Professional Documents
Culture Documents
Abstract
Elderly patients patients (older than 65 years) account for only 11% of the US population yet they account for 34% of health care
expenditure. The disproportionate usage of health care costs by elderly patients is in striking contrast with that of other Western
Nations. It is likely that these differences are largely due to variances in hospitalization and the use of high technology health care
resources at the end of life. The United States has 8 times as many intensive care unit (ICU) beds per capita when compared to
other Western Nations. In the United States, elderly patients currently account for 42% to 52% of ICU admissions and for almost
60% of all ICU days. A disproportionate number of these ICU days are spent by elderly patients before their death. In many
instances, aggressive life supportive measures serve only to prolong the patients death. Such treatment inflicts pain and
suffering on the patient (with little prospects of gain) and incurs enormous financial costs to the health care system. We
present the case of an 86-year-old female who spent almost 3 months in our ICU prior to her death. The fully allocated hospital
costs for this patient were estimated to be US$254 945 (US$5100/d). With the increasing age of the population and the projected
increased demand for ICU beds, we review the benefits and burdens of admitting elderly patients to the ICU.
Keywords
ICU, futile care, elderly, surgery, aging
Case Report
An 86-year-old female presented to our hospital with symptoms of abdominal pain and diarrhea. She had undergone
an open abdominal aortic aneurysm repair 15 years previously.
She had a history of hypertension and hypercholesterolemia.
A computed tomography scan demonstrated celiac artery
occlusion, high-grade superior mesenteric artery (SMA)
obstruction, and a right common iliac artery aneurysm.
Cardiac evaluation demonstrated concentric left ventricular
hypertrophy, diastolic dysfunction, and tricuspid regurgitation with moderate pulmonary hypertension. The patient
underwent an open thoracoabdominal aneurysm repair using
a fenestrated graft and SMA stenting. On postoperative day
1, the patient required surgical exploration for hemorrhagic
shock. She was noted to have 2 L blood in the peritoneum with
several small bleeding branches of the left internal iliac and a
splenic laceration which required a splenectomy. On postoperative day 4, she was taken back to the operating room for
abdominal closure. She underwent additional relook abdominal explorations and a tracheotomy. Her hospital course
was further complicated by acute pancreatitis, renal failure
requiring hemodialysis, ventilator-associated pneumonia,
urinary tract infection, progressive respiratory failure, and
neurological decline progressing to coma. By the end of the
second hospital week, the patient was assessed by the critical care team as being in established multisystem organ
704
Table 1. Hospital Charges of the Patients.a
100 022
88 423
13 580
5725
(3770)
(749)
(70)
(63)
2808 (24)
8062 (58)
12 826 (53)
5290 (23)
12 438 (94)
41 659 (45)
5419 (29)
21 545 (7)
59 038 (193)
21 472 (32)
16 542 (9)
100 537
116 516
107 358
2769 (39)
6216 (42)
31 856 (176)
49 200 (50)
155 250 (50)
48 480
US$821 721
Anesthesia (7)
General surgery (7)
Critical care (49)
Infectious diseases (37)
Nephrology (48)
Cardiology (33)
Palliative care(3)
Total
Charges
Medicare
Payments
24 435 (est)
12 700
12 645
5215
10 638 (est)
4965 (est)
577
71 175
4050
7630
8685
3834
8177
3430
400
35 206
3000 (est)
5111
6260
2665
5587 (est)
2470 (est)
288
25 381
This led us to explore the appropriateness of providing critical care to elderly patients (discussed subsequently).
Furthermore, as we are currently in the midst of a health
care financing crisis, we were curious as to the economic
costs of such care. To this end, we obtained a detailed
breakdown of the patients hospital bill. The aggregate hospital charge was US$821 721 (summarized in Table 1). The
fully allocated hospital costs were estimated to be US$254
945 (US$5100/d). Total physician charges (US$71 175),
total Medicare charges (US$35 206), and total payment
(US$25 381) we obtained from our billing office; as not all
the physicians involved in the care of this patient were part
of our practice plan, the charges and payments for these services were estimated using the Medicare rates. The physician charges and payments are summarized in Table 2.
50000
Medications
Laboratory tests
Basic metabolic panel (BMP)
Complete blood count (CBC)
and differential count
Lactic acid
Magnesium
Arterial blood gasses (ABGs)
Troponins
Microbiology
Radiology
Chest X-ray
CT scans
Blood, blood products, and testing
Red blood cells
Platelets
Surgery and surgical supplies
Anesthesia
Respiratory therapy
ABG collection
Patient assessment
Suctioning
Ventilator
Room and board
Miscellaneous charges
Total hospital Charges
UK
Germany
Sweden
Spain
US
40000
30000
20000
10000
20
40
60
80
Age
Figure 1. Annual per capita health care costs by age. Adapted from
Paul Fischbeck, Carnegie Melon University, James Hilston, Pittsburgh
Post-Gazette, December 13, 2009.
