Breathing Tubes Fail to Save Many Older Patients

Republished from: https://www.nytimes.com/2018/06/22/health/breathing-tubes-intubation-older-patients.html

One-third of patients over age 65 die in the hospital after they are put on ventilators. Doctors are beginning to wonder if the procedure should be used so often.

By Paula Span
June 22, 2018

Earlier this year, an ambulance brought a man in his 80s to the emergency room at Brigham and Women’s Hospital in Boston. He had metastatic lung cancer; his family had arranged for hospice care at home.

But when he grew less alert and began struggling to breathe, his son tearfully called 911. 

“As soon as I met them, his son said, ‘Put him on a breathing machine,’” recalled Dr. Kei Ouchi, an emergency physician and researcher at the hospital.

Hospice patients know that they’re close to death; they and their families have also been instructed that most distressing symptoms, like shortness of breath, can be eased at home.

But the son kept insisting, “Why can’t you put him on a breathing machine?”

Dr. Ouchi, lead author of a new study of how older people fare after emergency room intubation, knew this would be no simple decision.

“I went into emergency medicine thinking I’d be saving lives. I used to be very satisfied putting patients on a ventilator,” he told me in an interview.

But he began to realize that while intubation is indeed lifesaving, most older patients came to the E.R. with serious illnesses. “They sometimes have values and preferences beyond just prolonging their lives,” he said.

Often, he’d see the same people he’d intubated days later, still in the hospital, very ill, even unresponsive. “Many times, a daughter would say, ‘She would never have wanted this.’”

Like all emergency doctors, he’d been trained to perform the procedure — sedating the patient, putting a plastic tube down his throat and then attaching him to a ventilator that would breathe for him. 

But, he said, “I was never trained to talk to patients or their families about what this means.”

His study, published in the Journal of the American Geriatrics Society, reveals more about that.

Analyzing 35,000 intubations of adults over age 65, data gathered from 262 hospitals between 2008 and 2015, Dr. Ouchi and his colleagues found that a third of those patients die in the hospital despite intubation (also called “mechanical ventilation”).

Of potentially greater importance to elderly patients — who so often declare they’d rather die than spend their lives in nursing homes — are the discharge statistics.

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.

All intubated patients proceed to intensive care, most remaining sedated because intubation is uncomfortable. If they were conscious, patients might try to pull out the tubes or the I.V.’s delivering nutrition and medications. They cannot speak.

Intubation “is not a walk in the park,” Dr. Ouchi said. “This is a significant event for older adults. It can really change your life, if you survive.”

A study at Yale University in 2015 following older adults before and after an I.C.U. stay (average age: 83) confirmed what many geriatricians already understood. Depending on how disabled patients are before a critical illness, they’re likely to see a decline in their function afterward, or to die within a year.

Those who underwent intubation had more than twice the mortality risk of other I.C.U. patients. “You don’t get better, most of the time,” said Dr. Ouchi. While outcomes remain hard to predict, “a lot of times, you get worse.”

Intubation rates are projected to increase. But so has the use of alternatives known as “noninvasive ventilation” — primarily the bipap device, short for bi-level positive airway pressure.

A tightfitting 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.

“There are cases where noninvasive ventilation is comparable or even superior to mechanical ventilation,” said Dr. Douglas White, a critical care physician and ethicist at the University of Pittsburgh School of Medicine.

Dr. Ouchi, for instance, explained to his patient’s distraught son that intubation would thwart his father’s desire to remain communicative. The patient, able to see though not to say much, died four days later in a hospital room with bipap and morphine to reduce his “air hunger.”

Most patients in the Mayo review died within a year, too. But bipap may provide an interim option, giving families and physicians time to decide together whether to intubate an ailing older patient, who at this point probably can’t direct his own care. 

The harried emergency room environment, after all, hardly encourages thoughtful discussions about patients’ prognoses and wishes. Those can become fraught conversations anyway, as Dr. White’s previous research has demonstrated.  

His 2016 study showed that when physicians and surrogate decision makers have very different expectations about a critically ill patient’s odds of recovery, it’s not merely because family members fail to grasp what the physician explained.

“Other things get in the way of making good decisions,” Dr. White pointed out. “A lot of this has to do with psychological and emotional factors” — like “optimism bias” (Most people with this condition will die, but not my mom) or “performative optimism” (If we maintain hope, our mom will get better).

