The ICU is no place for the Elderly - PRO: Francesca Rubulotta, CON: Karin Amrein

Francesca RubulottaMD, PhD, FRCA,FFICM,

Chair of the Division of Professional Development of the ESICM

UEMS/EACCME Governance board EBICM member

Centre for Perioperative Medicine & Critical Care Research

Imperial College Healthcare NHS Trust

SMACC DUBPRO

ICU is no place for the Elderly

DEFINITIONS

Elder is any individual of any gender

and any nationality older than

me… regardless my current

age or what my ultimate age is

going to be!

ICUis …

DOCTOR????

WHICH DOCTOR IN EUROPE???

Intensive care medicine: finding its way in the "European labyrinth".

• Rubulotta F, Moreno R. Rhodes, A. ICM 2011

Models of training programmes

Supra Speciality

Multiple Sub Speciality

SingleSub Speciality

Primary Speciality

Common training framework The projectEU Directive 2012

Patients?

In reality the ICU is very

DANGEROUS

!"#$%$&'(

#)'%"*+#&,-$#."-*& #

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways

Chartered Flight

Drilling Industry

Chemical Industry (total)

Fatal risk

Anesthesiology ASA1

Innovative medicine (grafts, oncology …) ICU Trauma centers

!"#$%&'()*"% +,-#)%()*"%

Professional fishing

+'()*"% .)*"%

Himalaya mountaineering

Combat A/C, war time

Medical risk (total)

Scheduled surgery Chronic care

Radiotherapy, Biology Blood transfusion

Finance Fire Fighting Food Industry

Processing Industry

Amalberti R. et al.: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764.

Average rate per exposure of catastrophes and associated deaths in various industries and human activities !

“Hospitals are fine for people who need acute

treatments ... Hospitals are hugely dangerous and inappropriately used…

They are a great place to be if you have no choice but to risk your life to get better.”

Prof George Taler, Georgetown”

Acute

Overall IN = 32% PR = 50%

Age >= 63 IN = 44% PR = 55%

Age >= 85 IN = 80% PR = 64%

Age < 85 IN = 41% PR = 55%

Congestive Cardiomyopathy

IN = 56% PR = 58%

NO Congestive Cardiomyopathy

IN = 39% PR = 54%

Chronic Liver Disease IN = 71% PR = 64%

NO Chronic Liver Disease

IN = 38% PR = 53%

Age < 63 IN = 21% PR = 44%

Age >= 46 IN = 26% PR = 48%

Age < 46 IN = 13% PR = 38%

Chronic Liver

Disease IN = 56% PR = 62%

NO Chronic Liver Disease IN = 25%

PR = 47%

P0

P1

P2

P3 P3

P4

P4

Demographics

• 20,183 patients (10,375F and 9808M)

• 46% over 70

• 56% ASA 3 or higher

• 53% required surgery within 6 hours

• P-POSSUM risk of death>10% in 46%

• 30 day mortality found to be 11%

• 10% reoperation rate

The mean age of patients who

arrested was 70 years

Age was also an important indicator of

deterioration, with most cases occurring in

patients older than 70 years, and the study

authors suggest that closer monitoring is

warranted for this population.

29% of Medicare beneficiaries

wind up in their last month of life.

“The focus appears to be on

providing curative care in the acute

hospital,” an accompanying

editorial said, “regardless of the

likelihood of benefit or preferences

of patients.”

Chronic

The Hospital Is No Place for the Elderly

Medical treatment for aging,

chronically ill patients is costly and

often ineffective

?

Can they get better care at home

Cannot be!

5th June 2016

Technology's biggest untapped market is

elderly care. For the first time in history,

14% of the world is over 65. How can

technology assist them cheaply and

efficiently?

Business case

• The ideal world

• The reality ICU is very DANGEROUS

• Cheaper at home or dedicated

• Palliative care no beds (no plan B)

• The Hospital Is No Place for the Elderly

Jan 2013-February 2015

ADULT: mixed surgical and medical

�If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made� Norman, The Design of Everyday Things, 2001

Managing risk of failure

…having a plan B too

Year review

Thank you

[email protected]

Too much is

not the answer

for not enough:

• Uno

• Nessuno

• Centomila

Jan 2013-February 2015

ADULT: mixed surgical and medical

�If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made� Norman, The Design of Everyday Things, 2001

CIAOThank you

Thank you

THEICUISNO PLACEFORTHEELDERLY!?

KARIN AMREIN

ELDERLY?

60?

71?

Photo: by permission ©AlexRotas,www.alexrotasphotography.co.uk

GERMANRECORD100m

• 70+:12.9SEC• 75+:13.5• 85+:14.7• 95+:21.4

• WORLDRECORD(USAINBOLT):9,58 s= 37,6 km/h

85?


MEN’S100MCOMPETITORSAGED85-89

91?


92?

+SARCOPENIADEMENTIA

...?

DISCRIMINATION?

Discrimination,noun

treatingapersonorparticulargroupofpeopledifferently,especiallyinaworsewayfromthewayinwhichyoutreatotherpeople,becauseoftheirskincolour,sex,AGE,etc.

WHO

...THECHRONOLOGICALAGEOF65YEARSASADEFINITIONOF'ELDERLY'OROLDERPERSON...

THECOMMONUSEOFACALENDARAGETOMARKTHETHRESHOLDOFOLDAGEASSUMESEQUIVALENCEWITHBIOLOGICALAGE,YETATTHESAMETIME,ITISGENERALLYACCEPTEDTHATTHESETWOARENOTNECESSARILY

SYNONYMOUS.

SAPS

31points,12%estimatedmortality

- 60yrs,31%(+12)- 70yrs,37%(+15)- 80yrs,44%(+18)- 90yrs,44%(+18)- 100yrs,44%(+18)

SAPS

NOFRAILTY

MALNUTRITIONDEMENTIA

...

AGEISJUSTANUMBER


expensivecare.com• Ring,Ring…• You:“Hello intensivecare.”• Caller:“Hello,this is the most junior EDdoctor,Ihave apatientwho needs to

come to ICU.”• You:“OK,what’s the story?”• Caller:“Mrs. Smithis a103year old lady from anursinghomewhere she’s

bed-boundwith anMMSEof 1and is doubly incontinent. She hasmetastaticcancer and endstage COPD. She’s come inwith pneumonia. She has arespiratory rateof 40,sats of 80%onanon-rebreather,pulseof 140,BPof70/40and alactate of 10.Oh,she’s alsogot aurea of 30and apotassiumof7. She needs to come to ICUfor ventilation and dialysis.Thanks.”

• You:“Hmmm. Thispoor lady sounds like she’s dying.Ithink you should speakto the family and tell them that.”

• Caller:“OhI’ve already spoken to the family. Iasked them if they want us todoeverythingand they said yes,theywant everythingdone,soyou have totake her.”

• Click.

CPR

HayesBInt Med J2013

Would the patient survive CPR?

No Possibly yes

Dying patient Very poor outcome likelyMedically unwell but not imminently dying

Uncertain CPR outcome

Discuss good dying Discuss why CPR not being offered

Discuss why CPR may be ethically inappropriate but accept opposite view

Discuss to make a decision about CPR

appropriateness

Figure 2 Four categories for cardiopulmonary resuscitation (CPR) decision-making discussions.

Hayes

EOLEMCRITASHLEYSHREVES

(25&165)

thecarenet.ca

advancecareplanning.org.au

Health & Medicine

The ICU is no place for the Elderly - PRO: Francesca Rubulotta, CON: Karin Amrein