Who gets the ventilator? A multicentre survey of intensivists' opinions of triage during the first wave of the COVID-19 pandemic

Frailty prevalence in 42 European countries by age and gender: development of the SHARE Frailty Atlas for Europe

Comparative frailty prevalence data across European countries is sparse due to heterogeneous measurement methods. The Survey of Health, Ageing and Retirement (SHARE) initiative conducted interviews with probability sampling of non-institutionalized elderly people in several European countries. Previous frailty analyses of SHARE datasets were limited to initial SHARE countries and did not provide age- and gender-stratified frailty prevalence. Our aim was to provide age- and gender-stratified frailty prevalence estimates in all European countries, with predictions where necessary. From 29 SHARE participating countries, 311,915 individual surveys were analyzed. Frailty prevalence was estimated by country and gender in 5-year age bands using the SHARE Frailty Instrument and a frailty index. Association of frailty prevalence with age, gender, and GDP per capita (country-specific economic indicator for predictions) was investigated in multivariate mixed logistic regression models with or without multiple imputation. Female gender and increasing age were significantly associated with higher frailty prevalence. Higher GDP per capita, with or without purchasing power parity adjustment, was significantly associated with lower frailty prevalence in the 65-79 age groups in all analyses. Observed and predicted data on frailty rates by country are provided in the interactive SHARE Frailty Atlas for Europe. Our study provides age- and gender-stratified frailty prevalence estimates for all European countries, revealing remarkable between-country heterogeneity. Higher frailty prevalence is strongly associated with lower GDP per capita, underlining the importance of investigating transferability of evidence across countries at different developmental levels and calling for improved policies to reduce inequity in risk of developing frailty across European countries.

Health Professional vs Layperson Values and Preferences on Scarce Resource Allocation

Importance

COVID-19 prompted rapid development of scarce resource allocation (SRA) policies to be implemented if demand eclipsed health systems' ability to provide critical care. While SRA policies follow general ethical frameworks, understanding priorities of those affected by policies and/or tasked with implementing them is critical.

Objective

To evaluate whether community members and health care profesionals (HCP) agree with SRA protocols at the University of California (UC).

Design, Setting, and Participants

This survey study used social media and community-partnered engagement to recruit participants to a web-based survey open to all participants aged older than 18 years who wished to enroll. This study was fielded between May and September 2020 and queried participants' values and preferences on draft SRA policy tenets. Participants were also encouraged to forward the survey to their networks for snowball sampling. Data were analyzed from July 2020 to January 2024.

Main Outcomes and Measures

Survey items assessed values and preferences, graded on Likert scales. Agreement was tabulated as difference in Likert points between expressed opinion and policy tenets. Descriptive statistics were tested for significance by HCP status. Free text responses were analyzed using applied rapid qualitative analysis.

Results

A total of 1545 participants aged older than 18 years (mean [SD] age 49 [16] years; 1149 female participants [74%], 478 health care practitioners [30%]) provided data on SRA values and preferences. Agreement with UC SRA policy as drafted was moderately high among respondents, ranging from 67% to 83% across domains. Higher agreement with the interim policy was observed for laypersons across all domains except health-related factors. HCPs agreed more strongly on average that resources should not be allocated to those less likely to survive (HCP mean, 3.70; 95% CI, 3.16-3.59; vs layperson mean, 3.38; 95% CI, 3.17-3.59; P = .002), and were more in favor of reallocating life support from patients less likely to those more likely to survive (HCP mean, 6.41; 95% CI, 6.15-6.67; vs layperson mean, 5.40; 95% CI, 5.23-5.58; P < .001). Transparency and trust building themes were common in free text responses and highly rated on scaled items.

Conclusions and Relevance

This survey of SRA policy values found moderate agreement with fundamental principles of such policies. Engagement with communities affected by SRA policy should continue in iterative refinement in preparation for future crises.

