COVID-19 Ethical Issues in Decision-making Regarding the Elderly Affected by Coronavirus Disease 2019: An Expert Opinion David Martínez-Sellés,1 Helena Martínez-Sellés2 and Manuel Martinez-Sellés2,3 1. School of Medicine, Autonomous University of Barcelona, Barcelona, Spain; 2. School of Medicine, Complutense University of Madrid, Madrid, Spain; 3. Cardiology Department, Gregorio Marañón University Hospital, CIBERCV, European University of Madrid, Madrid, Spain Abstract The coronavirus disease 2019 (COVID-19) pandemic is resulting in ethical decisions regarding resource allocation. Prioritisation reflects established practices that regulate the distribution of finite resources when demand exceeds supply. However, discrimination based on sex, race or age has no role in prioritisation unless clearly justified. The risk posed by COVID-19 is higher for elderly people than for younger people, so older adults should be prioritised in preventive measures. In the case of people who already have COVID-19, healthcare professionals might prioritise those most likely to survive. Making decisions based on chronological age alone is not justified; in addition to age, other aspects that determine theoretical life expectancy must be taken into account. Individualised correct prioritisation in the allocation of scarce resources is essential to good clinical practice. Keywords COVID-19, ethics, elderly, prioritisation, resources, age, life expectancy Disclosure: The authors have no conflicts of interest to declare. Received: 24 April 2020 Accepted: 27 April 2020 Citation: European Cardiology Review 2020;15:e48. DOI: https://doi.org/10.15420/ecr.2020.14 Correspondence: Manuel Martinez-Sellés, Servicio de Cardiología, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain. E: mmselles@secardiologia.es Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non- commercial purposes, provided the original work is cited correctly. Nearly every country is now affected by the coronavirus disease 2019 example sex mismatch might influence the outcome of a heart (COVID-19) pandemic. The disease is spreading rapidly and is taxing the transplant.3,4 global healthcare system, particularly intensive care units (ICUs). Physicians are faced with ethical decisions regarding the allocation of Prioritisation does not mean that one life is more valuable than another, these precious resources, especially ventilators. Although only a few of as all lives are equally valuable. When resources are insufficient to save those infected with severe acute respiratory syndrome coronavirus 2 all those in need, prioritisation means allocating the available assets in (SARS-CoV-2) require admission to intensive care, the burden on the most effective way. This method allows priority treatment of healthcare systems is unprecedented. This article focuses on ethical patients more likely to benefit from the scarce resource. Prioritisation issues in decision-making regarding COVID-19, particularly in the should be as objective as possible but also flexible to changes in clinical elderly. situation. Transparent mechanisms to determine which patients will receive a specific resource are desirable and should be explained to Madrid has been one of the cities with the higher number of COVID-19 patients who finally receive an organ, to those who are denied and to cases and casualties so far. We have suffered from limited resources the public. and lived with these ethical issues on a daily basis. Also, Spain is experiencing population ageing at a rate that is unprecedented in Ageism Europe and COVID-19 infection is particularly severe in the elderly.1,2 Ageism encompasses stereotyping, prejudice and discrimination against people on the basis of their age. Ageism is widespread and an Prioritisation insidious practice that has harmful effects on the health of older adults. Prioritisation for the allocation of scarce resources is not confined to A recent systematic review showed that the significant adverse the COVID-19 outbreak. Transplant organs are examples of scarce relationship between ageism and health is even more consistent than resources where prioritisation criteria for allocation are common and the relationships found in systematic reviews of the effects of racism physicians have to make a case-by-case evaluation in order to on health.5 Moreover, European doctors worry about the care they will establish which patient receives the organ. Prioritisation reflects receive when they are old, with 80% of healthcare professionals established practices that regulate the distribution of finite resources anxious about how they would be treated, suggesting they realise that when demand happens to exceed supply. Discrimination based on ageism is very common.6 Paradoxically, increasing numbers of elderly sex, race or age has no role in prioritisation unless clearly justified, for people are remaining healthy and some of them have important © RADCLIFFE CARDIOLOGY 2020 Access at: www.ECRjournal.com 1 COVID-19 Figure 1: Queen Elizabeth II and Pope Francis Queen Elizabeth II, aged 94, and Pope Frances, aged 83. Would they receive optimal management if they had severe COVID-19? Sources: Cubankite/Shutterstock.com and AM113/ Shutterstock.com. Table 1. Therapeutic Planning Checklist for Elderly European Geriatric Medicine Society insists that advanced age alone Patients Admitted to Hospital due to COVID-19 should not be a criterion for excluding patients from specialised hospital units.8 If an elderly patient is dismissed from a specialised • Discuss the full therapeutic plan with the patient (and family members) hospital unit for any reason, access to medical attention, symptomatic • Ask about advance directives treatment and palliative care must be ensured. This last point is essential, as palliative care is frequently suboptimal in elderly patients • Identify any next of kin who might be involved in end-of-life decisions with other conditions, such as heart failure, and this is probably the • Obtain relatives’ contact information (the more the better) case in COVID-19.2,9,10 • Include the therapeutic plan clearly in the clinical history • Assess and record whether or not the patient is a candidate for mechanical Therapeutic Adaptation after COVID-19 Admission ventilation In patients with advanced age who are admitted to hospital due to a • Assess and record whether or not the patient is a candidate for severe SARS-CoV-2 infection, it is very important to establish a cardiopulmonary resuscitation therapeutic adaptation plan from the time