The authors of this article respond to the American Geriatric Society’s (AGS) position paper on the importance of not using age as exclusion factor when considering allocation of scarce resources during the COVID-19 pandemic in the emergency department (ED). They also provide recommendation to provide high quality care to older adults in the ED during the pandemic.
When a COVID-19 patient that is an older adult presents to the ED they are often in respiratory distress or their illness severity is high. This leads to quick decision making. An informed clinical decision needs to considered with knowledge of the patient, their history, their prognosis, and their values which may be difficult to obtain in an urgent situation.
One of the first pieces of information given when a patient presents to the ED is their chronological age. Without further information on a patients history, a team may use the chronological age of a patient (consciously or subconsciously) to guide them in their clinical decision making.
Many ED’s have decision rationing frameworks that to attempt to avoid age as the primary criteria. Triage frameworks to assess likelihood of survival some may include:
- Sequential Organ Failure Assessment (SOFA), which relies on laboratory values
- Clinical Frailty Scale (CFS), can be used before laboratory values are returned in cases of urgent decision making
In addition to age, another piece of information typically know on arrival is that the patient was from transferred from a “facility,” which is often misinterpreted. Although skilled nursing facilities (SNF) often house the frail, chronically ill, and long term residents, there are many facilities that house otherwise healthy older adults that are receiving short term care.
COVID-19 may cause delirium in older adults and impair their decisional capacity. Older adults can also have visual and hearing impairment, impairing their capacity to express their wishes. With the COVID-19 pandemic, many hospitals and ED’s have limited the amount of visitors, which takes away advocates for cognitively impaired individuals. These advocates, with the proper PPE, should be allowed to accompany the patient. To gain more information about the family, the care team should make an effort to talk to the family, make telephone calls to health care proxy/surrogate decision makers, outpatient providers, skilled nursing facility providers, and extensively review outpatient and hospital visit history.
Other suggestions to assist in optimal decision making for older adults include:
- Involving triage teams, other disciplines/providers, and administrative leadership in decision making Providers should be made aware of advanced directives and have goals of care conversations
- Providers may consider delaying intubation when possible to allow for more time to make informed decisions, as many patients can be maintain on external oxygen for a period of time