key: cord-0777881-yj2wrr9t
authors: Chase, Jocelyn
title: Caring for Frail Older Adults During COVID‐19: integrating public health ethics into clinical practice
date: 2020-06-17
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16666
sha: e44174f6cbae6ea54a5a378d34bdcec3afabbd2e
doc_id: 777881
cord_uid: yj2wrr9t

During the COVID‐19 pandemic, principles from both clinical and public health ethics cue clinicians and health care administrators to plan alternatives for frail older adults who prefer to avoid critical care, and for when critical care is not available due to crisis triaging. This paper will explore the COVID‐19 Ethical Decision Making Framework, published in British Columbia, Canada, to familiarize clinicians and policy makers with how ethical principles can guide systems change, in the service of frail older adults. In British Columbia, the health care system has launched resources to support clinicians in proactive advance care planning discussions, and is providing enhanced supportive and palliative care options to residents of long term care facilities. If the pandemic truly overwhelms the healthcare system, frailty, but not age alone, provides a fair and evidence‐based means of triaging patients for critical care and could be included into ventilator allocation frameworks. This article is protected by copyright. All rights reserved.

Long term care facilities (LTCF) in Canada have been host to the most devastating outbreaks of COVID- 19 and the majority of the country's deaths (1) . Most patients in Canadian LTCFs are over the age of 80, and nearly all have comorbidities and substantial frailty (2) , making them vulnerable to infection. In the US, an epidemiologic study from a Washington state care facility showed that nearly two-thirds of residents contracted COVID-19 infection during an outbreak. The majority of residents experienced respiratory symptoms, half were transferred to hospital, and the death rate was 33.7% (3) .

Given the burdens of COVID-19 for frail older adults, clinicians and health care administrators should carefully consider how frailty affects pandemic planning.

While most pandemic ethics literature focuses on critical care restrictions and ventilator allocation in settings of resource scarcity (4), these frameworks do not comprehensively serve the needs of frail older adults, especially those who wish to avoid critical care. This paper will use principles drawn from both clinical ethics and public health ethics to encourage clinicians to reframe COVID-19 discussions towards what can be done for frail older adults, using examples from British Columbia's (BC) pandemic response (5) .

The medical profession has viewed hospitalization and critical care measures, including non-invasive ventilation as well as intubation and ventilation, as important means to support severely affected individuals through COVID-19 infection (6) . However, as we care for our frail patients with COVID-19, a sobering reality is becoming apparent. A frail individual has reduced ability to withstand medical This article is protected by copyright. All rights reserved. Accepted Article stressors due to a baseline decline in physiological reserve. Substantial research has associated frailty with adverse health outcomes, including mortality and admission to hospital (7) . Although age is a risk factor for frailty, not all older adults are frail (8) . In Canada, the Clinical Frailty Scale is a validated tool that assigns frailty based on a combination of factors including functional status, cognition, and comorbidity (9) . Patients are graded on a scale from very fit (1) to severely frail (7), with scores over 5 representing increasing frailty. Although no studies have yet looked at frailty as an outcome marker in COVID-19 infection, a large body of evidence has established that frailty is good general predictor of post critical care functional decline and mortality (10, 11) . Further, emerging research from China, Europe and the US demonstrates that older adults experience substantial morbidity and mortality following severe COVID-19 infection (3, (12) (13) (14) (15) .

As society responds to the health care system pressures arising from the COVID-19 pandemic, we must consider the accumulating body of medical evidence alongside the values and ethical principles that shape decision making. For older adults, a frailty paradigm is a helpful contributor to ethical decision making, even before addressing issues of resource scarcity.

Clinical ethics (CE) frameworks primarily consider the needs and rights of individual patients, while also keeping in mind community safety and resource stewardship more broadly (16) . The four principles of western bioethics include autonomy, beneficence, non-maleficence and justice. The principle of autonomy supports voluntary and informed patient decision making, in keeping with individual values and preferences. The principle of beneficence charges health care providers to provide treatment that offers the most overall benefit to the patient. The principle of non-maleficence requires that clinicians This article is protected by copyright. All rights reserved. Accepted Article not intentionally harm a patient, either through acts of commission or omission. The principle of justice considers the fair distribution of resources in a health care system.

During COVID-19, clinicians and administrators should also consider principles from public health ethics (PHE), whose central aim is to improve the health of the general population. PHE principles inform public health actions, including rationing (17) . The PHE principles in this paper, summarized in Table 1 , are taken from the British Columbia COVID-19 Ethical Decision Making Framework (5) . The framework and its principles arose following deliberations by a team of provincial ethicists, and have influenced actions taken by clinicians and health care administrators in BC.

