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.