Scope of treatment and clinical-decision making in the older patient with COVID-19 infection, a European perspective.

PURPOSE: Older patients were particularly vulnerable to severe COVID-19 disease resulting in high in-hospital mortality rates during the two first waves. The aims of this study were to better characterize the management of older people presenting with COVID-19 in European hospitals and to identify national guidelines on hospital admission and ICU admission for this population. METHODS: Online survey based on a vignette of a frail older patient with Covid-19 distributed by e-mail to all members of the European Geriatric Medicine Society. The survey contained questions regarding the treatment of the vignette patient as well as general questions regarding available services. Additionally, questions on national policies and differences between the first and second wave of the pandemic were asked. RESULTS: Survey of 282 respondents from 28 different countries was analyzed. Responses on treatment of the patient in the vignette were similar from respondents across the 28 countries. 247 respondents (87%) would admit the patient to the hospital, in most cases to a geriatric COVID-19 ward (78%). Cardiopulmonary resuscitation was found medically inappropriate by 85% of respondents, intubation and mechanical ventilation by 91% of respondents, admission to the ICU by 82%, and ExtraCorpular Membrane Oxygenation (ECMO) by 93%. Sixty percent of respondents indicated they would consult with a palliative care specialist, 56% would seek the help of a spiritual counsellor. National guidelines on admission criteria of geriatric patients to the hospital existed in 22 different European countries. CONCLUSION: This pandemic has fostered the collaboration between geriatricians and palliative care specialists to improve the care for older patients with a severe disease and often an uncertain prognosis.

Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study.

BACKGROUND: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. AIM: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. SETTING/PARTICIPANTS: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. RESULTS: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty (p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure (p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. CONCLUSIONS: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.