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

Abstract

Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty ( p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure ( p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.

Outcomes of COVID-19 Critically Ill Extremely Elderly Patients: Analysis of a Large, National, Observational Cohort

“…The allocation of ICU beds to elderly patients was not only costly and associated with poor outcomes, but would also possibly withhold valuable ICU resources from younger patients. Consequently, the problem of ICU beds allocation to elderly patients during the COVID-19 pandemic has been addressed heterogeneously by different health care systems [ 14 , 15 , 16 ], and this challenging age category was targeted by different public health measures [ 13 ].…”

“…To relieve the pressure on healthcare units, some stakeholders adopted different strategies for ventilator and ICU bed allocation based on age, comorbidities, or severity scores [ 14 , 15 , 16 ]. Some elderly patients chose not to be mechanically ventilated, through anticipated directives [ 17 ].…”

Terminal care in oldest old dying from COVID-19 in the acute hospital

“…High doses of morphine and midazolam were given starting from the point of view of comfort care in non-COVID-19 respiratory care, while, due to the double track followed, more uncertainty in patients and families existed resulting in more persisting symptoms and the need for higher dosage of oxygen and medication. Decisions not to escalate treatment in cases of respiratory failure was observed in two thirds of this cohort [10]. This prevalence is higher compared to non-COVID situations, possibly due to the fact that COVID-patients have a higher risk for ICU referral, with a longer stay and duration of mechanical ventilation and a higher risk for less successful rehabilitation.…”

“…This prevalence is higher compared to non-COVID situations, possibly due to the fact that COVID-patients have a higher risk for ICU referral, with a longer stay and duration of mechanical ventilation and a higher risk for less successful rehabilitation. The degree of decisions not to escalate treatment was associated with the degree of premorbid frailty [10]. Furthermore, patients with the highest CFS (8)(9) and therefore the poorest prognosis, are often not hospitalized but are taken care of at home or in residential care.…”

Communication in palliative care during the COVID-19 pandemic: Lessons from rapidly changing, uncertain, complex, and high-stake interventions

“…Finally, in this issue, Piers et al 17 describe early resuscitation orders in oldest-old patients who were hospitalized with COVID-19 in Belgium. Timely, honest, and compassionate conversations may help frail patients and their families to prepare for uncertain but possible adverse outcomes.…”