Stand-by resuscitation: a new approach more appropriate to elderly patients and their families
Communiqué from the French National Academy of Medicine [[1]]
November 10, 2021
The management of diagnostic and, above all, prognostic uncertainty is at the heart of physician’s profession and requires an appropriate communication with the patient and his or her entourage [1]. The goal of an efficient use of health care resources and avoidance of inappropriate interventions is faced with prognostic uncertainties, especially in elderly patients suffering from multiple pathologies and life-threatening emergencies [2-4].
Critical care (resuscitation, intensive care) offers multiple possibilities for the management of life-threatening organ failure. The decision to admit patients to this critical care is based on an estimate of the probability of remote survival, but also on the expected quality of life after the acute episode. For more than 40 years, resuscitation physicians have developed severity scores allowing this estimation. These scores integrate some comorbidities, as well as physiological disorders, but do not take into account how the disease progresses in response to the treatments undertaken. Despite these scores, the critical care admission decision is often made difficult by the lack of information on the patient’s basic condition, the non-presence of the family, the absence of an advance directive, and especially the uncertainty about the response to treatment.
In order to avoid a loss of chance for elderly patients who may benefit from resuscitation treatments and because “doubt should benefit the patient”, a stand-by resuscitation approach is proposed. This “more open to critical care admission” strategy is only possible if the level of critical care provided is reviewed soon after admission for such care. Some aspects of the initial treatment, including intubation, may be limited from the outset, while other less aggressive treatments are started at admission. In any case, the initial care plan is discussed again during a listen and exchange meeting with the family for an informed and shared decision. This meeting is organized a few days after admission to critical care. The Anglo-Saxons use the term “time-limited trial”, which emphasizes the limited period of time during which a dynamic analysis of the response to treatment is carried out [5]. This time-limited trial also makes it possible to gather information that was initially missing (history, opinion of the attending physician), and external experts to participate in the meeting with the family (geriatricians, organ specialists).
The modalities, results and consequences of this meeting of listening, exchange and reassessment must be detailed as follows:
– Time since admission for critical care. In cancer patients, this period may be up to 2 weeks depending on the pre-existing conditions and the severity of the disease [6];
– Modalities of carrying out the reassessment meeting (participants; traceability of decisions made);
– Decisions made as to whether or not to continue critical care (either treatment limitation, such as not starting hemodialysis, or treatment discontinuation, such as stopping vasoactive drugs);
– Reduction in the duration of life-sustaining critical care;
– Prevention of complicated family bereavement linked to unnecessary prolongation of critical care.
The admission of very old patients for critical care is likely to increase in European countries over the next decades. For many elderly patients, decisions on whether to continue or limit/discontinue heavy critical care will have to be made [6]. The prognosis of cancer patients is being changed by new therapies and this wait and see approach is probably also appropriate for this type of patient. These decisions should make it possible i) to find a way between two pitfalls: the loss of chance for the patient and the unreasonable continuation of critical care; ii) to improve equal access to critical care for the patients likely to be concerned, taking into account the means available.
The French National Academy of Medicine underlines the interest of the concept of “stand-by resuscitation” which, by its temporality, makes it possible to reinforce an ethical approach in the management of elderly patients likely to require heavy critical care.
References
- Smith AK, White DB, Arnold RM. Uncertainty-the other side of prognosis. N Engl J Med. 2013 Jun 27;368(26):2448-50
- Ranzani OT, Besen BAMP, Herridge MS. Focus on the frail and elderly: who should have a trial of ICU treatment? Intensive Care Med. 2020 May;46(5):1030-1032.
- Flaatten H, Beil M, Guidet B. Prognostication in older ICU patients: mission impossible? Br J Anaesth. 2020 Nov;125(5):655-657
- Beil M, et al. On predictions in critical care: The individual prognostication fallacy in elderly patients. J Crit Care. 2021 Feb;61:34-38.
- Vink EE, Azoulay E, Caplan A, Kompanje EJO, Bakker J. Time-limited trial of intensive care treatment: an overview of current literature. Intensive Care Med. 2018 Sep;44(9):1369-1377.
- Guidet B, et al., VIP1 study group. Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit. Intensive Care Med. 2018 Jul;44(7):1027-1038.
[1][1] Press release from the Academy’s Rapid Communication Platform validated by the members of the Governing Board on November 10, 2021.
