ESICM Consensus: Management and Challenges of Very Old Patients in Critical Care

Academic Background

With the global aging population, the proportion of “very old patients” (aged 80 years and above) in intensive care units (ICUs) is rapidly increasing. This group is characterized by functional impairments and a high prevalence of complex multimorbidity, with significant biological and functional heterogeneity among individuals. These factors pose major challenges to traditional evidence-based medicine approaches in guiding clinical practice. Existing clinical studies often exclude very old patients, leading to a scarcity of high-quality evidence for this population and considerable uncertainty in medical decision-making. Therefore, the European Society of Intensive Care Medicine (ESICM) initiated a Delphi study to provide guidance through expert consensus on the management of very old critically ill patients.

Source of the Paper

This paper was co-authored by an international team of experts, including Michael Beil (NHS Highland, UK), Laura Alberto (Conicet, Argentina), Richard S. Bourne (Sheffield Teaching Hospitals NHS Foundation Trust, UK), and others. It was published in the journal Intensive Care Med in 2025, with the DOI 10.1007/s00134-025-07794-4.

Research Process

The study employed the Delphi method, collecting expert opinions through multiple rounds of questionnaires to reach a consensus. Below are the main steps of the research:

1. Study Design and Expert Recruitment

The study was initiated by ESICM’s Health Services Research and Outcome (HSRO) section, inviting experts from intensive care, emergency, and geriatric medicine fields to participate. Ultimately, the research team consisted of 28 experts, with an additional 82 experts completing two rounds of the Delphi survey.

2. Literature Review

In August 2023, the research team conducted a PubMed search for clinical trials related to very old critically ill patients and found a lack of high-quality studies targeting this group. As a result, they decided to explore expert empirical knowledge using the Delphi method.

3. Delphi Survey

• First Round: Launched in December 2023, it included 48 statements and 2 checklists. Experts rated each statement using a 9-point Likert scale (1 indicating “strongly disagree” and 9 indicating “strongly agree”).
  
• Second Round: Launched in March 2024, adjustments were made based on the results of the first round. Experts were shown the statistical results of the first round before voting and had the opportunity to provide feedback on the wording of the statements.

4. Definition of Consensus

Consensus was categorized as “strong consensus” (≥90% agreement or disagreement among experts) or “moderate consensus” (80%-90% agreement or disagreement). Ultimately, the research team issued recommendations for the 48 statements and 2 checklists that reached consensus.

Key Results

The study covered various aspects of managing very old critically ill patients, including fundamental principles, ICU admission decisions, in-ICU management, post-ICU transfer management, and infrastructure and service development. Below are some key findings:

1. Fundamental Principles

• Age should not be the sole criterion for ICU admission: 92.4% of experts agreed with this point.
  
• Patient preferences should be incorporated into decision-making: 97.3% of experts believed that patient attitudes toward functionality, quality of life, and life-sustaining treatment should be prioritized.
  
• Importance of geriatric characteristics: 97.3% of experts considered frailty, chronic multimorbidity, and pre-existing functional impairments as critical factors affecting critical care management.

2. ICU Admission Decisions

• Treatment escalation plans: 95.4% of experts believed that treatment escalation plans should be clarified upon admission.
  
• Time-limited trials: For patients with uncertain prognoses, 95.5% of experts supported conducting time-limited trials after obtaining consent from patients or their families.

3. In-ICU Management

• Delirium management: 95.4% of experts supported developing guidelines for the prevention, detection, and management of delirium.
  
• Early mobilization: 96.8% of experts believed that early rehabilitation programs should be initiated within the ICU.

4. Post-ICU Transfer Management

• Medication review: 92.1% of experts believed that medication reviews should be conducted before or shortly after ICU transfer.
  
• Rehabilitation plans: 93.6% of experts supported developing rehabilitation plans at the time of ICU discharge.

Conclusions and Implications

Through expert consensus, the study provided comprehensive guidance for managing very old critically ill patients, covering the entire process from ICU admission to post-discharge management. These recommendations emphasize the importance of personalized treatment and advocate for gradual implementation in contexts with limited healthcare resources. The scientific value of the study lies in addressing the research gap in managing very old critically ill patients, while its practical value lies in offering actionable guidance for clinical practice.

Highlights of the Study

1. Multidisciplinary Collaboration: The study integrated expert opinions from intensive care, emergency, and geriatric medicine fields, ensuring the comprehensiveness and practicality of the recommendations.
   
2. Holistic Management: From ICU admission to post-discharge management, the study provides guidance covering the entire patient journey.
   
3. Personalized Treatment: The study emphasizes tailoring treatment plans based on individual patient characteristics and preferences, reflecting a patient-centered approach.

Other Valuable Information

The study also proposed future research priorities, including exploring the pathophysiological mechanisms of critical care management in very old patients, challenges in decision-making, and optimal models for multidisciplinary collaboration. These research directions will provide a scientific basis for further optimizing the management of very old critically ill patients.

Through this study, ESICM has established new standards for managing very old critically ill patients, offering important references for global medical practice.