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

Should Frailty be Used to Guide Resource Allocation in This Context?

Regardless of whether or not frailty is useful to predict adverse outcomes in COVID-19, the more challenging and important question may be whether frailty should be used for this purpose.

Frailty is distributed along socio-economic gradients.[12] Individual wealth and neighbourhood deprivation were both independently associated with frailty in a nationally representative population-based English study,[13] suggesting the importance of environmental factors and broader social determinants in shaping health in old age. It is likely that the impacts of COVID-19 are also unequally distributed, with the Office for National Statistics reporting that age-standardised mortality rates from COVID-19 (between the 1 March and 17 April 2020) were more than two times higher in areas of high socio-economic deprivation, compared to the least deprived areas of England.[14] There is also growing evidence that older adults of minority ethnic and racial backgrounds are disproportionately affected by COVID-19. It is likely that racial and ethnic differences in the social determinants of health contribute to these health disparities.[15,16] There is potential that decision-making based on grading by CFS could exacerbate the way that frailty is structured according to cumulative lifetime disadvantages (e.g. due to poverty), and social identities (e.g. race, gender, sexuality). This was recognised by the recent American Geriatric Society (AGS) position statement on resource allocation strategies during the COVID-19 pandemic, which recommends that stakeholders consider the inequitable distribution of social health determinants in decision-making.[15]

There are important ethical considerations when using frailty indices as tools for rationing care. As a resource allocation strategy, frailty is evidently better than chronological age, as a construct that helps identify the heterogeneity of physiological ageing. Yet, due to the CFS being validated for adults aged over the arbitrary cut-off of 65 years, the guideline still risks obliquely promoting a differential treatment of older people, with 'individualised' assessments of frailty for younger adults, and CFS-based decision-making for older adults.[9] We must guard against the idea that scoring an older patient by CFS precludes taking into account their wishes and concerns as individuals, hence geriatrics skill and expertise is critical for the appropriate implementation of the guideline.

The AGS and Canadian Geriatrics Society have both recommended against the unethical and unlawful allocation of resources on the basis of age alone, but crucially, the AGS also cautions against the use of ancillary criterion such as 'long-term predicted life expectancy'.[15] It is also advised that decision makers should focus on potential short-term outcomes, so as not to disadvantage older people. Interestingly, while the CFS can provide an indication of likely short-term outcomes, such as in-hospital survival,[6,8] it was originally validated against mortality at 5 years,[5] thus it can also be viewed as an indicator of medium-term life expectancy. Rationing care based on estimated physiological reserve is undoubtedly intimately linked with chronological ageing, and the ethical implications of this have yet to be fully grappled with.