Intensive care of the very old – questioning the relationship between illness severity and the moral imperative to deliver life-saving care

TL;DR

This paper examines the ethical and practical challenges of providing intensive care to very old patients, questioning if current practices are based on sound medical and moral reasoning.

Contribution

The paper introduces a philosophical framework to analyze how aging and dying are medicalized, influencing decisions in intensive care for the elderly.

Findings

Age is increasingly classified as a disease, driving the moral imperative to provide life-saving care despite questionable benefits.

Medicalization of aging leads to increased decisional uncertainty in intensive care for very old patients.

A broader approach combining philosophy and social theory is needed to guide care for elderly critical illness.

Abstract

Intensive care provision to very old patients is rapidly growing owing to demographic changes and increasing treatment intensity. However, intensive care carries only questionable benefit for the oldest patients, and many of them die after prolonged organ support. Departing from a clinical perspective, this study aims to explore the drivers for the expansion of critical care in advanced age, despite widespread awareness of its potential harms to patients, their families, healthcare professionals, and society.

Theoretical study into the possible consequences of the medicalization of ageing and dying on intensive care provision for very old patients, applying Ian Hacking’s concepts of human, interactive and natural, indifferent kinds as a philosophical framework.

The physiological consequences of ageing are a risk factor for falling critically ill, and for dying from critical illness, while age itself is not regarded as a disease, despite having recently been classified as such. Understanding old age as a human, interactive kind explains the medicalization of ageing and dying as a self-perpetuating process. Defining the natural processes of ageing and dying as disease results in a morally strong call for clinical efforts to provide life-saving care to very old patients despite its questionable overall benefit. As a consequence, adhering to this narrow, medically defined relationship between illness severity and treatment intensity results in vastly increased decisional uncertainty in advanced age compared to younger patient populations in intensive care units.

Delivering the right level of care to very old patients with critical illness requires a more comprehensive clinical approach with philosophical concepts and social theories complementing medical scientific knowledge.

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