ESCALATE Version 1

• Research type

  Research Study

• Full title

  Escalation to intensive care for the older patient: an exploratory qualitative study of critical care patients aged over 65 years and their next of kin during the COVID-19 pandemic.

• IRAS ID

  285543

• Contact name

  David Antcliffe

• Contact email

  d.antcliffe@nhs.net

• Sponsor organisation

  Imperial College London

• Duration of Study in the UK

  1 years, 9 months, 1 days

• Research summary

  Research Summary

  TITLE Escalation to intensive care for the older patient: an exploratory qualitative study of critical care patients aged over 65 years and their next of kin during the COVID-19 pandemic.
  DESIGN Questionnaire, Semi-structured interviews analysed using thematic analysis
  AIMS To understand views on escalation to intensive care in older adults and their next of kin who have experienced an intensive care admission with COVID-19 respiratory failure
  OUTCOME MEASURES Not applicable
  POPULATION Adults aged 65 years or older admitted to intensive care in the UK with COVID-19 respiratory failure and their NoK
  ELIGIBILITY Inclusion criteria:
  Patients (where they are still alive) and/or NoK will be included in the study if:
  1. The patient was admitted to an intensive care unit with a primary confirmed or suspected diagnosis of COVID-19 respiratory failure
  2. The patient was aged 65 years or older at the time of admission to intensive care.
  3. The interval between ICU admission and invitation to interview will be between 2 and 24 months

  Exclusion criteria:
  Participants will be excluded if any of the following apply:
  Unable to give consent.
  Unable to attend the interview.
  Unable to participate in an interview in English
  If their age is less than 18 years.

  DURATION 24 months

  Research results
  Escalation to intensive care for the older patient. An exploratory qualitative study of patients aged over 65 years and their next of kin during the COVID-19 pandemic: the ESCALATE study.

  This qualitative research study was carried out by a team of clinical (medical and nursing) researchers with intensive care, internal medicine and cancer backgrounds at Imperial College Healthcare NHS Trust, under the sponsorship of Imperial College London.

  Patient and public involvement and engagement was sought from the charity ICUSteps during the study design and drafting of research materials, which enabled us to include perspectives from patients who have experienced an intensive care admission.

  Background
  Older people comprise the majority of hospital medical inpatients so decision-making regarding their admission to the intensive care unit (ICU) is important. ICU is perceived as traumatic for patients and loved ones, and long-term impact on quality of life can be considered unacceptable, meaning that there can be bias against admitting older people to ICU. The COVID-19 pandemic highlighted the challenge of selecting those who could most benefit from ICU.

  Objective
  This qualitative study aimed to explore the views and recollections of escalation to ICU from older patients and Next of Kin (NoK) who experienced a COVID-19 ICU admission.

  Setting
  The main site was a large NHS Trust in London, which experienced a high burden of COVID-19 cases.

  Subjects
  30 patients, NoK of survivors and NoK of deceased patients were recruited.

  Methods
  Semi-structured interviews were conducted and thematic analysis performed using a framework approach.

  Results
  There were five major themes: Inevitability (a sense that the illness and its management are out of the control of the patient or their loved ones), Disconnect (differences between hospital and lay person narratives and the challenge of bridges to that gap), Acceptance (accepting the consequences, good or bad, of an intensive care admission as unalterable), Implications for future decision making and Unique impact of the COVID-19 pandemic. Life was highly valued and ICU perceived by participants to be the only course of action. Prior understanding of ICU and explanations around the time of admission decision-making were limited. Despite the benefit of hindsight, having experienced an ICU admission and its sequelae, most could not conceptualise thresholds for future acceptable treatment outcomes.

  Conclusions
  • Despite traumatic experiences during and following ICU admission, this cohort of older patients ≥ 65 years and NoK focussed on survival from acute illness.
  • Patients and NoK struggle to conceptualise thresholds for future acceptable treatment outcomes despite benefit of hindsight, having experienced an ICU admission and its sequelae.
  • There is limited public understanding of what an ICU admission involves, emphasising the importance of engaging with patients and NoK around the time admission to the ICU is being considered.
  • Bereaved NoK are willing to engage in qualitative research and can bring valuable perspectives.

  Next steps
  The results of this study have been published in peer-reviewed journals as a research article in Age and Ageing and a letter in BMJ Supportive and Palliative Care. They have also been presented at the Intensive Care Society and British Geriatric Society conferences.

  All participants who had expressed an interest in hearing the results of the study were sent a copy of the report and a lay summary.

  This research has informed a new programme of PhD research looking at decision-making around treatment escalation planning for older adults in the acute hospital setting.

  We wish to thank all of the patients and loved ones who gave their time to share their experience.

• REC name

  London - Surrey Research Ethics Committee

• REC reference

  20/PR/0779

• Date of REC Opinion

  12 Jan 2021

• REC opinion

  Further Information Favourable Opinion