key: cord-1013172-ugs0lgw9
authors: Martínez-Sellés, David; Martínez-Sellés, Helena; Martinez-Sellés, Manuel
title: Ethical Issues in Decision-making Regarding the Elderly Affected by Coronavirus Disease 2019: An Expert Opinion
date: 2020-05-18
journal: Eur Cardiol
DOI: 10.15420/ecr.2020.14
sha: 184385a14d59146ab3d3015fe5555515d77c8390
doc_id: 1013172
cord_uid: ugs0lgw9

The coronavirus disease 2019 (COVID-19) pandemic is resulting in ethical decisions regarding resource allocation. Prioritisation reflects established practices that regulate the distribution of finite resources when demand exceeds supply. However, discrimination based on sex, race or age has no role in prioritisation unless clearly justified. The risk posed by COVID-19 is higher for elderly people than for younger people, so older adults should be prioritised in preventive measures. In the case of people who already have COVID-19, healthcare professionals might prioritise those most likely to survive. Making decisions based on chronological age alone is not justified; in addition to age, other aspects that determine theoretical life expectancy must be taken into account. Individualised correct prioritisation in the allocation of scarce resources is essential to good clinical practice.

international responsibilities. For instance, Pope Francis is now 83 years old and Queen Elizabeth II is 94 ( Figure 1 ).

The risk posed by COVID-19 is higher for elderly people than for younger people. 2 For this reason, medical and political authorities should offer older adults strict preventive measures to minimise the risk of exposure and infection. In the event that an effective vaccine for SARS-CoV-2 is developed, priority should be given to vaccination of the elderly, with the aim of maximising the number of lives saved. This is also true for other preventive measures, such as possible pre-or post-exposure prophylaxis. 7 In the case of people with COVID-19, the situation is different. When allocating resources in these scenarios, healthcare professionals might prioritise those most likely to survive over those with remote chances of survival. Making a decision based on chronological age is not justified. In addition to age, other aspects that determine theoretical life expectancy must be taken into account. Biological age and the use of frailty scales and comprehensive geriatric assessment are essential for this purpose. The recent statement of the Executive Board of the European Geriatric Medicine Society insists that advanced age alone should not be a criterion for excluding patients from specialised hospital units. 8 If an elderly patient is dismissed from a specialised hospital unit for any reason, access to medical attention, symptomatic treatment and palliative care must be ensured. This last point is essential, as palliative care is frequently suboptimal in elderly patients with other conditions, such as heart failure, and this is probably the case in COVID-19. 2, 9, 10 Therapeutic Adaptation after COVID-19 Admission pneumonia, but this is also the case for young patients with severe comorbidities. 11

During the peak of the outbreak, more than two-thirds of beds in most hospitals in Madrid were occupied by patients with COVID-19. Figure 2 depicts the official numbers of patients admitted to hospital, admitted to ICUs, who died and who recovered in Spain between mid-March and the middle of April. 12 Non-invasive ventilation was attempted frequently, even using improvised alternative strategies like the modified Easybreath diving mask to administer continuous positive 

Confinement is an effective way to decrease SARS-CoV-2 transmission and is a way to win time until effective therapies are developed and/or an effective and safe vaccine is available. However, the stay-at-home policy has negative effects in those with advanced age (Figure 3) . The 

The COVID-19 pandemic has isolated the elderly not only at home but also in hospitals. Visits are usually not permitted. Several patients of advanced age with severe infection have died alone in the hospital or in nursing homes.

The suffering of the family does not end there, as containment measures also apply in the context of mourning, which adds trauma to that of death itself. Corpses are considered potentially infectious, so are deposited as soon as possible in a body bag that will never be reopened. During the peak of the outbreak in Madrid, we had so many deaths that an ice rink had to be used as a provisional morgue. It was frequently impossible for families to see their deceased loved ones one last time.

The rules of social distancing put in place by the health authorities applies also at funerals. Services must be limited to close family members only (with a maximum of three people), usually with video recording and streaming for those who wish to attend the funeral from a distance. Finally, the vast majority of older people in Spain are Catholic.

The fact that public masses have been cancelled makes the situation even more difficult for families.

COVID-19 in elderly patients raises some ethical issues; however, most of these issues are similar to ethical problems in other conditions, such as heart failure. [17] [18] [19] The correct prioritisation for the allocation of scarce resources should be based on various factors relating to the individual. Chronological age should not be the only factor that influences the decision-making process. This is essential to good clinical practice. 

Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories

Joint document of the Geriatric Cardiology Section of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology

Sex-mismatch influence on survival after heart transplantation: a systematic review and meta-analysis of observational studies

Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry

Global reach of ageism on older persons' health: a systematic review

European doctors worry about the care they will receive when they are old

Fair allocation of scarce medical resources in the time of COVID-19

Statement of the EuGMS Executive Board on the COVID-19 epidemic

Consensus document and recommendations on palliative care in heart failure of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology

Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement

Facing Covid-19 in Italy -ethics, logistics, and therapeutics on the epidemic's front line

Daily evolution of COVID-19 in Spain

Recomendaciones éticas para la toma de decisiones en la situación excepcional de crisis por pandemia COVID-19 en las unidades de cuidados intensivos

Off-label therapies for COVID-19. Are we all in this together?

Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review

Cardiac and arrhythmic complications in patients with COVID-19

Covid-19 and some ethical issues in France

Whose life to save? Scarce resources allocation in the COVID-19 outbreak

Reflections on ethical issues in palliative care for patients with heart failure