Rationing Care by Frailty During the COVID-19 Pandemic

Emma Grace Lewis; Matthew Breckons; Richard P. Lee; Catherine Dotchin; Richard Walker


Age Ageing. 2021;50(1):7-10. 

In This Article

Abstract and Introduction


The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals' suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals' risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.


Since the emergence of the novel coronavirus in Wuhan China in December 2019, it has become apparent that older people are at an increased risk of death from coronavirus disease 2019 (COVID-19).[1] Underlying medical conditions that are more prevalent with increasing age, such as hypertension and cardiovascular disease, also increase the risk of death from the virus.[2] It is understandable that frailty, which increases with ageing, and is closely related to multimorbidity, has been employed in clinical decision-making during this pandemic.

In this context, frailty provides a means of estimating an individual's physiological ageing and reserve to withstand and survive acute 'stressor events', such as a viral infection. However, the concept of frailty has long been used by geriatric medicine as an important means of promoting older people's holistic care through the comprehensive geriatric assessment (CGA).[3] There is robust evidence that this individualised care, delivered by an expert multidisciplinary team, improves outcomes for older people admitted to hospital with acute medical problems, significantly improving the likelihood of survival, and reducing the need for institutionalisation.[4]

Frailty's original conceptualisation was John Brocklehurst's dynamic 'balance beam', where the older person was acknowledged to have capacities for resilience that were balanced over time to a greater or lesser degree, against their deficits.[3] Over recent years the emphasis has been increasingly on quantifying and comparing individuals' 'deficits'.[3] 'Deficits' are defined by Rockwood et al.[5] as health-related signs, symptoms, disabilities or diagnoses, which, according to the author's frailty index, can be counted to estimate an individual's frailty level. Frailty by this measure has been applied widely throughout primary care in the UK using routinely collected patient data. Another example of the more technical approach to frailty assessment is the popular Clinical Frailty Scale (CFS), validated against the Canadian Study of Health and Ageing frailty index.[5] This pictorial scale with corresponding vignettes allows an individual to be categorised on a scale between 'fit' and 'very severely frail', producing a quick means of estimating an individual's risk of death or institutionalisation.[5] When devised in 2005, the authors cautioned that the judgment-based CFS might be better utilised by clinicians with experience in the care of older people, and concluded that its application for clinical practice remained unclear.[5]