In their most recent study, he and his colleagues experimented with a support program for families with relatives in I.C.U.s., nearly all intubated. 

When a specially-trained nurse checked in daily to explain developments and answer questions, families rated their communications more highly and felt more satisfied with their loved ones’ care.

The University of Pittsburgh Medical Center’s health system has begun adopting the program in its 40 I.C.U.s.

But discussing how aggressively an older person wants to be treated remains a conversation — probably a series of them — best held before a crisis. 

Intubation, for instance, is often something a physician can foresee.  Older patients who have cardio-respiratory conditions (emphysema, lung cancer, heart failure), or who are prone to pneumonia, or who have entered the later stages of Alzheimer's or Parkinson's disease — any of them may be nearing this crossroads.

When they do, Dr. Michael Wilson, a critical care physician at the Mayo Clinic, opts for a particularly humane approach.

As he recently described in JAMA Internal Medicine, before he inserts the tube, he explains to the patient and family that while he and the staff will do everything they can, people in this circumstance may die.

“You may later wake up and do fine,” he tells his patient. “Or this may be the last time to communicate with your family,” because intubated patients can’t talk.

Since setting up intubation generally takes a few minutes, he encourages people to spend them sharing words of comfort, reassurance and affection. Without that pause, “I have stolen the last words from patients,” he told me.

His editorial has drawn attention from critical care physicians around the world. 

Dr. Wilson has used this approach about 50 times in his I.C.U., so he has learned what patients and families, given this opportunity, tell one another.

“It’s nearly always, ‘I love you,’” he said. “‘I hope you do well.’”

How to Talk About Moving to a Retirement Home: ‘It’s a Journey’

Reprinted from: https://www.nytimes.com/2018/04/27/business/retirement-home-move-talk.html

Having a conversation about moving — whether it’s with a relative, even a spouse — brings up lots of anxiety. Here’s how to go about it.

By Peter Finch
April 27, 2018

Dawn and John Strumsky agree about most things, a tendency that has served them well in 45 years of marriage. But there was one subject where they did not see eye to eye for the longest time: their retirement future.

Ms. Strumsky wanted desperately to move into a retirement community, to live as “a princess” unburdened by the cooking, cleaning or yardwork required at their Maryland home. Mr. Strumsky didn’t just resist the idea, he detested it. During one argument with his wife, he shouted, “By God, I’ll sit in the burned-out, firebombed ruins of this home before anybody pulls me out!”

Mr. Strumsky, 78, tells that story with a laugh. Because, as he puts it, “I’ve done a 180 on this.” He finally gave in to his wife’s wishes, and in 2011 they moved to Charlestown, a retirement community outside Baltimore. Today, it might have no bigger fan than John Strumsky. One measure of his devotion: He’s the author of an exhaustive, 364-page history of Charlestown that management hands out to prospective residents.

His reluctance to move into a retirement community was not unusual. People often vow they’ll never do it, for any number of reasons. They fear giving up their independence. They can’t bear leaving their home. They don’t like confronting their own mortality. This can lead to bitter squabbles with members of their family and other loved ones who want them to move.

“I’ve heard more than one adult child say, half-jokingly, ‘If Mom doesn’t check in to a retirement home, I’m going to need to,’” said Katherine Pearson, a specialist in elder law and a professor at Pennsylvania State University’s Dickinson Law School.

So how do you persuade an unwilling senior to at least consider it? The key is to be patient, said Tom Neubauer, executive vice president at Erickson Living, which operates 19 retirement communities. “Inherently there’s a sense of denial, particularly as it relates to aging, and you’re trying to defeat that.”

He likened the process to helping a high school student choose a college: “You can’t just hand them a brochure and say, ‘This is where you’re going.’ It’s a journey.”

Mr. Neubauer’s mother, Betty, moved into a retirement home three years ago. He had started encouraging her about three years before that. The discussion, he said, was less about “You need to do this” and more about “How do we maximize your years in retirement?”

He focused on “really getting her to reflect on her life as she knew it,” he said. “I got her to recognize that the stairs in her house were pretty steep, that the weather had more of an impact on her ability to get out and do things, that she wasn’t pursuing all her hobbies as much anymore because people weren’t driving at night. It ended up being very easy.”

