Very old patients need palliative care,not intensive care - an empirical and normative analysis
Published in Mechanical Engineering and Philosophy & Religion
We found clear and consistent evidence – both quantitative and qualitative – that high chronological age is a key factor against ICU admission. Among all the variables we compared, only being 80 years or older clearly stood out as linked to not being admitted to intensive care.
Across every data source, high age kept reappearing as a justification for non-admission. In medical records, “considering age” was mentioned again and again. In the COVID Rounds, Moral Case Deliberations (structured reflections on ethically complex patient cases), and follow-up interviews, the phrase “very old” was used repeatedly when decisions were discussed.
Another powerful justification across all data was about not harming the patient. This included avoiding unworthy suffering, not subjecting patients to what was described as torture when ICU care offered no benefit and recognising ventilator treatment as risky. For patients over 80, ICU care was often described as unacceptable; at 90, death was seen as a natural event. One ICU consultant put it poignantly:
“Ninety feels like, if you’ve had a good life and you’re spry and healthy ... if you die suddenly, then it’s expected. And better than dragging to the ICU and tormenting the person.”
Interestingly, few justifications were directly linked to the pandemic. The patterns we found mirror those from pre-COVID studies, suggesting that what we captured ordinary clinical decision-making, not crisis-specific thinking.
Normative discussion
When discussing chronological age as a factor, our findings align with two key ethical principles: non-maleficence and justice.
Non-maleficence implies here sparing patients from unnecessary suffering and loss of dignity. Distributive justice connects with the ICU prioritisation literature, which tends to exclude patients “with a fuller lifecycle.” In intensive care, defining what counts as a need becomes crucial.
According to Swedish legislation, healthcare needs are defined by both the severity of a condition and the potential benefit of treatment. For very old patients, with higher ICU mortality and poorer recovery rates, the potential benefit is often limited. From this perspective, ICU care may not truly meet very old patients’ needs.
Following the legal principle of Need and Solidarity, treatment should only be prioritised when there is potential for benefit. Our results therefore suggest that many very old patients are better served by palliative rather than intensive care.
A call for courage and clarity
We believe it is time for a national – and perhaps international – guiding policy on triage systems for very old patients in everyday care. Such a policy should be developed with courage and transparency, openly supporting a palliative approach for the very old.
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BMC Medical Ethics
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