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 globally^2,3. 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 treatment^3-5.

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 ICU^6,7. Frailty increases the risk of negative health outcomes, the chance of complications and is more common in older age^8,9. 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 pandemic^11,14. 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.