Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic

Abstract

The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider–patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity.Key pointsThe patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users’ viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted.Educational aimsTo explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic

Clinical Frailty Scale (CFS) Indicated Frailty is Associated with Increased In-Hospital and 30-Day Mortality in COVID-19 Patients: A Systematic Review and Meta-Analysis

“…The relatively high mortality and the required work intensity means a burden for the staff and relatives alike, and is, last but not least, costly [50,51]. Therefore, prolonged, advanced organ support can be regarded as medically futile in those cases, whose chances are extremely limited for survival [52,53]. Hence predictors of survival have been extensively researched.…”

Lessons Learned From the COVID-19 Pandemic as Experienced by Older Adults Treated for COVID-19

“…Several studies emphasised the importance of SDM in relation to COVID-19; however, the older adults in our study experienced little involvement in decision making ( Cardona et al., 2020 ; Köther et al, 2021 ; Paladino et al, 2021 ; Simpson et al, 2020 ). This study confirms that when older adults are in acute poor condition, it is difficult to participate in SDM ( Dyrstad et al, 2015 ; Ekdahl et al, 2010 , 2011 ; Gauthier, 2005 ).…”

Supporting decision-making on allocation of ICU beds and ventilators in pandemics

“…Patients who stand to benefit the most from ICU admission typically suffer from a critically severe, treatable and potentially reversible deterioration of health. ICU treatment should also be consistent with the values and preferences of the patient [13,74]. When patients’ are deteriorating despite ongoing ICU care, withdrawal of life-sustaining therapies, and transfer to ward and palliative care has to be considered.…”

“…Policies were based (exclusively or in combination) on subjective perceptions of benefits to patients and medical need, ethical considerations, and objective clinical scoring systems [12]. A common gap in these recommendations is the lack of integration of patient values and treatment preferences [13].…”