Managing Older Adults With Presumed COVID-19 in the Emergency Department

A Rational Approach to Rationing

Tony Rosen, MD MPH; Lauren E. Ferrante, MD MHS; Shan W. Liu, MD SD; Emily A. Benton, MD; Mary R. Mulcare, MD; Michael E. Stern, MD; Kevin Biese, MD; Ula Hwang, MD MPH; Martine Sanon, MD

Disclosures

J Am Geriatr Soc. 2020;68(8):1631-1635. 

In This Article

Strategies to Improve Decision-making in the ED if Rationing is Required

Despite challenges, interdisciplinary care teams working collaboratively in the ED should make every effort to obtain additional information about an older adult to guide decision-making especially if rationing is required. This includes talking with family (in the waiting room if necessary), making telephone calls to the health care proxy/surrogate decision maker, outpatient providers, and skilled nursing facility providers, and also extensively reviewing charts including information from outpatient visits and other hospitals if available.

We support the ongoing efforts in many states, health systems, and hospitals to design rationing frameworks that attempt to avoid using age as a primary criterion. These triage frameworks aim to use objective criteria to assess likelihood of survival, such as the Sequential Organ Failure Assessment (SOFA) score,[8] which relies on laboratory values. The Clinical Frailty Scale (CFS) tool can be used before the return of laboratory values, making it useful in urgent ED decision-making. Recognizing that baseline functional status is an important predictor of survival of critical illness, the CFS is a 9-item pictorial scale that may be applied in the ED. It provides a pre-acute illness description of a patient's functional baseline as robust, vulnerable or frail.[9] This scale is used as an early decision point in the assessment algorithm recommended by the National Institute for Health and Care Excellence in the United Kingdom.[10]

We offer below additional suggestions to assist in optimal decision-making for older adults. These include first, involving triage teams, other disciplines and providers, and administrative leadership in decision making. Second, providers should be aware of advance directives and have goals of care conversations. Finally, providers may consider delaying intubation when possible to allow for more informed decision-making.

The Value of Dedicated Triage Teams, Interdisciplinary Collaboration, and Inclusion of Administrative Leadership in Decision-making

Whenever possible, the care team in the ED should not be making the decision about whether to intubate or resuscitate a patient independently. The AGS position statement advocates for triage teams who are not involved in clinical care to support and assist with the decision making if rationing is necessary. Health systems should be developing these teams and related protocols immediately in preparation for potential resource shortages. Decisions about activating these teams should be made at the administrative level, since hospital and health system leadership may have knowledge that frontline providers don't have regarding when resource demand exceeds supply.

It is possible however, that such teams may not be available and frontline providers may still be responsible to make decisions about rationing of resources. If decision-making by frontline providers is necessary, these decisions are ideally made collaboratively between disciplines. In many EDs, pulmonary/critical care physicians, hospitalists, anesthesiologists, geriatricians, palliative care clinicians and other specialists have become more involved in ED patient care during this pandemic. This interdisciplinary approach which allows for integration of different viewpoints and expertise, has been formalized with protocols in some hospitals. Pulmonary/critical care specialists, in particular, are likely to be aware of current and future resource availability. They have experience with longer-term treatment strategies and prognosis of critically ill COVID patients. In larger EDs, we recommend that, whenever possible, providers discuss cases with other professional colleagues who are not part of the patient's care team for another perspective and support, reducing the burden on any individual. Also, the ED care team should consider reaching out to the Administrator on Call, who can give advice and activate the hospital's ethics and legal teams. Protocols, procedures, and resources change frequently during the COVID pandemic, and health system and hospital leadership should ensure that providers from all disciplines, including trainees, are aware of any updates.

The Critical Role of Advanced Directives & Goals-of-care Conversations

Geriatricians and other outpatient providers have an important role to play assisting ED clinical decisions that are appropriate and patient-centered. The AGS position statement recommends that widespread and urgent advance care planning discussions are critical, and if possible, should be initiated before patients are exposed to or contract COVID. Advance Care Planning (ACP) is not rationing, but proactively identifies patients who do not wish to receive aggressive, invasive interventions. The patient's ACP directives should be clearly documented in an easily accessible location along with family phone numbers, as providers may need access to this information quickly to make appropriate decisions and avoid inappropriate intubations. For patients coming from a skilled nursing facility, a Medical Orders for Life-Sustaining Treatment (MOLST) or Physician Orders for Life-Sustaining Treatment (POLST) as well as a Health Care Proxy form should be included with the transport paperwork. The care team should be aware of these documents and they should be reviewed to guide clinical care. SNFs and Emergency Medical Services (EMS) transporting the patient may assist the ED by having this information easily accessible.

