COVID-19 and ‘conversations not had’ with people with frailty in acute settings

Abstract

COVID-19 and 'conversations not had' with people with frailty in acute settings COVID-19 has had a devastating impact on communities globally. In the United Kingdom and elsewhere, the pandemic has led to sharp increases in hospital admissions and deaths, with a disproportionate effect on older people with frailty. This surge of individuals experiencing rapid health decline and being 'sick enough to die' has put a spotlight on the need to ensure professionals in acute hospitals are supported to talk openly about end of life care with people with frailty and their families. Preparedness to engage in sensitive conversations about nearness to end of life with people with frailty and their families is essential during an acute admission to hospital. Older people living with frailty are, by definition, at greater risk of morbidity and mortality from infection with COVID-19. Timely and compassionate communication between professionals, people with frailty, and their families about goals and preferences for care, including end of life care, is an essential part of a person-centred approach. 1 When part of a process of advance care planning, these conversations can increase the likelihood of people receiving care that is in line with their preferences and improve bereaved relatives' satisfaction with end of life care. 2 Challenges faced by professionals in talking about serious illness and increasing risk of end of life with patients and families are well-documented. Difficulties around prognostication and identifying the 'best time' to discuss end of life care, fear of causing distress, and feelings of being inadequately skilled for these conversations, are commonly reported. 3 Perhaps as a result, a recent audit in the United Kingdom found that during unscheduled hospital admissions, fewer than 10% of people aged 80 and over had an advance care plan that was available to the admitting medical team. Even when people had a previous hospital admission within the last 30 days, availability of advance care plans was still only 15%. 4 This suggests that some of the people most at risk of morbidity and mortality from COVID-19 will likely enter the acute care setting with little documented evidence of their goals and preferences for life-sustaining treatments and end of life care, and those later discharged may rarely have these conversations recorded on route.

National and international non-therapeutic recommendations for adult palliative and end-of-life care in times of pandemics: A scoping review

“…The consensus of the synthesized literature is that GoC /ACP needs to be updated or created, especially for seriously ill people, to prevent triage discussions and to assign a specific contact person for each patient if possible. This is especially the case for patients who are older or suffer from advanced chronic diseases and patients that live in community and nursing homes/long-time care settings (Abbott et al, 2020; Adams, 2020; Alhalabi and Subbiah, 2020; Arya et al, 2020; Bajwah et al, 2020; Battisti et al, 2020; Bern-Klug and Beaulieu, 2020; Borasio et al, 2020; Brighton and Evans, 2020; Brown et al, 2020; Clarfield et al, 2020; Cooper and Bernacki, 2020; Desai et al, 2020; Estella, 2020; Fadul et al, 2020; Flint and Kotwal, 2020; Gillessen and Powles, 2020; GovScot and SPCPA, 2020; Hendin et al, 2020; Hopkins et al, 2020; Inzitari et al, 2020; Janssen et al, 2020; Kamal et al, 2020; Kent et al, 2020; Knights et al, 2020; Kotze and Roos, 2020; Kunz and Minder, 2020; Lawrie and Murphy, 2020; Michels and Heppner, 2020; Mohile et al, 2020; Moore, 2020; Moore et al, 2020; Mottiar et al, 2020; Münch et al, 2020; NHS, 2020; Núñez et al, 2020; Peate, 2020; Petriceks and Schwartz, 2020; Raftery et al, 2020; Rhee et al, 2020; Rosa et al, 2020; Selman et al, 2020; Sieber, 2020; Spicer et al, 2020; Szczerbińska, 2020; Task Force in Palliative Care (PalliCovidKerala), 2020; Ting et al, 2020; Wallace et al, 2020; Weinkove et al, 2020; WHO, 2020). If possible technical possibilities (e.g., telecommunication) can be used for GoC /ACP, to keep the risk of infection low for all involved (Mehta and Smith, 2020; Lopez et al, 2021).…”

“…patients who are older or suffer from advanced chronic diseases and patients that live community and nursing homes/long-time care settings (Abbott et al, 2020;Adams, 2020;Alhalabi and Subbiah, 2020;Arya et al, 2020;Bajwah et al, 2020;Battisti et al, 2020;Bern-Klug and Beaulieu, 2020;Borasio et al, 2020;Brighton and Evans, 2020;Clarfield et al, 2020;Cooper and Bernacki, 2020;Desai et al, 2020;Estella, 2020;Fadul et al, 2020; Flint and Kotwal, 2020; Gillessen and…”

Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study

“…8 Timely, honest and compassionate conversations may help frail patients and their families to prepare for uncertain but possible adverse outcome. 9,10 Acute hospitals are known to be places where advance care planning is often lacking. 11,12 However, there is evidence that a majority of patients who know they are at the end of their life want to avoid ICU 13,14 and that goals of care conversations during the COVID-19 pandemic are feasible even in acute care settings.…”

Development of a theory-based intervention to increase cognitively able frail elders’ engagement with advance care planning using the behaviour change wheel

“…However, their engagement with ACP is uncommon for multiple, complex reasons including lack of clarity around what ACP means, and lack of a terminal diagnosis [15][16][17][18]. This means priorities are often not discussed prior to significant deterioration [19], leading to crisis decision making which the person may not have capacity for [8,20], a concern that has been highlighted during the COVID-19 pandemic [21].…”