Friday, June 22, 2018

Breathing Tubes Fail to Save Many Older Patients

Older Patients

Earlier this year, an ambulance brought a person in his 80s to the ER at Brigham and Women’s Hospital in Boston.

He had metastatic lung cancer; his family had arranged for hospice care reception.

But when he grew less alert and commenced struggling to breathe, his son tearfully called 911.

“As soon as I met them, his son said, ‘Put him on a breathing device,’” recalled Dr. Kei Ouchi, an emergency physician, and researcher at the hospital.

Hospice patients know that they’re on the brink of death; they and their families have also been instructed that the majority distressing symptoms, like shortness of breath, are often eased at home.

But the son kept insisting, “Why can’t you set him on a breathing machine?”

Dr. Ouchi, lead author of a replacement study of how older people fare after ER  intubation, knew this is able to be no simple decision.

“I went into medicine thinking I’d be saving lives. I won't to be very satisfied putting patients on a ventilator,” he told me in an interview.

But he began to understand 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 an equivalent people he’d intubated days later, still within the hospital, very ill, even unresponsive.

“Many times, the 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 then attaching him to a ventilator that would breathe for him.

But, he said, “I was never trained to speak to patients or their families about what this means.”

His study, published within 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 3rd of these  patients die within 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 1 / 4 of intubated patients head 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.

except for 80- to 84-year-olds, that figure drops to 19 percent; for those over age 90, it slides to 14 percent.

At an equivalent time, the death rate climbs sharply, to 50 percent within the eldest cohort from 29 percent within the youngest.

All intubated patients proceed to medical care, most remaining sedated because intubation is uncomfortable.

If they were conscious, patients might attempt to pull out the tubes or the I.V.’s delivering nutrition and medications. they can't speak.

Intubation “is not an enter the park,” Dr. Ouchi said.

“This maybe 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.

counting on how disabled patients are before a critical illness, they’re likely to ascertain a the decline in their function afterward, or to die within a year.

Those who underwent intubation had quite twice the mortality risk of other I.C.U. patients.

“You don’t recover, most of the time,” said Dr. Ouchi. While outcomes remain hard to predict, “a lot of times, you worsen .”

Intubation rates are projected to extend. But so has the utilization of alternatives referred to 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 also as intubation does.

But they continue to be conscious and may have the mask removed briefly for a sip of water or a brief 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 the majority survived to discharge.

Many, treated on ordinary hospital floors, avoided medical care.

“There are cases where noninvasive ventilation is comparable or maybe superior to mechanical ventilation,” said Dr. Douglas White, a critical care physician and ethicist at the University of Pittsburgh School of drugs.

Dr. Ouchi, as an example, explained to his patient’s distraught son that intubation would thwart his father’s desire to stay communicative.

The patient, ready to see though not to say much, died four days later during a room with BiPAP and morphine to scale back  his “air hunger.”

Most patients within the Mayo review died within a year, too.

But BiPAP may provide an interim option, giving families and physicians time to make a decision together whether to intubate an ailing older patient, who at now probably can’t direct his own care.

The harried ER environment, after all, hardly encourages thoughtful discussions about patients’ prognoses and needs.

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 a few critically ill patient’s odds of recovery, it’s not merely because relations fail to understand what the physician explained.

“Other things get within the way of creating good decisions,” Dr. White acknowledged.

“A lot of this has got 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 up-to-date 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 elucidate 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.

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