Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care

Lauren R Pollack; Jamie T Nomitch; Lois Downey; Sudiptho R Paul; May J Reed; Alison M Uyeda; Whitney A Kiker; Danae G Dotolo; Elizabeth Dzeng; Robert Y Lee; Ruth A Engelberg; Erin K Kross

doi:10.1016/j.jpainsymman.2024.04.021

Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care

J Pain Symptom Manage. 2024 Apr 27:S0885-3924(24)00741-3. doi: 10.1016/j.jpainsymman.2024.04.021. Online ahead of print.

Authors

Affiliations

¹ Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA. Electronic address: Lrp2@uw.edu.
² Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA.
³ Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA.
⁴ University of Washington School of Medicine (S.R.P.), Seattle, Washington, USA.
⁵ Division of Geriatric Medicine (M.J.R.), University of Washington, Seattle, Washington, USA.
⁶ Department of Medicine (E.D.), University of California San Francisco, San Francisco, California, USA.

PMID: 38685288
DOI: 10.1016/j.jpainsymman.2024.04.021

Abstract

Context: Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences.

Objectives: To better understand decision-making regarding mechanical ventilation in people living with dementia.

Methods: This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use.

Results: The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization.

Conclusion: Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.

Keywords: Communication; Critical care; Dementia; Goals of care; Mechanical ventilation; Older adults.

Abstract

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