Elderly exclusion from hospital/ICU

KyussB

Something that flew under the radar for me, is that there are strong signs that many EU countries have an unstated policy of excluding the elderly (70-80+) from hospital/ICU.

This includes Ireland, too - not all hospitals though - excuse the source:

Guidelines established by the Saolta Hospital Group show that anyone who scores more than eight points in the system should not be sent to ICU during the Covid-19 crisis.
...
Patients are given points for their age with people over 80 hit with seven points – just one shy of the exclusion total - despite government ethical guidelines advising that patients should not be excluded from treatment because of their age.

https://www.thesun.ie/news/5319621/coronavirus-in-ireland-points-system-intensive-care-elderly/

The UK:

One care home manager in Hove told me their GP had even told them "none of your residents aged over 75 will be admitted to hospital". They said they felt "shocked and numb" to hear that.

https://www.bbc.co.uk/news/uk-politics-52155359

Reports of UK nursing home residents being pressured into signing DNR's as well - some even having DNR's applied without being consulted properly.

Spain/Italy have also done this, when their hospital system was overwhelmed:
https://www.express.co.uk/news/world/1263321/Spain-coronavirus-death-toll-surge-ICU-elderly-vulnerable-doctor-news-latest
https://www.haaretz.com/us-news/.premium-in-u-s-coronavirus-crisis-will-trump-save-the-elderly-or-condemn-them-to-death-1.8687478

Balf

KyussB wrote: »

Something that flew under the radar for me, is that there are strong signs that many EU countries have an unstated policy of excluding the elderly (70-80+) from hospital/ICU.

There's been a lot of coverage, so its hard to stay in touch with it all. But, yes, this is a feature of debates on the topic.

Our gubbermint guidance is here:

https://www.gov.ie/en/publication/13ead5-ethical-considerations-relating-to-critical-care-in-the-context-of-c/

I don't know how much this impinges on actual clinical decisions on the ground, but the issues are unavoidable. The key point is this

"Access to intensive care should generally be reserved for those patients most likely to benefit (those who will most likely survive their acute illness with reasonable long-term functional status). No single factor (e.g. a person’s age) should be taken, in isolation, as a determining factor and decisions should not be made arbitrarily or in such a way as to result in unfair discrimination."

Its a subtle distinction, but an older person will usually have less 'long term functional status' ahead than younger people. To say nothing of the fact that they've already enjoyed more 'long term functional status', so its fair to give some else a chance if resources are scarce.

So how about "Its not about your age or disability, its your long term functional status"

KyussB

The trouble is, there seems to be a prevalent bias to it being reduced to age. It seems like this is even the case, when the hospital system hasn't yet been overwhelmed, as well.

It reeks of making an economic calculation about a persons life, instead of putting in the resources to maximize the health systems capacity now, before any potential surge/peak - if there's any possibiliy of being overwhelmed still remaiing, then we're not doing enough to rapidly expand capacity.

As long as the capacity is there, it should be up to the person to decide whether treatment should be held back, not the doctor. The elderly are the most vulnerable group, with the highst fatality rate.

Balf

KyussB wrote: »

It reeks of making an economic calculation about a persons life, instead of putting in the resources to maximize the health systems capacity now, before any potential surge/peak - if there's any possibiliy of being overwhelmed still remaiing, then we're not doing enough to rapidly expand capacity..

I don't think any reasonable person could say that economic calculations are driving this. If they were, we wouldn't have closed down large parts of business and put a quarter of the workforce on the dole, while paying empty private hospitals €100 million a month just in case we need them.

If anything, we haven't had enough economic calculation. If this circus is meant to drag out beyond May, we need a lot more economic calculation before we find ourselves reemerging in the palaeolithic era.

is_that_so

Henry has commented at length about how they approach nursing homes and that they determine where the greatest benefit might be to the patient. Oftentimes staying where they are may be the best place for them.

KiKi III

This happens all the time across our health service and around the world.

If you’re diagnosed with cancer at 65 you might be offered chemo, whereas with the same cancer at 85 you would be offered palliative care.

