de Lange, Dylan W

Haas, Lenneke E M

van Delden, Johannes J M

van Dijk, Diederik

Utrecht University Repository

COMMENTARY Open AccessShould we deny ICU admission to theelderly? Ethical considerations in times ofCOVID-19Lenneke E. M. Haas1* , Dylan W. de Lange2 , Diederik van Dijk3 and Johannes J. M. van Delden4Keywords: ICU, Critical care, Ethics, Triage, Age, Elderly, COVID-19IntroductionThe SARS-CoV-2 (COVID-19) pandemic leads to severeshortages of intensive care unit (ICU) facilities in manycountries. Although most people appear to be asymp-tomatic, some reports suggest that 5 to 25% of infectedpeople require hospitalization and 2–4% require mech-anical ventilation [1]. This strains many ICUs beyondtheir maximum capacity. National critical care societieshave adopted protocols to increase their beds up to200% or more. However, although a lot of effort can bedone to increase the ICU capacity, demand may still out-pace the supply. As a consequence, a scenario can arisein which not every patient who needs ICU treatmentcan be admitted, and difficult decisions about allocationof ICU beds need to be made [2–4]. In this article, wediscuss the use of age as a criterion for ICU treatment intimes of scarce ICU capacity by contrasting it with de-ciding under normal conditions.Deciding about ICU treatment under normalconditionsMedical treatment has to be justified by serving the well-being of the patient, and it should be aligned with thewishes of the patient. The burden of an ICU treatmenthas to be carefully balanced against the estimated chanceof recovery. This chance of recovery is affected by ageand many other factors like the admission diagnosis,severity of organ failure, comorbidities, frailty, and pre-admission performance status [5]. Sometimes, ICU ad-mission might be more appropriate for a fit 90-year-oldpatient than for a vulnerable 65-year-old patient.Elderly patients (defined as 70 years and older) have ahigher risk of death and of functional decline than youn-ger patients. However, the majority of them survives,and in addition, several studies have demonstrated thatelderly ICU survivors might accept their disabilities andaccommodate to a degree of physical disability quitewell, consider their quality of life to be good or satisfac-tory, and report good emotional and social well-beingafter hospital discharge [6].The carefully balancing of pros and cons of ICU treat-ment should be done before ICU admission (as AdvanceCare Planning) but also during a (prolonged) ICUadmission.What is common to all decisions on starting, continu-ing, or foregoing life support is that they should be justi-fied by the autonomous wish of the patient and thebenefit of treatment for that unique patient. Age mayplay a role in these decisions in several ways. It is proxyfor the medical condition of the patient, and advancedage is clearly a factor that should be weighed togetherwith other risk factors for a poor outcome of ICU treat-ment. Elderly patients themselves may also have the feel-ing that they have lived life to its full and that thereforelife-sustaining treatments should not be applied in theirown case. There is, however, no valid reason to limitICU admissions to those under a specific age.© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: lvlelyveld@diakhuis.nl1Department of Intensive Care, Diakonessenhuis, PO box 80250, 3508 TGUtrecht, the NetherlandsFull list of author information is available at the end of the articleHaas et al. Critical Care          (2020) 24:321 https://doi.org/10.1186/s13054-020-03050-xOutcomes of elderly ICU patients with COVID-19Elderly patients admitted to the ICU with COVID-19 areat increased risk of death [7, 8]. Although we need morerobust data about short-and long-term outcomes of eld-erly patients admitted to the ICU because of COVID-19,the mortality rates reported up to now are 40 to 80% [7,9]. These numbers will even become higher, since at thetime of reporting a substantial portion of the patientswas still in the ICU and the follow-up was short.Using age as a selection criterion in time ofscarcityIn circumstances of a pandemic, not only the autonomyof the patient and proportionality of treatment, but alsoshortage of resources may play a role in decisions aboutICU treatment. Emanuel and colleagues proposed to usea utilitarian framework [10]. This strategy aims tomaximize the benefits for the largest number of peopleand prioritize care based on the (estimated) greatest ad-vantage of ICU treatment, the so called incrementalprobability of survival. According to this approach, forinstance, parents of young children should be prioritized,then parents of teenagers, middle-aged people, then eld-erly. Chances of survival rates after ICU admission de-crease with increasing age, making age an importantfactor in this utilitarian approach.The use of age as a selection criterion in case of scar-city can also be justified by pointing