Timely goals of care documentation in patients with frailty in the COVID‐19 era: a retrospective multi‐site study

Abstract

Background: Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients.Aims: To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients.Methods: Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC. Results:The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93). Conclusion:Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.

Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID‐19 pneumonitis

“…Consequently, goals of care decisions for the frail and older patients are a significant risk factor for death and adverse outcomes, especially in the face of the current pandemic. 2,17,35 Our study found that frail patients with COVID-19, regardless of their treatment limitation status, were likely to die in hospital, had longer hospitalization and were less likely to be discharged home. A recent individual patient data meta-analysis found that triaging patients just based on their frailty status was not justified.…”

“…Consequently, goals of care decisions for the frail and older patients are a significant risk factor for death and adverse outcomes, especially in the face of the current pandemic. 2 , 17 , 35 …”

“…We demonstrated a clear trend that a higher prevalence of treatment limitations was associated with increasing frailty. Consequently, goals of care decisions for the frail and older patients are a significant risk factor for death and adverse outcomes, especially in the face of the current pandemic 2,17,35 …”

“…2 , 3 , 15 , 16 Despite that, a recent study identified that timely goals of care documentation occurred less frequently in patients with frailty during the COVID‐19 pandemic than in the pre‐COVID‐19 era. 17 …”

“…2,3,15,16 Despite that, a recent study identified that timely goals of care documentation occurred less frequently in patients with frailty during the COVID-19 pandemic than in the pre-COVID-19 era. 17 The geographic isolation and very strict public health measures ensured that the Australian and New Zealand healthcare system was not overwhelmed in 2020, 18 allowing improved access to ICU earlier for all patients. This was however not the case in 2021 when a higher volume of cases put significant strain on the healthcare system in parts of Australia.…”