It’s about the likelihood the treatment would work, and also whether ongoing treatment is a better decision than palliative care. Being resuscitated, intubated, put on a ventilator only to die a few days later anyway is a horrible way to spend your last few days on earth.

biko

"Thanks for building the country we live in, but if you get sick we throw you under the bus".
Kinds regards, people less likely to get sick.

jam_mac_jam

If people are in their eighties how likely are they to recover from these types of invasive treatments. At a certain point you have to draw the line to prevent unnecessary suffering and pain for the patient involved.

Sometimes its better to let go but with the increased medical capabilities people expectations have greatly increased over the years.

PCeeeee

biko wrote: »

"Thanks for building the country we live in, but if you get sick we throw you under the bus".
Kinds regards, people less likely to get sick.

Biko. With the greatest of respect there is a bit more nuance than that. The post above yours goes a way towards explaining it.

Clinical decisions like this were being made long before Covid.

jam_mac_jam

biko wrote: »

"Thanks for building the country we live in, but if you get sick we throw you under the bus".
Kinds regards, people less likely to get sick.

Nobody is getting thrown under a bus. It's about putting people under extreme treatment for a small hope they will recover when in likelihood you will just prolong pain and suffering for no reason.

Doctors are not monsters, they are obviously considering the best outcome for the patient.

Manach

Looking at this through the lens of law and ethics ( from my reading of Keown, John. "The Law and Ethics of Medicine" ) would suggest that cost is one of the key drivers, in that the state does not wish to spend money ( even on line items such as Palliative Care ) on those that are deemed uneconomical. The older morality of valuing each life at every stage of development has been overturned with the emphais on the economic well-being and not the human being.

KevRossi

This is something that's wildly exaggerated by the arse rag that is The Sun. There's plenty of coverage of people in their 80's and 90's being treated in ICU's and surviving COVID. It makes for a bit of hysteria, which is what they thrive on.

As it stands, our ICU's are nowhere near capacity and there's plenty of spaces in hospitals. Nobody who needs it is being refused treatment. Of course, if we hadn't done the lockdown and if the services had been overwhelmed, then they would take certain people over others, and age/health condition would be a factor.

Here's a 97 year old who was treated and survived COVID-19

The One Doctor

KyussB wrote: »

The trouble is, there seems to be a prevalent bias to it being reduced to age. It seems like this is even the case, when the hospital system hasn't yet been overwhelmed, as well.

It reeks of making an economic calculation about a persons life, instead of putting in the resources to maximize the health systems capacity now, before any potential surge/peak - if there's any possibiliy of being overwhelmed still remaiing, then we're not doing enough to rapidly expand capacity.

As long as the capacity is there, it should be up to the person to decide whether treatment should be held back, not the doctor. The elderly are the most vulnerable group, with the highst fatality rate.

ICU beds are limited by experienced staff. ICU staff are at a severe premium, they (both nurses and doctors) are a very experienced, educated and tough bunch and make the difference between life and death in thousands of cases. Training up ICU staff takes time, effort and money. Given that the hospitals are nearing capacity, training new ICU staff is a lower priority right now.

ICU is not like a hotel, you can't just hire anyone to fill the gaps. ,Therefore we're stuck with the capacity we have right now and triage applies for sound reasons.

splinter65

biko wrote: »

"Thanks for building the country we live in, but if you get sick we throw you under the bus".
Kinds regards, people less likely to get sick.

This is nonsense. My mother is a fit and active and healthy 85 year old. But the idea that she would spend her last days on a ventilator with a tube down her throat lying on her stomach is totally disgusting to both her and me.
I see all the people in nursing homes are to be tested. Can you imagine being 95 with some dementia sitting comfortably in your armchair and seeing a health worker dressed head to foot in PPE heading towards you to stick the swab up your nose?

ZX7R

It also about cost not just age .
If two people are sick and it costs €20,000 to cure one person.
The person most likely to progress after being cured will be chosen first.
It's not viable to spend the same money on the other person if there is limited likely hood of progress after a treatment.

Balf

KiKi III wrote: »

It’s about the likelihood the treatment would work, and also whether ongoing treatment is a better decision than palliative care. Being resuscitated, intubated, put on a ventilator only to die a few days later anyway is a horrible way to spend your last few days on earth.

I sometime wonder if posters with obviously unrealistic views on this topic have much experience of actually being with a close relative in the last few weeks of their life.

iamwhoiam

biko wrote: »

"Thanks for building the country we live in, but if you get sick we throw you under the bus".
Kinds regards, people less likely to get sick.

