Tool not needed because of own expertise
Not all healthcare professionals use the AGE-ICU consistently. Some find
the tool very helpful to support in the decision. Other
healthcare professionals indicated that the tool is not neededand that their own expertise is sufficient to estimate the chances of
survival. “I don’t need that tool to make the right decision”
[Interview 3]. Many healthcare professionals describeintuition being the base for ICU admission and estimation of
someone’s chances. On the other hand, some respondents argued that it
would be best to fill in the AGE-ICU for every patient. “But I
think that the people who don’t look fit, for them you fill in the tool.
But it would be very good to use the tool for the people that do look
fit. But now you often see that the tool is only used for people where
you think at first sight… hmm this patient does not look good, that
feeling…” [Interview 2].
The covid-19 crisis is distinguished from other diseases due to
emotional and physical isolation. Healthcare professionals initiated
that the conversations about treatment limitations are also difficult
for the patients and their families. It is more difficult for the
families to fully trust the professionals when family is not always
allowed to be around the patient and apprehend what is happening. The
healthcare professionals also mentioned that many patients are afraid
and have the feeling that they are given up on. But because of all the
news about COVID-19, people know better what to expect from the disease
and ICU admission. “And that’s where corona helped” [Interview
6].Discussion
This study has answered the main research question: “How do healthcare
professionals experience conversations about treatment limitation with
older hospitalized COVID-19 patients and how does a tool for
risk-assessment contribute to these conversations?” The main findings
suggest that the AGE-ICU seems to be a helpful tool which structures
thoughts and gives a good overview of the patients functioning and
health status. It can be assumed that the AGE-ICU is an easy-to-use
tool, that assists healthcare professionals in the triage and risk
assessment of older patients infected with COVID-19. The conversations
can be difficult and specifically in situations with cultural
differences.
The right moment for the conversation is a difficult consideration.
Patients will always be overwhelmed wherever and whenever the
conversation will be held. Patients that are infected with the
coronavirus can deteriorate very quickly18, therefore
it would be best that the conversation is performed before this occurs.
It is most conducive if patients have thought and talked about treatment
limitations before the acute moment.
According to healthcare professionals advance care planning is
important, to prepare patients for this moment19. If
patients know that they no longer want treatment, this can also save
unnecessary treatment or transportation to the hospital. However, in
reality many patients have not thought about it yet, because advance
care planning is not yet standardized20. Therefore, it
is even more important that healthcare professionals are provided with
tools, such as the AGE-ICU, to contribute to the conversation at the
moment a treatment decision has to be made.
The healthcare professionals indicated that for some patients it is very
clear if ICU treatment could be beneficial or not, consequently the
AGE-ICU is most often used for patients in the grey area. However, how
these cases of doubt are identified is unclear and often based on the
healthcare professional’s subjective assessment. According to them, the
AGE-ICU is a suitable tool to objectify their assessment in cases where
it is not clear or difficult to estimate the chances of survival.
Whereas many healthcare professionals find the AGE-ICU valuable, some
indicate that their own expertise is sufficient for the assessment of
older COVID-19 patients. Perhaps, the most serious disadvantage of not
using a tool is the in-transparency for the patients because the
decision is subjective. Recent literature investigated tools for advance
care planning and goals of care discussions, they concluded that
consensus about using tools for these discussions does not exist among
healthcare professionals19. This is in line with the
findings of this study. The AGE-ICU is a tool that could be used to
objectify the healthcare professional’s assessment regarding frailty,
resulting in a better decision. Additionally, the tool is helpful to
explain a decision to the patient because by using the tool it is more
insightful for patients.
The AGE-ICU can be used as a visualizer for the patient, they can get
insight in their current functioning and health status which can be very
clarifying. Also, patients are more involved in the decision. By
applying shared-decision making the autonomy of patients is respected
and another advantage is that shared-decision making is associated with
higher patient satisfaction13. This research shows
that in times healthcare professionals find the conversation difficult
to perform. Especially in situations with cultural differences in
opinion, which sometimes leads to unpleasant discussions. On the other
hand, the healthcare professionals mentioned that when these situations
occur, it makes no difference if the person that performs the
conversation is an experienced doctor or not. By using the AGE-ICU the
healthcare professionals’ assessment is objectifiable and doctors,
experienced in these conversations or not, can develop their skills.
Additionally, by using the tool the considerations can be transparent
for the patient. Even more important, is the tone of communication and
sensitivity in the way the news is delivered21. Myers
et al (2018) concluded that communication skills development is required
to perform effective conversations about goals of care and advance care
planning education19.
Hubbard et al. (2020) concluded that a screening tool needs to be a part
of the healthcare professional’s assessment and that the severity of the
acute illness, the likelihood of treatment success and the degree of
frailty needs to be considered5. The AGE-ICU screening
tool contributes to objectify the professionals’ assessment, shows
chances of success and includes frailty. Every patient needs an
individual approach and therefore the AGE-ICU only makes the patients’
health status and functioning visual, but does not conclude anything.
A limitation of this study is the risk for subjectivity from the
researchers. The data is interpreted as open as possible, nonetheless
preformed prejudices and the lens that the researchers build through
experiences can be a risk for subjectivity. The analysis is performed by
two researchers to minimize the risk for subjectivity.
Conclusion
The AGE-ICU is a tool that contributes to conversations about treatment
limitation, which are often experienced as difficult by health care
professionals. It gives a clear overview of risk factors for adverse
outcome in older COVID-19 patients and offers insights through a
user-friendly interface. The AGE-ICU helps to objectify the patients’
health status and functioning and helps the healthcare professionals
with the difficult conversation with the patient and their family.
Additionally, the AGE-ICU contributes to shared-decision making because
it helps patients to understand the suggested decision. Given the fact
that the ER can be hectic sometimes, it is necessary to continue to
develop the tool, so that it is also user-friendly in hectic times on
the ER. A possible area of future research would be to investigate the
patient’s perspective on the conversations about treatment limitation
and the value of the AGE-ICU in this conversation.
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Acknowledgments
The authors express their gratitude to the healthcare professionals of
St. Antonius hospital Nieuwegein who participated in the study. This
research did nog receive any funding in the public, commercial, or
non-profit sectors.
Conflict of interest statements
The authors declare no conflict of interest.
Figure Legends
Figure 1: Conversation about treatment limitation themes and subthemes.
This figure depicts the different themes and subthemes derived from the
data evaluating the experiences of healthcare professionals regarding
conversations about treatment limitation.
Figure 2. AGE ICU themes and subthemes. This figure depicts the
different themes and subthemes derived from the data evaluating the AGE
ICU tool.
Appendix
Figure 3: Conversation about treatment limitation; Codes, Subthemes and
Themes. This figure depicts the different codes derived from the data
evaluating the experiences of healthcare professionals regarding
conversations about treatment limitation. The figure shows the subthemes
and themes conjugated from the codes.
Figure 4: AGE ICU evaluation; Codes, Subthemes and Themes. This figure
depicts the different codes, subthemes and themes derived from the data
evaluating the AGE ICU tool. The figure shows the subthemes and themes
conjugated from the codes.