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Editorial

The disease is indicated for the icu, but the patient is not..., dear colleague

A doença tem indicação de uti, mas o paciente não..., caro colega

Einstein Francisco Camargos

We, geriatricians, have more often been facing a situation in the clinical practice of disagreement with the physician who is taking care of the elderly in emergency services. In one of these situations, recently, a 90-year-old patient in a severe stage of Alzheimer’s dementia sought medical care in a private hospital from Brasília. After one week of home treatment with antibiotics for an infection of the upper airways, she remained with low fever and apathic. Her general condition was regular, without dyspnea and maintained oral feedings, despite some episodes of dysphagia. The tests performed in her admission presented abnormalities that were compatible with ongoing infection. Even though her children verbally manifested the wish of not admitting the patient in an intensive care unit (ICU), my physician colleague insisted on making it, even after my advice to admit her in a general ward. After the disagreement, with the use of expressions that were not very technical, I felt in the obligation of saying: “The disease is indicated for the ICU, but the patient is not!”.

We can simply determine that the private health system is not able, nor technically or socially speaking, to deal with the elderly in his/her final stage of life. Practical experiences have showed us the financial bias of this logic in the daily life. As an example, one of the largest private hospitals of Brasília has substantially increased its number of beds in the ICU. According to information of its internet webpage, there are 349 beds! It means one third of the hospital beds. Brasília has one of the largest (maybe the largest) amounts regarding beds in the ICU per 10,000 inhabitants. This increase occurred in all private hospitals of the city, and the result is a frequent, unnecessary, dangerous and ineffective hospitalization of elderlies in these environments, especially for individuals with chronic diseases at a severe stage or even at a terminal phase.

In the United States of America, the expenses with hospitalized patients in the ICU represent half of the hospital costs. A study that has been recently published in the Journal of the American Medical Association showed that elderly hospitalization did not present a significant impact on mortality, functional status or quality of life regarding physical health in the six months after hospitalization.1 There are indeed serious gaps in literature regarding the criteria for patient admission to an ICU.2 Contrarily, this topic has not been widely discussed in Brazil.

A study was recently published in this edition of Geriatrics, Gerontology and Aging stating that two thirds of the elderly in Brazil die in hospitals and the rates of occurrence in hospitals have increased during the last years with concomitant decrease of home deaths.3 Many factors explain this finding, including social factors, but the incentive to hospitalization might be one of them.

Another obscure aspect of this system is its “internal protocols” that are far from the evidence-based medicine and hence improve requests for unnecessary exams, and become a justification for ICU hospitalizations. Believe it or not, there are cases of bacterial tonsillitis in the ICU diagnosed as “sepsis”, according to the mentioned protocols. In the elderlies, the diagnosis of “Sepsis due to urinary tract” has been established based even on unsuccessful urine exam (for instance, asymptomatic bacteriuria). By the way, the supposed technical dressing of a protocol for services in most of the cases admitted in an emergency service do not have scientific background. It would be better to make a reassessment protocol of cases admitted to the ICU. It would not be a surprise if the result of this reassessment showed that most of elderly hospitalizations are unnecessary.

Finally, we should remember that the ICU environment is not the most appropriate for performing complex clinical diagnoses and they are not by far the most pleasant for the elderly. This also deserves to be studied.

This instigates a more energetic and investigative attitude of the society protection organizations, especially from federal and regional medicine councils so that they may investigate similar situations.

 

Einstein Francisco Camargos
Editor-in-Chief of Geriatrics, Gerontology and Aging

 

REFERENCES

1. Guidet B, Leblanc G, Simon T, Woimant M, Quenot JP, Ganansia O, et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA. 2017.

2. Boumendil A, Angus DC, Guitonneau AL, Menn A.-M., Ginsburg C, Takun K, et al. Variability of intensive care admission decisions for the very elderly. PLoS One. 2012;7(4):e34387.

3. Marcucci FCI, Cabrera MAS, Rosenberg JP, Yates P. Tendências nos locais de óbito no Brasil e análise dos fatores associados em idosos de 2002 a 2013. Tendências nos locais de óbito no Brasil e análise dos fatores associados em idosos de 2002 a 2013. Geriatr Gerontol Aging. 2017;11(1):10-17.


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