Principles used in CE and PHE overlap substantially and are not mutually exclusive. During nonpandemic times, clinicians use the CE principle of justice to balance the needs of individual patients while still ensuring the health of populations. This is illustrated by the need for driving restrictions in dementia and organ transplantation criteria. In pandemic settings, clinicians must try to uphold the PHE principle of respect (Table 1) , which mirrors the CE principle of autonomy, valuing individual patient preferences, as far as possible.

The COVID-19 pandemic highlights two major opportunities for ethical reflection. The first is that, regardless of resource abundance or scarcity, principles from both clinical and PHE encourage clinicians to focus on advance care planning, supporting frail patients to access care in keeping with their values and goals. Additionally, administrators must ensure that there is adequate supportive and palliative This article is protected by copyright. All rights reserved. Accepted Article care for patients who wish to avoid aggressive interventions. Pandemic planning must not focus exclusively on ventilators or critical care.

The second scenario for ethical reflection is when critical care scarcity causes tension between the PHE principle of fairness (Table 1 ) and the CE principle of autonomy (18) . If resources are limited, clinicians must think beyond their primary ethical duty to individual patients, to consider the wellbeing of communities. Health care providers, administrators, patients and families may be confronted with unfamiliar and uncomfortable rationing. Patient frailty should carry significant weight in resource allocation decision making. The two above scenarios will be explored in detail in the following sections.

Advance Care Planning During COVID-19

Caring for a frail older adult with severe COVID-19 is not different than caring for that same patient in the setting of any other critical illness, so long as resource scarcity does not rigidly confine treatment options. Specifically, advanced care planning (ACP) discussions during COVID-19 should include information regarding the poor outcomes observed in frail older adults who are critically ill with COVID-19 (3, (12) (13) (14) (15) . Patients who are frail, of very advanced age, near end of life, or who have serious medical diagnoses, such as severe heart failure and emphysema, benefit from a clear understanding of the role that hospitalization and critical care play in helping them to achieve their goals (19 -21) .

During the COVID-19 pandemic, clinicians should proactively engage their patients and substitute decision makers (SDM) in ACP discussions, rather than waiting until the patient is severely ill. During these discussions, patients can identify their preferred SDM, should they be unable to speak for This article is protected by copyright. All rights reserved. Accepted Article themselves. In British Columbia, the government has created new telemedicine billing codes to support this important work. Proactive goals of care discussions have taken place for numerous LTCF residents.

SDMs are included in these discussions by telemedicine because of COVID-19 visitation restrictions in place at LTCFs (22) . Experts in ACP have developed serious illness conversation scripts specific to COVID-19 (23, 24) .

Given the evidence of poor outcomes for frail older adults with severe COVID-19, clinicians may even wish to "flip the default" during ACP discussions, requiring frail patients to "opt out" of supportive and palliative care. However, in a case where a frail patient or SDM demands critical care despite being counseled against it, critical care should still be an option. As long as the health care system has capacity during standard operations, respect for autonomy often outweighs beneficence, nonmaleficence, and justice in day to day clinical ethics (25) Supportive Medical and Palliative Care During COVID-19

The health care system must support frail older adults who are disproportionately affected by COVID-19 illness and mortality, and minimize the burdens placed upon them (5) . Instead of asking "how do we ration a scarce resource", clinicians and health administrators should ask "how do we best deliver holistic care to the frailest and most vulnerable among us?" The PHE principle of reciprocity ( Table 1) reminds clinicians that providing excellent supportive and palliative care is a deliberate action, and not simply a philosophy of avoiding ventilators. If society cannot provide excellent supportive medical and palliative care, the public will rightly perceive that older people are being abandoned by the health care system. This article is protected by copyright. All rights reserved.

In British Columbia, the Public Health Officer has given an order that frail older adults who test positive for COVID-19 should remain on-site at LTCFs to receive supportive care by default, rather than transfer to an acute care facility (26) . All facilities with outbreaks are assisted by a rapid response infection control team (27), and LTCF nurses can now provide oxygen and parenteral fluids through hypodermoclysis, helping those who can recover to do so on-site (26) . Nurses have access to comfort- If a LTCF resident and their SDM believe that the benefits of transfer to hospital outweigh the burdens, they must take part in a goals of care discussion by telemedicine (26) . Following this discussion, they can apply to the medical health officer to seek an exemption to the order. Although the order limiting transfer to hospital appears restrictive, it ensures that patients and families are informed about the expected outcomes following transfer. In this way, British Columbia LTCFs have "flipped the default," requiring frail older adults to "opt out" of supportive and palliative care on-site, rather than reflexively transferring patients to hospital without first engaging in a robust discussion about the risks and benefits.

