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


Frailty provides a means of stratifying and quantifying the gradual reduction in physiological reserve that occurs as the body ages. The main benefit of applying frailty indices, such as the CFS, to assist in decision-making during the COVID-19 pandemic is that, used with care, it may contribute to shared decision-making based on the likelihood of short-term survival, and is more informative and less discriminatory than chronological age alone. While it is evident that a decision aid may be beneficial to guide non-specialists during emergencies of resource-shortages, the implementation of this guideline, particularly in the absence of a significant pressure on resources could disadvantage older people with frailty who wish to be considered for critical care. One major limitation of the CFS, as applied in the current NICE guideline, is that it has the potential to reinforce established patterns of inequality.

While full CGA is neither practical nor warranted for all, the increased involvement of geriatricians early in older people's hospital admission is likely to improve the quality of care for older people admitted with COVID-19, allowing important social determinants of health to be fully considered. While we have discussed issues relating to assessment and decision-making for older people who reach hospital, this commentary has not addressed the significant impact of COVID-19 in care homes, and challenges relating to decision-making in the community.

Our incomplete understanding of this novel disease means that there is urgent need for more research investigating the short-term predictive abilities of the CFS in COVID-19, particularly with regards to critical care interventions. 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 to sustain or worsen unequal health outcomes. With the initial UK peak of infections behind us, geriatric medicine should take this opportunity to re-commit to fostering an approach to clinical decision-making based on frailty assessment that balances risk with resilience for older individuals of every CFS score.