Impact of Early Limitation of Therapeutic Effort in Elderly COVID-19 Patients Admitted to the Intensive Care Unit-A Cohort Study

Abstract

(1) Background: Admission to the ICU and intensity of care provided to elderly COVID-19 patients are difficult choices guided by the expected patient-centered benefits. However, the impact of an early discussion of limitation of therapeutic effort (LTE) has been poorly investigated. (2) Methods: We performed a single-center retrospective cohort study including all ≥70-year-old COVID-19 patients admitted to the ICU. Factors associated with early LTE discussion (defined as before or up to 2 days post-ICU admission) and in-hospital mortality were evaluated. (3) Results: Eighty-two patients (59 M/23 F; 78 years (74−82) [median (interquartile range)]; 43/82 with LTE) were included. The in-hospital mortality rate was 55%. Early LTE was decided upon for 22/82 patients (27%), more frequently in older (p < 0.001) and frailer patients (p = 0.004). Using a multivariable logistic regression model including clinical frailty scale grade ≥4, hospital acquisition of COVID-19, ventilation support modality and SOFA score on admission, early LTE was not associated with mortality (adjusted odds ratio = 0.57 (0.15−2.00), p = 0.39). LTE resulted in less frequent invasive mechanical ventilation (23% versus 65%, p = 0.001), renal replacement therapy (5% versus 27%, p = 0.03) and norepinephrine infusion (23% versus 60%, p = 0.005), and shorter ICU stay (6 days (2−12) versus 14 days (7−24), p = 0.001). (4) Conclusions: In this small sample exploratory study, we were unable to demonstrate any increase in in-hospital mortality associated with early LTE discussion in elderly COVID-19 patients while reducing the use of organ support techniques. These findings require confirmation in larger studies.

Keywords: COVID-19; death; elderly; frailty; intensive care unit; limitation of therapeutic effort.

Figure 1

Study flowchart. COVID-19, coronavirus infectious disease-2019; ICU, intensive care unit.

Figure 2

Forrest plot representing the odds ratios of in-hospital mortality according to the clinical frailty scale grade, the hospital-acquired origin of COVID-19, the ventilation support modality initiated during the first 24 h and the early discussion of limitation of therapeutic effort. Comparisons were performed using a multivariable logistic regression model. Points represent the adjusted odds ratios and lines represent 95% confidence intervals. * Compared with high-flow nasal oxygen or conventional oxygen taken as reference. aOR, adjusted odds ratio; CI, confidence interval; SOFA, Sequential Organ Failure Assessment.