These forms do not supplant a conversation with the patient and family. Care teams should not automatically assume patients who already have advanced directives in place do not wish aggressive care to manage COVID. It is possible that the advanced directive envisioned a very different scenario far in the future rather than a potentially survivable acute viral infection. In the setting of severe illness or disease progression, patients may also change their minds. Advanced care plans, even if previously documented, should be reviewed and affirmed throughout the disease course.

Many older adults will present to the ED without existing advanced directives. The ED is not the ideal location to set goals of care, but, during the COVID crisis, it is commonly necessary to initiate ED goals of care discussions. Providers should be prepared to have discussions to facilitate clinical decision-making aligned with the patient and family's wishes. Vital Talk (www.vitaltalk.org) and The Center to Advance Palliative Care (https://www.capc.org) both have helpful resources to guide clinicians in these challenging conversations. Providers should also consider discussing goals of care with older adults with mild illness, even those who do not require hospital admission, as many may experience deterioration of clinical trajectory.

A potential resource to assist with these goals of care discussions is a Palliative Care or Geriatrics consultation, if available. Geriatricians and Palliative Care providers are accustomed to navigating difficult conversations in seriously ill and vulnerable patients. Many hospitals have already deployed Palliative Care teams to the ED or expanded their existing role to assist with these conversations. Additionally, Palliative Care can contribute by providing guidance on symptom management for patients and developing or expanding existing Palliative Care and hospice units for patients who opt for non-invasive, supportive care. As the COVID crisis has increasing numbers of cases in rural areas with less well-resourced hospitals, it will be important to consider the telehealth availability of geriatrics and palliative care services to help with these challenging clinical scenarios.

Delaying Intubation may Allow for Better Decision-making

The decision whether or not to intubate a patient is the core decision most likely to drive rationing during the COVID crisis. Ventilators, the personnel and expertise to manage them, and the ICU beds required for care are the scarce resources during this pandemic Therefore, understanding the evolving approaches to intubation during COVID is important. At the height of an outbreak, an ED can expect many patients in respiratory distress to arrive over a short period of time. Intubating patients early or determining if they do not want or should not be offered intubation, reduces the number of patients needing very close monitoring. Additionally, many of the tools typically used to temporize and potentially avoid intubation in patients with respiratory distress or respiratory failure such as nebulized medications, high flow nasal cannula, and Bilevel Positive Airway Pressure (BiPAP) can aerosolize the virus and are therefore may be discouraged during this pandemic. Further, successfully intubating a patient puts their respiratory system into a closed ventilatory circuit, protecting providers and other patients from aerosolized virus. Initial experience suggested that patients did not improve on other therapies and early intubation improved outcomes.[11,12] Rushed, emergent intubations, while not ideal for a patient under any circumstances, often increased the risk of COVID exposure to providers due to inadequate time to don PPE properly while racing to save the patient's life. As a result of this, early intubation strategies were adopted initially in the COVID crisis management in the US.[13] Thus, the decision about whether to intubate a patient was often made early in the ED evaluation, sometimes minutes after initial arrival. These circumstances made it often very difficult to involve multiple disciples, have informed goals of care discussion, or to assess adequately the patient's prognosis and the risk vs benefit of intubation.

As ED and critical care providers have learned more about COVID-19 and its initial management, it has been recognized that many of these patients may actually be maintained with external oxygen. Procedures such as proning, previously reserved for intubated patients, are now recognized to be effective for non-ventilated COVID patients who are able to self-monitor,[14] and have been adopted into medical care. These treatment strategies have increased the amount of time available for interdisciplinary decision-making about whether intubation is necessary. Older adults should be considered as candidates for these additional procedures and respiratory strategies.

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