Discussing treatment limitations in frail older COVID-19 patients: A
Framework Analysis.
Sophie Anna Lochtenberg (MS)1*, Elise Linde Pel (MD,
MA)2* , Roeline Pasman1 , Peter
Noordzij (PHD, MD)3
*Both authors contributed equally.
1. Department of public and occupational health, Amsterdam Public Health
research institute, Expertise Center for Palliative Care, Amsterdam UMC,
VU University, Amsterdam, the Netherlands
2. Erasmus Medical Centre, Department of Geriatrics, Rotterdam, The
Netherlands
3. St. Antonius Hospital Nieuwegein, Department of Anesthesiology,
Intensive Care and pain management, Nieuwegein, The Netherlands.
Corresponding author: E.L. Pel, email address:
e.pel@erasmusmc.nl
Abstract
Aims and objectives: The COVID-19 pandemic caused an increase in
hospitalizations for frail older people and required healthcare
professional to make difficult ethical and medical decisions regarding
intensive care unit admission and treatment. This study investigates the
experiences of healthcare professionals with the use of a decision
support tool when discussing treatment limitations with older patients
with COVID-19.
Methods: A qualitative approach was chosen to obtain further
in-depth information on the experiences of the healthcare professionals
with the conversations about treatment limitation and on the
contribution of a decision support tool for frail older adults with
COVID-19. The framework method was used for the data analysis.
Results: The following themes illustrate the analyzed concepts
for the subject conversations about treatment limitation: careful
consideration, the conversation is a part of the job, the burden of the
conversation, scheduling conversation and acquiring skills to perform
the conversation. The concepts of the theme AGE-ICU evaluation are
included in the following themes: considered and comprehensible
overview, confirmation of own assessment, every decision is context and
person dependent, contributes to considered decision and tool not needed
because of own expertise.
Conclusion: A decision support tool for older patients with
COVID-19 may help the healthcare professional to objectify the patients’
health status and functioning and discuss risk factors for adverse
outcomes. Besides this, the tool helps to initiate the difficult
conversation with the patient and their family. Finally, the AGE-ICU
contributes to shared-decision making because it helps patients to
understand the suggested decision and patients are more involved in the
decision-making process.
Keywords: treatment limitation, decision-making tool, COVID-19,
frailty, framework method.
Introduction
The global pandemic of coronavirus disease 2019 (COVID-19) caused by
SARS-CoV-2 has been overwhelming worldwide1. According
to the World Health Organization in November 2021 more than 260 million
people are infected and over 5 million people have died due to COVID-19
globally2,3. Consequently, the COVID-19 pandemic
caused an increase in hospitalizations for people of all ages with
pneumonia1. This resulted in shortage of hospital
resources and required healthcare professionals to make difficult
ethical and medical decisions regarding intensive care unit (ICU)
admission and treatment3-5.
The decision about ICU admission in frail older patients can be complex
and could have serious consequences. Triage criteria are often used to
support the healthcare professionals in this
decision7. Probability of treatment benefit, age and
frailty are the most commonly used criteria to admit a person to the
ICU6,7. Frailty increases the risk of negative health
outcomes, the chance of complications and is more common in older
age8,9. Older patients with comorbidities have a
higher risk of hospitalization and mortality due to
COVID-197. However, ICU admission is not always the
right choice for all older patients8. It is a
burdensome treatment and can have profound short- and long-term
consequences6. Furthermore, the majority of COVID-19
survivors who are discharged from the ICU often leave with significant
morbidity and a long and uncertain road to recovery6.
Healthcare professionals always aim to provide care in the best interest
of the patients8. Usually, only patients with a
reasonable chance to recover with a satisfactory health are admitted to
the ICU and patients with low chances of survival are not admitted to
the ICU10. In older frail COVID-19 patients the
advantages and disadvantages of ICU treatment need to be carefully
weighted. Knowing the complexity and the risks of the treatment, it is
important that patients are involved in
decision-making11. Healthcare professionals are
obliged to have a conversation with the patient about the various
treatment options including treatment limitations8.
These conversations can be difficult to initiate and are often avoided
by healthcare professionals due to fear of causing distress for the
patient12. A decision support tool that includes the
patients’ risks and characteristics can be used to guide healthcare
professionals in this conversation and could be the starting point for
decision-making. Therefore, risk assessments could be the base for the
healthcare professional to inform the patients and their families to
make a well-considered decision regarding treatment9.
Besides this, the decision not to be treated in the ICU can prevent
patients from complications or dying in solitude due the strict COVID-19
rules that only allows one or two loved ones. Finally, by involving the
patients their autonomy is respected13.
