COVID 19: prioritise autonomy, beneficence and conversations before score-based triage

Abstract

At the start of the COVID-19 pandemic, mounting demand overwhelmed critical care surge capacities, triggering implementation of triage protocols to determine ventilator allocation. Relying on triage scores to ration care, while relieving clinicians from making morally distressing decisions under high situational pressure, distracts clinicians from what is essentially deeply humanistic issues entrenched in this protracted public health crisis. Such an approach will become increasingly untenable as countries flatten their epidemic curves. Decisions regarding ICU admission are particularly challenging in older people, who are most likely to require critical care, but for whom benefits are most uncertain. Before applying score-based triage, physicians must first discern if older people will benefit from critical care (beneficence) and second, if he wants critical care (autonomy). When deliberating beneficence, physicians should steer away from solely using age-stratified survival probabilities from epidemiological data. Instead, decisions must be based on individualised risk-stratification that encompasses evidence-based predictors of adverse outcomes specific to older adults. Survival will also need to be weighed against burden of treatment, as well as longer-term functional deficits and quality-of-life. By identifying the robust older people who may benefit from critical care, clinicians should proceed to elicit his values and preferences that would determine the treatment most aligned with his best interest. During these dialogues, physicians must truthfully convey the emergent clinical reality, discern the older person’s therapeutic goals and discuss the feasibility of achieving them. Given that COVID-19 is here to stay, these conversations aimed at achieving goal-cordant care must become a new clinical norm.

Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study

“…Studies also found that patients with active advance directives were less likely to be admitted to the ICU (11,37,38). To give precedence to respect of a distributive justice principle, our participants reported to have downgraded principles of autonomy and beneficence (39,40). This is in line with larger quantitative studies which found that patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors (41).…”

“…The population understands some words, like "therapeutic obstinacy, " and in fact the idea is to use these words, but not everyone is really able to understand them." (Participant 4, age range [31][32][33][34][35][36][37][38][39][40] One participant added that the difficulty to address endof-life issues is also common among HCPs and not only family members: "Colleagues lack sensitivity on this. .…”

“…Think about how difficult this is to accept." (Participant 4, age range [31][32][33][34][35][36][37][38][39][40] Participants also reported that the absence of the family members, who could not be close to the patients in the hospital and frequently interact with the care team, accentuated this form of paternalism and prevented a shared decision making approach.…”

Safety Consequences of Off-Label Drugs Used for COVID-19

“…As healthcare professionals, we have underutilized structural advantages to counter the false equivalency of authority. Stated more plainly: Patients will be more likely to listen to us when we acknowledge their autonomy, even if we are the ones prescribing the medication [26]. Finally, it has been noted that pro-vaccination conversations tend to be monothematic.…”

Covid-19: a call for mobilizing geriatric expertise

“…At presentation, geriatricians can support triage of patients, through applying diagnostic skills in atypical presentation and management of multimorbidity and polypharmacy. Expertise in evidence-based, prognostication-informed, person-centred goals discussions can improve care and ensure resources such as ventilators are appropriately used without rationing [ 20 ]. Compassionate, evidence-based, clear communication and shared decision-making are vital, since both the Covid-19 infection and its associated treatment can have long-term adverse impacts on quality of life that may be incompatible with a patient’s goals.…”