key: cord-0777112-fn49j0e2
authors: Colenda, Christopher C; Reynolds, Charles F; Applegate, William B; Sloane, Philip D; Zimmerman, Sheryl; Newman, Anne B; Meeks, Suzanne; Ouslander, Joseph G
title: COVID-19 Pandemic and Ageism: A Call for Humanitarian Care
date: 2020-07-14
journal: J Gerontol A Biol Sci Med Sci
DOI: 10.1093/gerona/glaa140
sha: 82040b47f1d8058131208cd770dd43e02c7d88ae
doc_id: 777112
cord_uid: fn49j0e2

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The severe acute respiratory syndrome coronavirus 2 is a deadly threat, and although all individ-uals are susceptible, advanced age is one of the risk factors for its direst consequences in those who are infected. There are precious few times when individ-uals can come together to make clear a common cause for advocacy and health. We, the consortium of the editors of the nation's major geriatric and ger-ontology journals, offer this perspective as a way to raise awareness about ageism in association with the coronavirus disease 2019 (COVID-19) pandemic, and to acknowledge the extraordinary work that healthcare providers across all disciplines, including geriatrics, are doing at the frontlines of care. We also offer these thoughts as advocates for older patients, their families, their providers, and the broader community.

COVID-19 transited the world with staggering speed, which speaks to the fact that the world is bor-derless when it comes to a virulent 50−200 nanometer mRNA virus. Initially, our nation's response to the pandemic was slow and poorly coordinated. Political and personal interests superseded evidence-based public health practices. Fortunately, steady and con-sistent efforts by teams of scientists and public health officials, and the visible impact of the illness in com-munities, have changed the narrative and nationwide response. To be sure, significant challenges with our healthcare and public health systems remain, and include supplychain shortages, insufficient hospital bed capacity, poor public engagement with preven-tive measures, and lengthy treatment and vaccine development.

We have been struck, however, by the emergence of an ageist bias towards older adults as part of the response and public discourse (1). For example, our col-league, Dr. Louise Aronson, in a sobering commen-tary in The Atlantic (2) wrote about ageism making the pandemic worse, pointed out how differently we might be acting if COVID-19 put young people, as opposed to older people, at more risk. She pointed out ageist comments such as COVID-19 being "Boomer removers" and perceptions about older adults as being irresponsible, and contrasted these observations with the more empathic actions taken by responsible businesses such as grocery stores that offered reserved hours for older customers. Her most challenging reflection, however, was her medical cen-ter's initial lack of developing specific prevention and management protocols for older adults.

We recognize the emerging thorny ethical and moral challenges that our frontline colleagues are beginning to face. One example is the need to decide who should or should not receive ventilator support when ventilators are in short supply. If medical resources were unlimited, the decisions of where, when and to whom they should be deployed is quite simple-everyone gets what is needed. COVID-19 has revealed significant inadequacies in the nation's supply of ventilators necessary for respiratory sup-port for patients in extreme respiratory distress. How, then, should decisions be made as to who should or should not be afforded access to them? Is the battlefield triage analogy applicable-meaning categoriz-ing patients as healthy enough to survive without a ventilator; likely to die even with a respirator; high likely of survival if a ventilator is used? If this strategy is employed, an unavoidable question is the extent to which age of the patient should be considered in the decision. Such issues have already arisen in Italy, and all to easily age was advanced as the criterion for decision making rather than developing more nuanced approaches, as proposed by White and Lo (3) .

The need to make such decisions, should it arise, will create not only ethical conundrums, but also con-ditions for moral injury for providers who may already be experiencing burn-out and perhaps loss of their own family members (4, 5) . Fortunately, many prognostic models in medicine demonstrate that age is but one of many factors in triage decisions such as this. Still, front line clinicians and families will face numerous care decisions that require multiple proba-bilistic judgments where guidelines may not be clear. These situations require the valued participation of interprofessional teams, in collaboration with the patient (if capable) and families, in order to bring about better decisions-tough though they may be. Experts in geriatric medicine and healthcare bring a critical informed voice to this decision-making.

Society's diminished valuation of individuals as they age is a continuing thread within ageism. Tack-ling ageism in this pandemic requires evidence that contravenes these preconceived notions, and we offer two examples as evidence-the value of wisdom and personal resilience. First, leaders who are older are often deemed wise. A most notable example is the scientific leadership coordinating the nation's response to COVID-19. These leaders are in their 60's and the most respected voice-coming from Dr. Anthony Fauci of the National Institutes of Allergy and Immunology, is 79 years of age.

During this national crisis the value of intergenera-tional wisdom should also not be discounted. For example, grandparents may have critical roles in nur-turing and helping their grandchildren understand the many personal sacrifices that are being made to fight COVID-19. Conversely shared wisdom may encourage younger family members, because of their technology nativism, to assist older family members reduce social isolation through video streaming and help them inter-pret what they are viewing or reading. Intergenerational engagement is known to reduce ageism and bias.

Resilience, the successful adaptation to adversity and to recover from crises with a sustained sense of purpose, has been an increasing focus of successful aging. Ageism is the implicit bias that older adults are less resilient and less capable to adapt to challenging events such as COVID-19. Older adults have shown remarkable agency in this crisis as witnessed by their willingness to engage in positive public health practi-ces such as social isolation, shelter at home and basic hand washing. Older adults have engaged in mean-ingful social connection through email, social media, and other forms of electronic communication. And older retired healthcare workers have demonstrated great moral purpose by volunteering their skills to help frontline healthcare providers treat those afflicted with COVID-19.

Last, we recognize that COVID-19 will require sus-tained efforts over an uncertain time frame. Specifi-cally, we urge greater attention to four goals: (1) make clinical research more inclusive of all ages, such as emergent use of experimental therapies and diag-nostic tools; (2) engage geriatricians and gerontolo-gists in institutional decisions regarding care, including rationing; (3) inform policy and funding with cognizance of the needs of vulnerable popula-tions (e.g., personal protective equipment for home care workers and better infection control in long term care facilities; and (4) emphasize the importance of personalized approaches to older adults that enact respect for autonomy, justice and beneficence.

In appreciation for the contributions that older adults make to society, we as editors of the nation's leading journals in geriatrics and gerontology believe that drawing upon the experience and resources across the life span will build resilience against despair. Our obligations are to steadfastly tackle age-ism in all of its forms, and to offer hope, compassion and empathy to those for whom we are responsible.

As COVID-19 Spreads, so Do Negative Stereo-types of the Young and the Old

Ageism is Making the Pandemic Worse. The Atlantic

A framework for rationing ventilators and critical care beds during the COVID-19 pandemic

Reframing clinician distress: moral injury not burnout

The National Academies of Sciences, Engineering, and Medicine. Tak-ing Action Against Clinician Burnout: A Systems Approach to Profes-sional Well-Being