To the Editor: Recent articles in the Journal by Kurrle1 and Finn and colleagues2 referred to advance care directives aiding the management of acute illness in elderly residents of aged care facilities. It is our experience that these directives are often unhelpful in elderly patients and, outside certain progressive medical conditions, can result in triage of elderly patients to inappropriate lower levels of care.

In chronic medical conditions where the clinical course allows time for patient or family understanding, and the course of organ failure is predictable, then certain supportive but ultimately futile therapies can be avoided by instituting an advance care directive that specifically excludes them. However, these directives are less helpful in acute illnesses. They usually refer to “intensive care”, and “life support”, sometimes specified as mechanical ventilation, dialysis or cardiopulmonary resuscitation. These “general” advance care directives fail, as they assume that prognosis is immediately apparent, and that treatment is “all or nothing”, both of which assumptions are clearly untrue.

Determining an accurate prognosis for recovery from a critical illness is difficult and takes time. It involves diagnosing the cause of the illness, quantifying the severity of comorbidities and, most importantly, assessing response to initial treatment. Whether severe sepsis is arising from the urinary tract or abdominal cavity may not be apparent initially. Many elderly patients survive severe septic shock caused by urosepsis with haemodynamic monitoring and short-term high-dose vasopressors. It is also not possible to distinguish which patients with severe respiratory failure will respond to non-invasive ventilation.

We followed up critical care patients aged 75 years and over who survived to hospital discharge over a 12-month period and confirmed that acceptance of critical care admission in elderly people is high (unpublished study; details available from the authors). This is the very population that, in our experience, frequently says they do not want to be placed on “life support”, if asked when well. Together with the fact that an accurate prognosis takes time, then a prudent approach should begin with the presumption of aggressive treatment for acutely unwell elderly patients, rather than a presumption of limited therapy or palliation.

Advance care directives that refer to therapies need to be specific and to recognise that critical care therapy can be graduated and readily terminated once a more accurate prognosis is known. Furthermore, some critical care therapies, such as non-invasive ventilation and high-concentration oxygen, can significantly improve patient comfort while management plans are formulated. In our experience, patients and their families are often very surprised when they understand the full implications of an advance care directive that refers to generic therapies, such as cardiopulmonary resuscitation and “intensive care”.