Decision not to treat elderly frail people with heroic efforts was a fact long long before Covid . In fact many elderly have signed that they want no ventilation, no recuss and no heroic intervention .I will be signing that myself when I get to a certain age and frailty . The decision to allow an elderly frail person die in peace in their own surroundings with staff who know them and love them is a kind one.

BrianD3

KiKi III wrote: »

This happens all the time across our health service and around the world.

If you’re diagnosed with cancer at 65 you might be offered chemo, whereas with the same cancer at 85 you would be offered palliative care.

It’s about the likelihood the treatment would work, and also whether ongoing treatment is a better decision than palliative care. Being resuscitated, intubated, put on a ventilator only to die a few days later anyway is a horrible way to spend your last few days on earth.

Chemotherapy isn't a good comparison as it is of limited benefit for most cancers regardless of patient age. And if you give it to everyone with cancer, it won't "overwhelm the health service". If the treatment is one of the newer targeted therapies it can be extremely expensive and the survival benefit is still small. An 85 year old has an average life expectancy of about 5 years, a 65 year old an average of about 20 years. If a therapy gave a survival benefit of 6 years then there could be a case for saying that it is not worthwhile giving it to an 85 year old - but the survival benefit from most non surgical cancer treatments is measured in months at best. Also, chemotherapy can used as part of palliative care.

You are correct about the intubation not being of benefit for some patients due to a combination of age AND overall health

However I have a bad feeling here (based on how the HSE operates and my own experiences of them) that they may have overshot in terms of keeping people out of hospital (not just ICUs) who in non Covid times would have been admitted. Throwing the baby out with the bathwater due to fear of The Surge. They know that there will be war if we get through this crisis having left sick people in their nursing homes (where staff don't have PPE and there are other problems) without having come close to overwhelming the hospitals. So now they're trying to shift the narrative that people are wrongly staying away from hospital when they are sick with non Covid conditions.

KyussB

If I make it to 80, I want to be the person deciding whether or not treatment involves too much suffering/pain.

The point here, is that the choice may be getting removed from people - so it's not actually about the wishes of the person anymore.

We need ICU surge capacity to be in excess anyway, due to the risks of repeat waves of infections - so it makes no sense to not use these resources for the elderly as well. It is neither economic nor moral to deny people care like that.

Where there are resource constraints, we need to be putting effort into alleviating them anyway. It's not expensive when you alleviate the resource constraints - certainly not on the large scale of things today.

PCeeeee

KyussB wrote: »

If I make it to 80, I want to be the person deciding whether or not treatment involves too much suffering/pain.

The point here, is that the choice may be getting removed from people - so it's not actually about the wishes of the person anymore.

We need ICU surge capacity to be in excess anyway, due to the risks of repeat waves of infections - so it makes no sense to not use these resources for the elderly as well. It is neither economic nor moral to deny people care like that.

Where there are resource constraints, we need to be putting effort into alleviating them anyway. It's not expensive when you alleviate the resource constraints - certainly not on the large scale of things today.

Kyuss, your choice will not be removed from you by your advancing age. You will be betrayed by your own body. The fact is when you are 80, you are likely to have a number of underlying conditions. These and your physical condition will dictate your treatment options, which will be decided by your physician. You can then decide your options based on the treatment available.

Even now we have only an illusion of choice, if (God forbid) you or I receive a terminal diagnosis tomorrow morning, then our Doctor will decide what options if any we have. How could it be any other way? I am not in a position to make that call.

KyussB

It's certainly not that way for the wealthy. No chance in fuck of that.

This isn't a cancer diagnosis with ultra-expensive pharma treatment options - it's a global pandemic that we were promised equal treatment on.

The decision of whether or not treatment involves too much suffering/pain, should be in the hands of the patient - there is no good reason to not have it that way for coronavirus treatment. That doesn't remove other factors from consideration.

The added problem is that there are strong signs that blanket decisions based on age may be getting made, with signs of this across multiple EU countries.

biko

People that make death decisions based on age will soon make death decisions based on other things.

"Is this person a productive members of my society?"

jibber5000

KyussB wrote: »

It's certainly not that way for the wealthy. No chance in fuck of that.

This isn't a cancer diagnosis with ultra-expensive pharma treatment options - it's a global pandemic that we were promised equal treatment on.

