Did the UK response to the COVID-19 pandemic fail frail older people?
Rowan H Harwood is a consultant geriatrician and Professor of End-of-Life Care at the University of Nottingham. He is Editor-in-Chief of Age and Ageing.
We must be generous in assessing responses to a crisis. Hindsight is a marvellous tool, and decisions made in good faith in real time may not work out in practice as circumstances evolve. It was right to plan for eventualities such as health services being entirely overwhelmed, and we are fortunate that this never came to pass.
However, we must also analyse and learn lessons so that in future we are even better equipped. I believe that four issues have not worked well for frail older people in the response to the COVID-19 pandemic.
Care homes were always vulnerable; residents are frail and live communally. The problems care homes faced were not properly anticipated and effective quarantine of an infected or exposed resident was always going to be difficult. Many care homes responded with early ‘lockdown’, electing to discontinue all visits to protect their residents. However, this was alongside the initial policy emphasis on freeing-up hospital beds by mandating early discharge to care homes, and working on the basis of optimistic infection control assumptions within them. Uncertainty over date of onset and length of infectivity, insufficient testing and relative lack of personal protective equipment in care homes has exacerbated their inherent risk. A precautionary approach would have protected care homes by quarantining new or returning residents for longer. The widespread outbreaks, mortality and threats to residents’ long-term wellbeing suggest we did not get this right.
Demonising acute hospital care
Acute hospital care is neither necessarily futile nor intolerably burdensome. Hospital admissions are driven by crises, acute illness or changes in function or behaviour where assessment and therapy can only be delivered in the hospital setting. We invest a lot of clinical effort in ensuring that people are managed ‘closer to home’ if that is possible, but that is not always possible for a variety of reasons. We know that systematic Comprehensive Geriatric Assessment and Management leads to the best outcomes in terms of survival and function. We also know that sometimes problems at the end of life also need hospital-level care. Most public discussion of hospitals has been around availability of Intensive Care Unit beds, but most patients do not go to ICU, and non-ICU hospital care still has plenty to offer frail older people: monitoring, oxygen, fluids, antibiotics for superadded infections, symptom relief, prevention of complications, optimisation of comorbidities and early rehabilitation. The aggressiveness of the treatment and degree of burden can (and should) be negotiated and agreed. Most ill patients recover and are discharged, and this has not changed. Recently, many with co-morbid conditions have avoided presenting to hospital, or have presented at a later stage of illness, which will have contributed substantially to the excessive overall mortality we have seen in the UK compared with other countries.
Advance care planning
We must all plan for the future, including our healthcare preferences, and this requires a realistic appraisal of treatment benefits. We appear to have come to assume that all frail older people are ready to die, and would not want even measured and relatively non-burdensome efforts to maintain life and encourage recovery of wellbeing and function. A Clinical Frailty Scale Score of 5 or 6 does not imply that death is imminent, even if it means that surviving an ITU admission is unlikely. We have legal and care planning mechanisms to ensure that unwanted medical care is avoided, but also that beneficial options are also considered. ‘Living well with frailty’ includes avoiding crises where possible, celebrating recovery and coping, and using a shared decision-making process to decide on acceptable care, and remains relevant in a pandemic. Driven by fear of overwhelming hospitals, we have identified people who would not survive an admission to ITU with COVID-19 pneumonitis, and suggested they should all prioritise comfort care, preferably out of hospital. In an overwhelmed health services this may have become reasonable, but in many places this has not happened. We have mixed up measures to target treatment to those who can best benefit with rationing. The ACP ‘brand’ has been damaged, and it will take time for us to reinstate it as a positive aspect of patient care.
‘Herd immunity’ is a vaccination concept. If a large enough proportion is vaccinated, an infectious disease no longer circulates within the population, and we say that ‘herd immunity’ has been achieved. This protects those who cannot be vaccinated or are otherwise especially vulnerable. Natural infection does not lead to ‘herd immunity’: measles and smallpox were endemic before vaccination. For measles the immune proportion needs to be >90% for herd immunity to occur, and when MMR vaccination rates dropped below this, outbreaks re-emerged. The public health response to an epidemic, as advocated by WHO, is case identification, contact tracing and quarantine. This is what worked for SARS and Ebola. In the absence of a vaccine, a viral epidemic has to be contained and suppressed, yet The UK abandoned this approach far too early and adopted a concept not designed for this application, that risks, rather than protects, the most vulnerable. Prevention was the only way to protect old, frail and vulnerable people.
In summary, whilst there have been aspects to celebrate in our national management of COVID-19, we are also left with questions around how the needs of our frailer population was considered and prioritised, and, how some of the decisions and lost opportunities may adversely impact continuing conversations around illness trajectories and anticipatory planning.