‘not being kept alive on prolonged life supports’ as the most important aspect of good quality care at the end of life (EOL). Across Canada, large numbers of elderly patients near the EOL and their families are faced with decisions about whether or not to use mechanical ventilation or other forms of life support technology used in intensive care units (ICUs). We do not know whether these patients and their families are informed about the realities of intensive care – that is, if they are aware of the likelihood of surviving a critical illness and the resultant health states. The outcomes of critical illness for this patient population and their families are unknown, despite the crucial importance of this information to guide clinical decision making. The goals of our research program are to understand the realities of critical care, and the expectations and attitudes of patients 80 years of age or older (80+) and their families about the use of life sustaining technology. Specifically, in this project, we want to determine the realities or outcomes of surviving critical illness. Our primary research question is: 1) What are the 12-month health-related quality of life (HRQOL), functional status, and survival of patients admitted to ICU who are 80+ years old? Our secondary research questions are: 2) Which patient characteristics are associated with 12-month HRQOL, functional status, and survival? 3) What is the satisfaction of family members with critical care, as measured by the Family Satisfaction in ICU (FS-ICU 24) instrument? 4) For patients surviving their ICU stay, what is the experience of family members caring for the patient during follow up, as measured by the Caregiver Reaction Assessment (CRA) instrument? 5) For patients who do not survive their ICU stay, what is the family satisfaction with EOL care, as measured using the CANHELP Satisfaction (Bereavement) instrument? 6) What is the health-related financial burden experienced by patients and their caregivers during their initial ICU hospitalization and up to 12 months after the index ICU admission? 7) What is the quality of decision making regarding the goals of care for an 80+ ICU patient? 8) What are the values that influence decisions about the goals of care for this population? To answer these questions, we are conducting a national, multicentre, cohort study of 800 patients age 80+ years who are admitted to Canadian ICUs. We will follow these patients prospectively for 12 months to measure study outcomes. In addition, using novel instruments that we have already developed and validated, we will follow family members of these patients to document their experience as caregivers, their satisfaction with care of their relatives, and the financial implications of having a critically ill loved one. This quantitative project will be complemented by a separate qualitative study in the community setting to further understand the expectations and attitudes of persons over 80 years of age regarding the use of life sustaining technology. Data emerging from this work will inform important clinical decisions regarding critical care and EOL care for this aged population. We presume that the short- and long-term mortality of 80+ year olds admitted to Canadian ICUs will be high and that the self-reported health-related quality of life and functional status of survivors after hospital discharge will be low. We anticipate that pre-morbid illnesses and functional status before admission to ICU will correlate with long-term clinical outcomes. We are uncertain as to the psychological and financial burden experienced by families when a loved one is in the ICU and during the recovery phase; our study will be the first to furnish such important information. By using administrative databases to complement information already being collected in this study, we will obtain a better understanding of the healthcare resource utilization and longer term survival of this cohort, and will be better positioned to offer effective ICU and follow-up care for this at-risk patient population.

Grant Success Our CIHR operating grant was confirmed March 2009. With funding from the CIHR Institutes of 1) Aging and 2) Respiratory and Circulatory Health, we held a successful, well attended conference on Aging and Critical Care in Kingston April 2-3 in conjunction with the REALISTIC 80 Start-Up Meeting for Investigators and Research Coordinators.

Study Progress to Date.

We have 20 sites actively screening and enrolling patients. There is 1 site that still is not ready to start enrolling. We have, to date, enrolled 147 patients in the follow up study and over 700 patients in the chart review. Given that enrollment is slower than expected, we have reached out for additional sites and have 2 more sites starting up soon.