Age, Frailty, Resuscitation and Intensive Care: With Reference to COVID-19

Abstract

Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who decides and how? This paper discusses the issues, biases, and potential harms involved in decision-making. The basis of decision making requires fairness in the distribution of resources/healthcare (distributive justice), yet much of the printed guidance has taken a utilitarian approach (getting the most from the resource provided). The challenge is to provide a balance between justice for the individual and population justice.

Age and Comorbidity Burden of Patients Critically Ill with COVID-19 Affect Both Access to and Outcome of Ventilation Therapy in Intensive Care Units

“…With the increasing invasiveness of a treatment, the probability of undesirable side effects rises, which may negatively affect the outcome. It is known that advanced age elevates the risk of such side effects [ 10 ]. Therefore, the harm–benefit balance of invasive ventilation strategies becomes rather critical with age.…”

“…There is an ongoing debate that the poor outcomes among senior adults may be the consequence of a high prevalence of comorbidities, a weak immune system, and a greater degree of frailty in this population [ 4 , 5 , 7 , 8 ]. An in-depth review of published data indicates that biological age, rather than chronological age, may play a role in COVID-19 prognosis [ 7 , 9 , 10 , 11 ]. The constriction of physiological reserves combined with an impaired ability to properly respond to acute challenges may translate into an increased susceptibility to stressors, such as a viral infection [ 5 , 6 , 12 ].…”

“…This may have had a particular impact on elderly and comorbid patients. Reports indicate that medical staff awareness of a patient’s advanced age and frailty may result in a curtailment of intensive care measures [ 2 , 6 , 10 ]. By implication, such special handling of a certain group of patients will affect the treatment outcome.…”

Device-based measurement of physical activity in cardiovascular healthcare: possibilities and challenges

“…Clinicians’ inferences about patients’ activity affect critical treatment decisions. Subjectively rated ‘frailty’ influences whether a patient is offered surgery, ventilated for pneumonia or resuscitated after cardiac arrest 5. Patients with heart failure are classified by the 4-point New York Heart Association (NYHA) score (I=no limitation of activity, IV=limitation even at rest).…”

Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis

“…Frailty assessment tools, such as the Clinical Frailty Scale (CFS), have been proposed as an adjunct to age-based criteria for critical care triage decisions (The National Institute for Health and Care Excellence, NICE triage guidelines) [ 15 ]. This guideline suggested that patients older than 65 years with a CFS score ≥ 5 might not benefit from ICU admission [ 10 , 12 , 16 ] and such patients were encouraged to establish goals of care documentation [ 9 , 12 , 13 , 17 ]. Despite this, frail patients with COVID-19 were admitted to ICU and had greater mortality but spent relatively fewer days in ICU compared with non-frail patients [ 18 ].…”