There is a need for tools to contribute to risk assessment to guide
healthcare professionals in decision-making during the COVID-19
pandemic11,14. Little research has been done on
discussing treatment limitations. Berghuis (2019 studied
physician-related factors concerning treatment limitations and states
that communication training is effective, but the thesis has argued that
more insight in perspectives of healthcare professionals is necessary
and to find out what facilitates them in these
conversations13. Griffith et al. (2020) researched the
process of decision-making around ICU admission during the COVID-19
pandemic. They concluded that a framework for decision-making around ICU
admission in which patients and their families are involved has the
potential to improve decision-making and complement clinical prediction
tools11. Taken together, the reported conclusions of
both studies appear to support the assumption that there is a need for a
decision support tool that guides healthcare professionals in
decision-making with older COVID-19 patients.
The high number of hospitalizations due to COVID-19 caused an increase
in conversations about treatment limitation. This demanded a tool to
contribute in the risk assessment among older COVID-19 patients. In St.
Antonius hospital the Anesthesia Geriatric Evaluation (AGE) screening
tool is developed to detect patients with increased frailty prior to
high-risk surgery15. Based on this tool the AGE-ICU
tool is developed during the first COVID-19 wave in March 2020, aiming
to support healthcare professionals in the decision about older COVID-19
patients and ICU admission. Examples of aspects that are included in the
tool are frailty, and cardiovascular and pulmonary risk factors
(Appendix I). The aim of this study was to evaluate the AGE-ICU tool,
which is designed to help healthcare professionals with the
conversations about treatment limitations in older COVID-19 patients and
to investigate the experiences of the healthcare professionals with
these conversations.
Method
A qualitative approach was chosen to obtain further in-depth information
on the experiences of the healthcare professionals with a decision
support tool to discuss treatment limitations in older COVID-19
patients. This tool was used by healthcare professionals at COVID-19
wards in St. Antonius hospital in Nieuwegein, a large teaching hospital
in the Netherlands. The tool is called AGE ICU and is described in
appendix 1.
Participants
In the period from February till the end of May 2021 participants were
recruited from St. Antonius Hospital, Nieuwegein. They were requested to
participate by email. It was required that the participants worked with
the AGE-ICU tool during the COVID-19 pandemic that started in March
2020. Doctors and residents of all ages, specialties and from various
departments were included. Six medical specialists and four residents
participated in this research.
Data collection
Semi-structured interviews were conducted with healthcare professionals
from St. Antonius hospital who used the AGE-ICU tool during the COVID-19
pandemic. The interviews were based on a predetermined topic guide with
example questions (Appendix I). Data collection was applied until no new
themes derived from the data, and saturation seemed to be reached.
Analysis
The method chosen for this research is the framework method. This
analysis is described by the National Centre for Social Research as a
content analysis method which involves summarizing and classifying data
within a thematic framework16. The framework method
consists of seven clear steps to follow and produce highly structured
outputs of summarized data17. Firstly, the interviews
were transcribed verbatim. After transcription the researcher had to get
familiar with the data by attentively reading the transcripts again. The
third step of the framework analysis is coding; the transcripts were
analyzed line by line and codes were used for the description of the
interpretation of a certain line. The fourth step is the development of
a working analytical framework which means that the codes from the third
step were grouped into categories. After development of the analytical
framework the data was charted into the framework matrix. Lastly, the
seventh step considered the interpretation of the data. The researchers
have been working iteratively, along the process of interviewing new
themes derived from the interviews and the topic guide has been
adjusted. The analysis was performed independently by two researchers
and the program ATLAS.ti was used for the coding process. Any
disagreement on the data, categories or themes between the two
researchers was resolved by discussion. The final analyses was discussed
with all authors.
Ethical considerations
The healthcare professionals gave permission via recorded consent to use
their experiences and interview data to evaluate the AGE-ICU tool. To
respect anonymity of the healthcare professionals, transcripts were
directly anonymized and audio records were deleted after transcription.
This research has been approved by the local research committee of St.
Antonius hospital, Nieuwegein (P21.005).
Results
Five main themes were derived from the data for the AGE-ICU evaluation
and five main themes for the conversation about treatment limitation.
These themes and its subthemes will be further explained below and are
supported by quotes from the healthcare professionals.
The healthcare professionals were first asked about the conversation
about treatment limitation in general, followed by questions about the
AGE-ICU and the evaluation of the contribution to the conversations
about treatment limitation.