The decision of whether or not treatment involves too much suffering/pain, should be in the hands of the patient - there is no good reason to not have it that way for coronavirus treatment. That doesn't remove other factors from consideration.

The added problem is that there are strong signs that blanket decisions based on age may be getting made, with signs of this across multiple EU countries.

It's not based on age. An 87 year old with zero comorbidites would have a 53% 10 year survival and thus would be ventilated.

A 75 year old with kidney disease diabetes heart failure and copd would have a 0% 10 year survival so wouldn't be ventilated.

It's based on clinical judgment not age

PCeeeee

KyussB wrote: »

It's certainly not that way for the wealthy. No chance in fuck of that.

This isn't a cancer diagnosis with ultra-expensive pharma treatment options - it's a global pandemic that we were promised equal treatment on.

The decision of whether or not treatment involves too much suffering/pain, should be in the hands of the patient - there is no good reason to not have it that way for coronavirus treatment. That doesn't remove other factors from consideration.

The added problem is that there are strong signs that blanket decisions based on age may be getting made, with signs of this across multiple EU countries.

Agreed. If you are very rich then you can leverage your wealth to provide treatment outside of the normal range. I'm not sure where the fact that we agree on this point leaves us? Great wealth allows for an extraordinary lifestyle. It doesn't apply to most of us.

'The decision of whether or not treatment involves too much suffering/pain, should be in the hands of the patient'. I would say it still does. Whether or not treatment will be effective is a decision that the clinical team makes. Who else can make this decision?

Equal treatment does not mean the same treatment for all, frighteningly, humanly, we are not all equal. Some of us (including as it happens myself) have health issues that leave us more vunerable, less likely to survive. That is life.

I hope you stay well Kyuss, you, me and everyone else. We are mortal, fragile, breakable.

iamwhoiam

biko wrote: »

People that make death decisions based on age will soon make death decisions based on other things.

"Is this person a productive members of my society?"

Its not based on age its a based on what is kinder for the patients . Always was

KyussB

jibber5000 wrote: »

It's not based on age. An 87 year old with zero comorbidites would have a 53% 10 year survival and thus would be ventilated.

A 75 year old with kidney disease diabetes heart failure and copd would have a 0% 10 year survival so wouldn't be ventilated.

It's based on clinical judgment not age

The scoring system that some hospitals are using - where 8 leads to denial of treatment - treats an age of 80 as a whole 7 points on the way to being denied...

It's absolutely based on age.

There are reports in other countries, like the UK, of cases where there's a bias towards blanket-banning past a certain age - e.g. 75.

beauf

You're a bit in denial here. If you need some massive invasive surgery or medical treatment your age (and health) will be a massive factor in your survivability. Your survivability will be massive factor in deciding if it's a viable use of resources. Part of this is how much distress will be caused and it worth this distress. This has always been the case.

There's no point comparing different countries. They all have different levels of crisis and resources.

MadYaker

biko wrote: »

People that make death decisions based on age will soon make death decisions based on other things.

"Is this person a productive members of my society?"

Ignoring all points and continuing the same line of flawed reasoning. cool.

eleventh

The One Doctor wrote:

Given that the hospitals are nearing capacity, training new ICU staff is a lower priority right now.

Are all hospitals nearing capacity?

beauf

eleventh wrote: »

Are all hospitals nearing capacity?

Capacity within the parameters of the current crisis.

All non essential treatments have stopped. This has allowed normally specialised hospitals to take some of the workload from the larger hospitals focused on the virus cases.

This is why we are in lockdown. To reduce the stress on a health system in war mode.

lozenges

jibber5000 wrote: »

It's not based on age. An 87 year old with zero comorbidites would have a 53% 10 year survival and thus would be ventilated.

A 75 year old with kidney disease diabetes heart failure and copd would have a 0% 10 year survival so wouldn't be ventilated.

It's based on clinical judgment not age

This is absolutely bang on.

It's to do with the clinical condition of the patient. Obviously the older you get the more likely that you will have one or more serious medical conditions. There are some very medically fit 70 year olds and some very medically unfit 40 year olds but on a population level it will mostly be older people who have multiple serious medical conditions.

It's the medical conditions that determine feasible treatment options, not age in and of itself.