The Practice of Foregoing Life Support in the Critically Ill “Old Old”: A Singapore Perspective

Objective: To study the practice of foregoing life support (FLS) therapy between the young old and the old old. Patients and Methods: This is a retrospective case-control study of case records for FLS events and illness characteristics among young old patients (55 to 74 years) and old old patients (75 years and older) admitted in 1998 to the medical intensive care unit (MICU). Results: Fifty-seven out of 282 patients (20.2%) had FLS orders. There was no statistical difference in the use of FLS orders between the young old and the old old (17.1% versus 27.0%, P = 0.06), although there was a trend towards more frequent use in the old old. APACHE II(M) score (APACHE II score calculated without inclusion of points for age) and a high risk admitting diagnosis correctly predicted 80.5% of FLS events. A higher frequency of relatives of old old patients (20.8%) initiated FLS discussions compared to the young old (6%). In both groups, the child was the main surrogate decision-maker (n = 38, 66.7%). Medical futility/poor prognosis was the most common reason for FLS, accounting for 86.9% of patients. Withdrawing or withholding of mechanical ventilation was the most common mechanism (66.7%) of FLS. The majority (61.4%) died in the MICU after FLS. Of the 57 patients who had FLS orders, 1 young old and 3 old old survived till hospital discharge. Conclusion: Illness severity, as reflected by the APACHE II(M) score and the presence of a high-risk diagnosis, rather than age, predicted FLS orders.