Intensive care admissions in older adults: are we moving from ageism to ableism?

PURPOSE: Across Europe, the proportion of older adults is increasing, raising complex questions regarding intensive care unit (ICU) admission decisions in late life. As chronological age is no longer recommended alone as an ICU admission criterion, functional independence and frailty have gradually helped refine medical assessment of older adults and guiding decisions. We aimed to study chronological age's influence in ICU admission decisions and if and how functional independence and frailty scales are currently used in France. METHODS: We conducted a qualitative study using semi-structured interviews of geriatricians, emergency physicians, and intensivists. Physicians' decision-making practices in critical situations were discussed. Data were analyzed using inductive thematic analysis within a constructivist and empirical ethics framework. RESULTS: We interviewed 15 geriatricians, 8 emergency physicians, and 9 intensivists. Chronological age continued to influence ICU admission decisions through references to life expectancy. Functional independence and frailty scales (ADL/IADL and CFS) were used to assess premorbid status, estimate prognosis, and facilitate interprofessional communication. However, scales sometimes functioned as decision-making shortcuts, reduced deliberation, and risked reinforcing self-fulfilling prophecies. Scores were also used to justify implicit value judgments, valuing functionally independent and fit patients and judging others to be less worthy of ICU admission. CONCLUSION: Chronological age continues to shape ICU admission decisions for older adults despite increasing reliance on functional independence and frailty scales. Though these provide structured decision-making support, their use may inadvertently embed normative assumptions about aging and functional independence. Greater reflexivity is needed to ensure patient-centered robust decision-making for older adults in critical care.