There is no evidence in Canada or the US that ventilator shortages are a substantial factor in any COVID-19 deaths, especially for frail individuals. Further, excellent ACP may curtail ventilator use if frail older This article is protected by copyright. All rights reserved.

Accepted Article patients decide that they prefer supportive or palliative care options. However, a major surge in patient volumes could still lead to the utilization of most ventilators within the health care system. If this were to occur, public health officials will trigger rationing protocols, and place limits on the authority of individual patient autonomy (5, 18) . The PHE principle of fairness describes the rationale to allocate resources in states of scarcity (5) . Fairness means that, although the welfare of all patients matters equally, not all patients with similar needs will receive the same treatment ( Table 1 ).

The public health principle of equity (Table 1) indicates that those who need and can most benefit from a scarce resource should receive it preferentially over those who will not benefit as much (5) . For example, patients who most need critical care include those with hypoxic respiratory failure from COVID-19. Should there be resource scarcity, ventilators will be provided only to those who are most likely to benefit. From the existing evidence, younger patients with fewer comorbidities are more likely to survive severe COVID-19 (12) (13) (14) (15) . In the setting of pandemic resource scarcity, the principle of equity suggests that younger patients who are not frail should have preferential referral to critical care because they are most likely to benefit.

The public health principle of consistency (Table 1) requires that triaging rules operate in the same way amongst individuals in a similar clinical group, and not in an ad hoc fashion open to the influence of bias (5) . Frailty provides a consistent and evidence-based model to apply when triaging patients for critical care (6, 7) , and has been used in some jurisdictions during COVID-19 (28). In British Columbia, a ventilator allocation framework (in draft) (29) , will outline the process, so that decision making is fair and consistent for all patients in the province. This article is protected by copyright. All rights reserved.

A ventilator allocation framework gives clinicians clear rules to follow (4). Relying on "heat of the moment" decisions and individual clinician judgment threatens the fidelity of any triaging protocol, and will be difficult to defend publicly. Society must not hold individual clinicians accountable for why one patient qualifies for critical care over another, and government bodies developing triage protocols must consider legal protection for clinicians. A committee of physicians, operations leaders and ethicists should review hospital operations regularly, and trigger the crisis triage protocol during critical levels of patient surge (29) . This committee can monitor triage decisions to ensure that individual clinicians understand and are adhering to triage criteria.

Decisions to withhold or withdraw critical care based on ventilator allocation frameworks will be unavoidably difficult for all involved. However, if clinicians inform patients and families about the standardized process and rationale for triage, they may be more likely to accept the decision as fair, even if they disagree with the outcome (5) . Decision makers should publish policies and triaging frameworks so the public can hold them accountable.

Whilst some may argue that excluding frail older adults from critical care in a pandemic is ageist, frailty is a much fairer means to allocate scarce resources than age alone. A robust older adult is likely to derive more benefit from critical care than a very frail older adult with substantial comorbidities (6, 7) . A frailty triaging model reduces the likelihood of an undesirable "first come, first served" resource allocation outcome. In COVID-19 ACP discussions, clinicians should emphasize the CE principles of beneficence and non-maleficence to discourage individual frail patients from critical care. This approach aligns with guidance from the PHE principle of fairness applied to frail populations, stewarding resources for those who can most benefit. This article is protected by copyright. All rights reserved.

During the COVID-19 pandemic, ethical principles prompt us to plan for patients who want and will receive critical care, and for patients who will not, either by preference or because of resource limitations. Regardless of resource abundance or scarcity during COVID-19, clinicians caring for frail older adults must conduct advance care planning conversations early and often, so patients can make informed health care decisions. Excellent advance care planning may curtail ventilator use if frail older patients choose supportive or palliative care. In this way, clinical ethics principles may support public health goals by reducing pressure on society's limited pool of critical care. If the health care system is truly overwhelmed, frailty scoring, but not age alone, is a fair and evidence-based means of allocating critical care resources to those will likely benefit. 

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The author has no financial or personal conflicts of interest to report.

The author listed is the sole contributor in the preparation of this article. The author would like to thank the British Columbia Provincial COVID-19 Ethics Task Force who developed the COVID-19 Ethical Decision Making Framework, referenced in this article.

This article was not sponsored. This article is protected by copyright. All rights reserved.Accepted Article