Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

Abstract

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth—length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

Baseline Frailty as a Predictor of Survival After Critical Care

“…This is the notion that "patients with equivalent relevant features should be treated similarly for triage decisions." 47 When determining the first level of allocation of critical care resources, baseline frailty may be informative when considered alongside other patient factors with equivalent survival probabilities, such as severity of illness and comorbidity. [48][49][50][51] We could not access acute physiology measures that are used commonly as covariates in adjusted models for ICU survivorship 52 and ventilator triage policies.…”

Evaluation of a hypothetical decision-support tool for intensive care triage of patients with coronavirus disease 2019 (COVID-19)

“…While the use of clinical frailty in COVID-19 triage has been defended 10 , there are other factors that are relevant to decisions about the benefit and appropriateness of intensive care. Co-morbidity has been clearly linked to mortality in patients with COVID-19, and is a risk factor for length of stay in intensive care 26,27 .…”

“…CFS 5 or above) there was uncertainty about benefit 7 . A draft UK national pandemic allocation guideline, developed by the UK Moral and Ethical Advisory Group (MEAG) in conjunction with the Intensive Care Society in late March 2020, proposed a scoring system incorporating age, frailty and co-morbidities (Figure 1) 9,10 . This suggested benefit of intubation and ventilation for patients with a Decision Support Tool (DST) score of eight or below, while for patients with a DST of >8 it would be appropriate to limit treatment (potentially including continuous positive airway pressure (CPAP)/non-invasive ventilation).…”

“…low survival). This would then provide a basis for rationing treatment in the event of a critical shortage in the availability of intensive care 10 . Secondly, such scores might correlate with the decisions about the appropriateness of intensive care ordinarily made by ICU specialists.…”

David Oliver: What has the pandemic taught us about using frailty scales?

“…I think that the explicit use of a CFS cut-off was a well intentioned attempt to put some structure and transparent decisions around the rationing, or at least targeting, of critical care for the people with covid-19 who were most likely to benefit when services were likely to be overwhelmed. And since the early pandemic decisions, several systematic reviews and cohort studies have indeed shown close correlations between very high scores and a poor chance of survival or benefit 1112131415. Better, surely, an explicit than a covert or opaque decision making process, and one that evolves as empirical evidence emerges?…”