Extracorporeal Membrane Oxygenation Support and Critically Ill COVID-19 Patient Outcomes: A Population-Based Cohort Study

We selected critically ill patients with coronavirus disease 2019 (COVID-19) who were receiving extracorporeal membrane oxygenation (ECMO) support and had been transferred to experienced centers. Thus, we aimed to evaluate factors that were associated with receiving ECMO support and factors that were associated with patient mortality. Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients admitted to an intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of COVID-19 were included. They were divided into two groups: ECMO group (n = 455) and non-ECMO group (n = 12,648). Receiving ECMO support was less associated with old age [odds ratio (OR), 0.95; 95% confidence interval (CI), 0.94-0.96; p  < 0.001], underlying severe disabilities (OR, 0.49; 95% CI, 0.29-0.83; p  = 0.008), and booster vaccination status (second: OR, 0.61; 95% CI, 0.39-0.94; p  = 0.024; third: OR, 0.40; 95% CI, 0.25-0.65; p  < 0.001). In addition, after adjusting for various variables, low mortality in patients with ECMO support was associated with having previously received a second booster vaccination (OR, 0.33; 95% CI, 0.14-0.77; p  = 0.010). Vaccination and booster therapy may lower the need for ECMO support and lower mortality among critically ill patients with COVID-19 with ECMO support.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices

BACKGROUND

Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies.

METHODS

Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems.

RESULTS

This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries.

CONCLUSIONS

This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU

BACKGROUND

Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU.

METHODS

This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST.

RESULTS

The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables.

CONCLUSIONS

Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.

Mortality among people admitted to Australian intensive care units for reasons other than COVID-19 during the COVID-19 pandemic: a retrospective cohort study

OBJECTIVE

To investigate in-hospital mortality among people admitted to Australian intensive care units (ICUs) with conditions other than coronavirus disease 2019 (COVID-19) during the COVID-19 pandemic.

DESIGN

National, multicentre, retrospective cohort study; analysis of data in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database.

SETTING, PARTICIPANTS

Adults (16 years or older) without COVID-19 admitted to Australian ICUs, 1 January 2016 - 30 June 2022.

MAIN OUTCOME MEASURES

All-cause in-hospital mortality, unadjusted and relative to the January 2016 value, adjusted for illness severity (Australian and New Zealand Risk of Death [ANZROD] and hospital type), with ICU as a random effect. Points of change in mortality trends (breakpoints) were identified by segmental regression analysis.

RESULTS

Data for 950 489 eligible admissions to 186 ICUs were available. In-hospital mortality declined steadily from January 2016 to March 2021 by 0.3% per month (P < 0.001; March 2021 v January 2016: adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.62-0.80), but rose by 1.4% per month during March 2021 - June 2022 (P < 0.001; June 2022 v January 2016: aOR, 1.03; 95% CI, 0.90-1.17). The rise in mortality continued after the number of COVID-19-related ICU admissions had declined; mortality increased in jurisdictions with lower as well as in those with higher numbers of COVID-19-related ICU admissions.

CONCLUSION

The rise in in-hospital mortality among people admitted to Australian ICUs with conditions other than COVID-19 from March 2021 reversed the improvement of the preceding five years. Changes to health service delivery during the pandemic and their consequences should be investigated further.

Coronavirus disease 2019 aftermath: psychological trauma in ICU healthcare workers

PURPOSE OF REVIEW

We aim to describe the extent of psychological trauma and moral distress in healthcare workers (HCW) working in the intensive care unit (ICU) during the coronavirus disease 2019 (COVID-19) pandemic. Specifically, we review reports on prevalence of mental health symptoms, highlight vulnerable populations and summarize modifiable risk factors associated with mental health symptoms in ICU HCW.

RECENT FINDINGS

The pandemic has resulted in a multitude of closely intertwined professional and personal challenges for ICU HCW. High rates of posttraumatic stress disorder (14-47%), burnout (45-85%), anxiety (31-60%), and depression (16-65%) have been reported, and these mental health symptoms are often interrelated. Most studies suggest that nurses and female HCW are at highest risk for developing mental health symptoms. The main personal concerns associated with reporting mental health symptoms among ICU HCW were worries about transmitting COVID-19 to their families, worries about their own health, witnessing colleagues contract the disease, and experiencing stigma from their communities. Major modifiable work-related risk factors were experiencing poor communication from supervisors, perceived lack of support from administrative leadership, and concerns about insufficient access to personal protective equipment, inability to rest, witnessing hasty end-of-life decisions, and restriction of family visitation policies.

SUMMARY

The COVID-19 pandemic has severely impacted ICU HCW worldwide. The psychological trauma, manifesting as posttraumatic stress disorder, burnout, anxiety, and depression, is substantial and concerning. Urgent action by lawmakers and healthcare administrators is required to protect ICU HCW and sustain a healthy workforce.