It’s best to start the retirement-home conversation with broad, open-ended questions, said Brad Breeding, founder of myLifeSite.net, a website that helps consumers research retirement communities. “What does peace of mind mean to you in this stage of your life?” he suggested. “What kinds of concerns do you have for your future?”

Let’s say a senior’s No. 1 goal is staying in her home. “O.K., in the next conversation I’ll start to talk about ‘What would we do if you had a fall in your home?’ Or ‘What would happen if you had a stroke?’” Mr. Breeding said.

One way to make retirement communities more attractive is to frame the move as a gift to their children. “It’s really removing the responsibility of caring for the parents, of not having to make frantic, last-minute arrangements if something changes in their health,” said Lesley Sargent, a residency counselor at the Sagewood retirement community in Phoenix.

Part of the problem is that many people hear “retirement community” and think “nursing home.” Today’s typical continuing care retirement community, or C.C.R.C., is a far cry from the sterile nursing-home environment of previous generations. While the communities usually have some hospital-like rooms for people who need more advanced care, most of their residences look and feel like ordinary apartments.

The best way around that objection is to let someone see firsthand. “You can always go for a meal just to experience what it’s like,” said Lindsay Hutter, chief strategy and marketing officer at Goodwin House, a senior living and care organization in Virginia.

The ideal approach: Create a social occasion where the senior you’re trying to convince can dine with friends, or friends of friends. With seniors, Ms. Hutter said, “our observation is that peers have a much greater influence than their children do.”

Some retirement communities let potential residents spend a few nights to see how they like it. Others offer rental programs that let seniors stay longer. Like a lot of C.C.R.C.s, Goodwin House will let nonresidents join a waiting list — known as its “priority club” — that allows them to use its restaurants and participate in activities. If they decide the community is not for them, the $1,000 waiting list fee is refundable.

Another common objection is the price. Indeed, C.C.R.C.s are expensive, with entrance fees generally equaling about what people would pay for a home in the local market. Sometimes these fees are partly or fully refundable if the resident decides to move out, though often they are not. On top of that, there is a monthly maintenance payment.

When Mickie Zatulove started urging her husband, Paul, to consider retirement communities a few years ago, he argued that they were “way overpriced.” He was “totally wrong about that,” Mr. Zatulove acknowledged recently from their apartment at Sagewood.

What Mr. Zatulove, an 86-year-old former investment adviser, failed to take into account: “Half the cost is the physical plant they provide,” he said. “The dining rooms, swimming pools, classrooms, fitness centers, beauty shops, spas, clinics, all within walking distance, with no stairs. And this is very important. Your purpose as you age is to keep your quality of life and participate in activities with companions in a safe environment.”

Remember, too, that maintaining a single-family house isn’t exactly cheap. Expenses like routine upkeep, security and yardwork will disappear once you move into a retirement community, said Frederick Herb, a Seattle retiree and author of the book “Holistic Living in Life Plan Communities.”

Still, the thought of leaving the family home is the biggest stumbling block for many retirees. This is partly because they have grown accustomed to their house and also because they are rattled by the thought of moving into someplace smaller.

A specialist in senior moving might be the answer to that problem. A cottage industry of these consultants has sprung up in recent years, and today the National Association of Senior Move Managers has more than 1,000 members. They don’t just move boxes. They’ll create digital floor plans to show clients how everything will look and fit in a smaller home. They’ll ship leftover items to relatives or to auctions. They’ll even come into the new home and hang photos just the way they were before.

“Our goal is to re-create their old space,” said Joel Danick, co-owner with his wife, Susie, of TAD Relocation in Maryland. “The more familiar we can make the new space, the quicker they’ll make the transition and get comfortable.”

What’s the secret to finding that comfort zone? People living in retirement communities agree that the best approach is to get out of your room, meet your new neighbors and allow yourself to enjoy their company.

For the once-skeptical Mr. Strumsky, it took only days for him to start feeling certain that he and his wife, who is 72, had made the right decision. About a week after moving in at Charlestown, he went out to walk the dog at night and ran into a pair of women he didn’t know who were chatting amiably in the parking lot. About 25 minutes later, he returned home and saw the same women, still talking.

“They were so unconcerned about their personal safety, they were oblivious to anything going on around them,” Mr. Strumsky said. “And it just hit me: I really wished my mother or my sister or my aunt could have had this experience, to feel that safe and secure. At that point, it was like a light bulb going on. It was an instant turnaround for me.”