Discussion
The United States is in the midst of a health care crisis; health
care expenditure currently accounts for 17.7% of the Gross
National Product when compared to 6% to 11% for other
Western Nations.1,2 Hospitalizations rather than physician and
other services are the major contributor to health care spending
in the United States.1 Elderly patients (older than 65 years)
account for 11% of the US population yet they account for
34% of health care expenditure.1 The disproportionate usage
of health care costs by the elderly patients is in striking contrast
with that of other Western Nations (see Figure 1). It is likely
that these differences are largely due to variances in hospitalization and the use of high technology health care resources at
the end of life. The United States has 8 times as many ICU beds
per capita when compared to other Western Nations.3 In the
United States, elderly patients currently account for 42% to
52% of ICU admissions and for almost 60% of all ICU
days.4-7 People who are older than 65 years of age are the fastest growing segment of the US population.8,9 By 2030, the population older than 65 years will double to approximately
70 million6,9,10 The aging of the population with the projected
increased demand for ICU beds requires us to examine the current pattern of ICU bed utilization in order to limit this costly
resource to those who are most likely to derive benefit and to
utilize our health care resources in a more cost-effective
manner.
A disproportionate number of ICU days are spent by elderly
patients before their death. Of the Medicare expenditures, 30%
is attributable to the 5% of beneficiaries who die each year,
resulting in per-capita spending on patients who died, that is,
6 times as great as for nondecedents.11 Kwok and colleagues
analyzed the use of in-patient surgical services among Medicare beneficiaries.12 They reported that in 2008, 18.3% of
patients who died underwent a surgical procedure in their last
month of life and 8% underwent a procedure during their last
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706
49% and 68% of cases, respectively.51,53-55 Surgery must be
therefore be considered very carefully in elderly patients.
The case we report is not unique. Huynh and colleagues analyzed the frequency and cost of treatment perceived to be
futile in 5 ICUs at an academic health care system in the
United States.56 In this study, 20% of patients were considered
to have received care that was probably futile. The daily
ICU cost was US$4004. Age was the most important predictor
of futile care. The decision to admit an elderly patient to an ICU
(and provide ongoing care) should be carefully evaluated and
should be based upon the patients comorbidities, acuity of illness, and prehospital functional status which includes quality
of life. Elderly patients with respiratory failure requiring ventilator support and those with circulatory failure requiring
hemodynamic support have a very poor prognosis, and such
patients are unlikely to benefit from admission to the ICU. A
time-limited trial in the ICU may be appropriate in elderly
patients whose prognosis is uncertain, in those with conflicted decision makers and in postoperative patients.57 The
patients progress over the next 4 to 6 days should then guide
further goals of care. Patients with nonresolving failure of 2
or more organ systems (multiple organ failure ) have a mortality approximating 100% and limitation of care should be considered at this time.32-37 A palliative care consult should be
obtained as part of the time-limited trial. The patients preferences (or surrogates best estimate of the patients wishes) with
regard to mechanical ventilation and other forms of lifesustaining treatment should be considered in all triage decisions. For dying patients with irreversible disease, admission
to the ICU (or ongoing care) is frequently inappropriate and the
care of these patients should be primarily focused on a palliative approach allowing a dignified death. A palliative care consult and an ethics consult should be considered in those
circumstances, where the goals of the patient and/or family
appear unrealistic and when long-term interventions such as
tracheostomy and percutaneous endoscopic gastrostomy tube
placement are being considered. Our case demonstrates the
enormous hospital costs of prolonging a patients death with
extraordinary life supportive measures. This money would be
better spent upfront in promoting health and well-being and
thereby preventing admission to the ICU. It is unclear why
Americans are so unaccepting of death and frequently want
everything to be done in the face of certain death. This may
be due to unrealistic expectations that patients and their families have with regard to what modern medicine can actually
achieve. These unrealistic expectations are perpetuated by misinformation provided by the lay press, television, and the Internet. It is likely that in many instances, physicians contribute to
these unrealistic expectations by failing to provide honest
information regarding the likelihood of a prolonged hospital
course, the need for prolonged rehabilitation in a long-term
acute care facility and about expected 1-year survival, functional status, cognitive status, and alternatives to continuing
aggressive life supportive measures.58
In conclusion, we believe that in the face of critical illness
discussions regarding the patients values and preferences,
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
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