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

Is Frailty, by CFS, a Helpful Predictor of Adverse Outcomes in COVID-19?

Emerging research shows that frailty could be helpful in predicting short-term adverse outcomes in patients admitted with COVID-19.[6] Adjusted odds ratios for 7-day mortality increased in a graded manner, by CFS group, in observational data from across the UK and one Italian site.[6] There is also a building evidence base showing that frailty in critical care, (frequently measured by CFS), is associated with increased mortality and higher likelihood of discharge to an institution.[7,8] The National Institute for Health and Care Excellence (NICE) in its recent rapid guideline produced a decision aid that recommends using the CFS for adults aged over 65 as part of a 'holistic assessment' to assist in clinical decision-making about the appropriateness of offering critical care to older people presenting with COVID-19.[9] This guideline has helpfully promoted timely discussions regarding resuscitation status and escalation of care, recommending that individualised care should not be compromised, and that the wishes of patients and family members are considered. However, the aims of the guideline as stated are 'to make the best use of NHS resources'; in this instance, critical care capacity. Thus, frailty scoring is being recommended as a basis for rationing access to potentially life-saving resources.

However, pre-COVID-19, it is clear that older people with frailty were frequently offered critical care, a recent meta-analysis finding that the prevalence of pre-admission frailty among the critical care population was 30%.[7] Assuming that these were appropriate critical care admissions, one would expect that older people with frailty would benefit from similar admission rates to critical care during the COVID-19 pandemic. In a retrospective study of over 15,000 adults aged >80 years, who were admitted to critical care in New Zealand and Australia, 39.7% were frail by CFS.[8] Older adults with frailty had poorer outcomes compared with the non-frail, yet their outcomes were surprisingly good; 88% survived to hospital discharge, 55% were discharged to their own homes and a further 24% were discharged to a rehabilitation facility.[8,10] With the caveat that these outcomes were recorded in a well-resourced health system, and are not data relating to COVID-19 outcomes, the important message is that frailty, while indeed associated with poorer outcomes, by no means indicates futility. In the UK, it is likely that fears of an overwhelming critical care demand influenced this frailty-based rationing, even where resources were available. Now that the initial UK peak of COVID-19 infections has passed, it may be a helpful time to review our practice.

One recommendation would be that physicians with expertise in older people's medicine should be involved early in discussions that inform the direction of care, to ensure that the NICE guidance is implemented prudently, using a holistic approach and the principles of shared decision-making, as supported by the Royal College of Physicians.[9,11]