at the “fair innings”that a patient has had, meaning that older patients havealready had their opportunity to reach a certain “mature”age, which has given them a fair equality of opportunity.The idea is that everyone should have an equal oppor-tunity to lead a life of a certain duration. While there isno hard and fast rule for what is an unfulfilled life agefor a person, most policies distributing lifesaving re-sources look to those under 18 as gaining priority whilethose in their 80s and beyond, who have had a chance toexperience life and flourish as human being, receivelower priority. We submit that this strategy does notamount to age discrimination as all people are treatedalike: when they become older, their claim on life-sustaining treatment decreases.ConclusionIn this article, we discussed two ways of using age in thetriage of ICU admission. Under normal circumstances,age should be weighed as a risk factor for poor outcome.Together with other risk factors, it may lead to theshared decision to forego ICU treatment. It cannot bejustified to withhold ICU admission for all patientsabove a certain age. In times of scarcity, however, we be-lieve it is justified to prioritize the younger patients, inorder to maximize the benefits for the largest number ofpeople, and because of the fair innings that an elderlypatient has already had.AbbreviationICU: Intensive care unitAcknowledgementsNone.Authors’ contributionsLH, DdL, DvD, and JvD contributed to the ideas of this paper. All authorscontributed to the writing of the paper and read and approved thesubmitted final version.FundingNot applicable.Availability of data and materialsNot applicable.Ethics approval and consent to participateNot applicable.Consent for publicationThe authors have approved the manuscript for submission and consent forpublication. The content has not been published elsewhere. The article doesnot contain individual person’s data.Competing interestsThe authors declare that they have no competing interests.Author details1Department of Intensive Care, Diakonessenhuis, PO box 80250, 3508 TGUtrecht, the Netherlands. 2Department of Intensive Care Medicine and DutchPoisons Information Center, University Medical Center Utrecht,Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. 3Department ofIntensive Care Medicine, University Medical Center Utrecht, Heidelberglaan100, 3584 CX Utrecht, the Netherlands. 4Department of Medical Humanities,University Medical Center, University Utrecht, Heidelberglaan 100, 3584 CXUtrecht, the Netherlands.Received: 23 May 2020 Accepted: 28 May 2020References1. Guan W-J, Ni Z-Y, Hu Y, Liang W-H, Ou C-Q, He J-X, et al. Clinicalcharacteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–20.2. Phua J, Weng L, Ling L, Egi M, Lim C-M, Divatia JV, et al. Intensive caremanagement of coronavirus disease 2019 (COVID-19): challenges andrecommendations. Lancet Respir Med. 2020;8(5):506–17.3. Rosenbaum L. Facing Covid-19 in Italy - ethics, logistics, and therapeuticson the epidemic’s front line. N Engl J Med. 2020;382(20):1873–5. https://doi.org/10.1056/NEJMp2005492. Epub 2020 Mar 18.4. Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV,et al. Triage: care of the critically ill and injured during pandemics anddisasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S–74S.5. Guidet B, de Lange DW, Boumendil A, Leaver S, Watson X, Boulanger C,et al. The contribution of frailty, cognition, activity of daily life andcomorbidities on outcome in acutely admitted patients over 80 years inEuropean ICUs: the VIP2 study. Intensive Care Med. 2020;46(1):57–69.6. Kaarlola A, Tallgren M, Pettila V. Long-term survival, quality of life, andquality-adjusted life-years among critically ill elderly patients. Crit Care Med.2006;34(8):2120–6.7. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020;323(16):1574–81. https://doi.org/10.1001/jama.2020.5394. Online ahead of print.8. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes ofcritically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-Haas et al. Critical Care          (2020) 24:321 Page 2 of 3centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475–81.9. ICNARC report on COVID-19 in critical care. 08 May 2020. ICNARC Case MixProgramme Database. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports. Accessed 19 Apr 2020.10. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C,Boyle C, Smith M, Phillips JP.Emanuel EJ, et al. N Engl J Med. 2020;382(21):2049-55. https://doi.org/10.1056/NEJMsb2005114. PMID: 32202722.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Haas et al. Critical Care          (2020) 24:321 Page 3 of 3

Should we deny ICU admission to the elderly?: Ethical considerations in times of COVID-19

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Should we deny ICU admission to the elderly?: Ethical considerations in times of COVID-19

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