The ED in not an Optimal Environment for Decision-making Regarding Rationing, Particularly for Older Adults
The ED might seem at first glance to be an ideal place to make decisions about rationing. Providers working in EDs are trained in disaster medicine, triage, and resource prioritization and are comfortable rapidly caring for multiple critically ill patients simultaneously. The setting requires bedside collaboration, with intensivists, hospitalists, and other specialists routinely co-managing patients in the ED. Also, social workers and nurses contribute significantly to patient care as part of an interdisciplinary team. Unfortunately, however, there are many reasons why making rationing decisions in the ED is far from ideal.
ED decisions are complicated by lack of critical data, insufficient time for careful consideration, new or existing cognitive impairment, and barriers to effective communication. Care in the ED is often provided with limited knowledge of the patient, their history, their prognosis, their values, and other factors that may inform a rationing of care decision. In many cases, even with significant effort, this information is difficult to obtain from charts and telephone calls. In addition, decisions may need to be made quickly before these details can be reviewed carefully and thoughtfully. COVID-19, similar to other infections, may cause acute delirium in an older adult, particularly in the setting of hypoxemia. This might impact the patient's decisional capacity and be incorrectly interpreted by the care team to be baseline cognitive impairment. Many older adults with hearing and visual impairment may have difficulty communicating with providers who are wearing masks, goggles, and other personal protective equipment (PPE). Therefore, even thoughtfully designed rationing strategies, such as those described in the AGS position paper may be difficult to operationalize effectively in the ED.
This process is made even more challenging during the pandemic because many EDs have implemented limitations on visitor policies to minimize spread of infection. Fortunately, EDs and hospitals have recently begun to recognize that caregivers and advocates for patients with cognitive impairment are a critical part of the care team, and they should be permitted to accompany patients after taking proper infectious disease precautions. They can also help provide valuable information about the patient to make more informed clinical decisions.
What is nearly always known, though, is a patient's chronological age. Unfortunately, the team caring for the patient in the ED may not know critical facts. Does the 83-year-old patient breathing at 28 breaths per minute in front of them have advanced cancer and mild cognitive impairment or no medical problems and recently ran a half marathon? Without access to other information, the team may use chronological age consciously and subconsciously to guide clinical management decisions. A recent study examining the effectiveness of rapid scoring systems in predicting mortality from COVID-19 presented findings separately for patients aged <65 and ≥65, negatively reinforcing the perceived importance of age in prognosis.
Another piece of information typically known immediately on patient presentation to the ED, but often misinterpreted, is that they were transferred from a "facility." Skilled nursing facilities (SNFs) often house older adults who are frail, chronically ill, and living in long term care residence. However, many of these facilities also house otherwise healthy older adults receiving short-term rehabilitation after a surgery or hospitalization. There is also a distinction between long-term SNF residents and those largely independent older adults who reside in assisted living facilities or senior housing. Unfortunately, teams providing care in the ED may inadvertently presume a patient from a "facility" has impaired baseline functional, cognitive, and medical issues.
J Am Geriatr Soc. 2020;68(8):1631-1635. © 2020 Blackwell Publishing