Why are advance directives so key? Look at tough stats on ventilator survival

intubation-300x181Grown-ups with the least bit of gray on them may want to step up their thinking on how they want to receive medical care under tough circumstances, especially if they consider a new, clear-eyed and hard-nosed study that dispels any myths about possible life-sustaining “miracles” of artificial breathing machines.

A research team with experts from Boston, San Francisco, and Dallas studied 35,000 cases in which adults older than 65 had undergone intubation and use of mechanical ventilators at 262 hospitals nationwide between 2008 and 2015.

They found that a third of patients intubated died in the hospital.

Here are more results, as reported by the New York Times:

Only a quarter of intubated patients go 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. But for 80- to 84-year-olds, that figure drops to 19 percent; for those over age 90, it slides to 14 percent. At the same time, the mortality rate climbs sharply, to 50 percent in the eldest cohort from 29 percent in the youngest.

Kei Ouchi, an emergency physician and lead author of the study, said he and others in his role may need to rethink how readily they intubate older patients and how they counsel them and their families about the procedure. He noted that its costs can be sizable, not for the procedure itself, but because intubated patients typically go from some of the most expensive care around in emergency rooms to intensive care units, where patients also can rack up staggering bills.

Intubation is so intrusive and discomforting that patients must be heavily sedated to prevent them from gagging and trying to remove the object planted in their windpipe and the intravenous lines that provide them with sustenance while they cannot eat, he said. For patients in dire shape, many of whom may be in the end phases of their lives, intubation means they cannot talk with family, loved ones, and friends, neither receiving comfort from them or giving it to them.

Medical science has advanced such that intubated patients can be sustained for some time, postponing inevitable death for many end-of-life patients but also doing so in a way that can be devastating to them and their families, Ouchi told the New York Times.

In my practice, I see the harms that patients suffer while seeking medical services, and I long have urged everyone I know to act while they are healthy to let their doctors, families, friends, and other loved ones — as well as their accountants and lawyers — know their explicit wishes for their medical care, including if they are in no condition to discuss and decide it.

Make time to talk with your spouse, doctor, and lawyer about your advance medical care directive, a form that you can get from groups like the AARP (the documents vary, state by state). Be sure that everyone who might need to see the document in stressful, potentially emergency situations know where it’s at, including, possibly as an attachment to your electronic health records.

End-of-life planning may seem cold and callous but it’s just the opposite. You want to protect yourself and your family from invasive, costly care that not only may be painful but unnecessary and unhelpful. It’s a common talking point — one in dispute — but the burden of medical services for patients in the last year of the life adds up to billions of dollars in the American health care system. We need to be humane and judicious in about procedures that save lives and sustain them for painfully short periods and to no avail.

By the way, patients and families also need to think carefully about resuscitation orders and the optimism that may underlie them. For the elderly, and especially for those who already are sick and frail, the most common procedure of CPR (cardiopulmonary resuscitation) can have poor outcomes. If patients are revived and sustain for some time, they often may experience pain: CPR may not seem invasive, but it often breaks ribs and can leave bruised patients in discomfort (rib injuries are among the most challenging, because they can affect all manner of everyday activities, including breathing, coughing, laughing, and eating). If elderly patients respond to CPR, they often then may need intubation and ….

One more note: The New York Times intubation story reported on an option with increasing use:  “noninvasive ventilation — primarily the bipap device, short for bi-level positive airway pressure.” The paper said this involves:

A tight-fitting mask over the nose and mouth helps patients with certain conditions breathe nearly as well as intubation does. But they remain conscious and can have the mask removed briefly for a sip of water or a short 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 most survived to discharge. Many, treated on ordinary hospital floors, avoided intensive care.

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