Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID‐19 pneumonitis

Abstract

Background The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission.

Persistent Critical Illness and Long-Term Outcomes in Patients With COVID-19: A Multicenter Retrospective Cohort Study

“…Second, the lack of treatment limitations may be associated with prolonged care in the ICU. Patients admitted to a hospital after 2020 were less likely to have treatment limitations, although COVID-19 itself was not associated with the lack of treatment limitations (24, 25). It is possible that goals of care may not have been explored in these patients.…”

Impact of frailty on long-term survival in patients discharged alive from hospital after an ICU admission with COVID-19

“…Our results support the assessment of frailty to better inform therapeutic choices and expectations regarding prognosis in severe COVID-19.3 Conversations about goals of care may be essential for those with multiple chronic conditions and greater baseline frailty levels. 17 , 31 Furthermore, it is essential for clinicians to discuss the expected outcomes with the patient and family when admitted to ICU. Our findings support the incorporation of frailty measurement in day-to-day ICU practice 17 and suggest developing international guidelines to consider frailty in clinical decision-making.…”

Prevalence and long-term outcomes of patients with life-limiting illness admitted to intensive care units in Australia and New Zealand

“… 22 More recent research suggests that there is a trend toward an increase in the prevalence of treatment limitation orders present at the time of ICU admission, 23 especially amongst those patients identified as frail, elderly or comorbid. 24 The determination of treatment limitations has historically been influenced by well-recognised patient factors such age and diagnoses. Our findings highlight the role that an objective indicator of the presence of LLI can play in predicting post-ICU outcomes.…”