of admission. This plan • Discuss the possibility of future withdrawal of life-sustaining therapies should be clearly documented in the clinical history, making it clear • Ask about religion/spiritual preferences whether or not the patient is a candidate for mechanical ventilation and, in case of their condition worsening, when to propose the international responsibilities. For instance, Pope Francis is now 83 withdrawal of life-sustaining therapies (Table 1). Decisions that years old and Queen Elizabeth II is 94 (Figure 1). maximise survival to hospital discharge, the number of years of life saved and the possibility of living each of the stages of life can be COVID-19 and the Elderly prioritised. In this regard, patients with minimal expected benefit The risk posed by COVID-19 is higher for elderly people than for younger should not be admitted to ICU and the admission of patients with a people.2 For this reason, medical and political authorities should offer life expectancy <1–2 years should be carefully evaluated. This older adults strict preventive measures to minimise the risk of exposure applies to patients of all ages. A utilitarian mentality should be and infection. In the event that an effective vaccine for SARS-CoV-2 is applied, which should prevent prejudice against the elderly. For developed, priority should be given to vaccination of the elderly, with example, a frail elderly patient might have a low chance of surviving the aim of maximising the number of lives saved. This is also true for the prolonged intubation required to recover from COVID-19 other preventive measures, such as possible pre- or post-exposure pneumonia, but this is also the case for young patients with severe prophylaxis.7 comorbidities.11 In the case of people with COVID-19, the situation is different. When The Madrid Experience allocating resources in these scenarios, healthcare professionals might During the peak of the outbreak, more than two-thirds of beds in most prioritise those most likely to survive over those with remote chances hospitals in Madrid were occupied by patients with COVID-19. Figure 2 of survival. Making a decision based on chronological age is not depicts the official numbers of patients admitted to hospital, admitted justified. In addition to age, other aspects that determine theoretical life to ICUs, who died and who recovered in Spain between mid-March expectancy must be taken into account. Biological age and the use of and the middle of April.12 Non-invasive ventilation was attempted frailty scales and comprehensive geriatric assessment are essential for frequently, even using improvised alternative strategies like the this purpose. The recent statement of the Executive Board of the modified Easybreath diving mask to administer continuous positive 2 EUROPEAN CARDIOLOGY REVIEW Ethical Issues: Elderly Affected by COVID-19 airway pressure therapy. Invasive ventilation was often necessary and, Figure 2: Official Daily Evolution of the Number of in spite of tremendous efforts by the hospitals (for example Gregorio Patients Admitted to Hospital, Admitted to Intensive Marañón University Hospital opened ICUs in operating rooms and in Care Units, who Died and who Recovered in Spain the library), there were not enough ICU beds for all the critically ill patients who needed them. The limited availability of ventilation support was even more problematic due to the prolonged intubation – often more than 3 weeks – that many of these patients required. The news that prioritisation criteria were being applied in Spanish hospitals sparked widespread controversy and triggered a debate about the right of every individual, particularly the elderly, to access specialised healthcare.13 Use of Off-label Therapies Effective therapies for this novel coronavirus are needed urgently and several clinical trials are now underway.14 Meanwhile, the use of use of off-label therapies based on in vitro data and early clinical experience with COVID-19 has increased dramatically; examples Source: Ministerio de Sanidad et al. 2020.12 include remdesivir, lopinavir, ritonavir, interferon, chloroquine, hydroxychloroquine, azithromycin, tocilizumab, steroids and cyclosporine. To date, no therapies have been shown to be Figure 3: Confinement – the Stay-at-home Policy – has effective.15 Moreover, some of these drugs have frequent and Positive and Negative Effects in Individuals of Advanced Age potentially life-threatening side-effects, particularly in the elderly. Most are known to prolong the QT interval and can have a Cons Pros proarrhythmic effect.16 Confinement: Pros and Cons Confinement is an effective way to decrease SARS-CoV-2 transmission Reduce infection and is a way to win time until effective therapies are developed and/or risk Physical and an effective and safe vaccine is available. However, the stay-at-home psychological effect s policy has negative effects in those with advanced age (Figure 3). The Win time psychological risk of confinement is particularly high among vulnerable Economic consequences populations, such as those in a situation of dependence or that live Wait for vaccine alone. The negative consequences are multifaceted, with physical, mental and social aspects. Staying at home for long periods of time facilitates sedentary behaviours and might worsen previous frailty or pre-frail conditions. At the time of writing this article, our parents/ grandparents (aged 82 and 78) have not left their home for 2 months. We are certainly concerned about their situation. Moreover, confinement is extremely negative for the economy and the elderly might end up suffering the consequences of a severe economic frequently impossible for families to see their deceased loved ones depression. Finally, the legal situation varies a lot from country to one last time. country. New laws have created legal frameworks that frequently restrict or prohibit the movement of people and vehicles. Some The rules of social distancing put in place by the health authorities countries have severe penalties for those who do not comply with the applies also at funerals. Services must be limited to close family new rules. members only (with a maximum of three people), usually with video recording and streaming for those who wish to attend the funeral from Family and Mourning a distance. Finally, the vast majority of older people in Spain are Catholic. The COVID-19 pandemic has isolated the elderly not only at home but The fact that public masses have been cancelled makes the situation also in hospitals. Visits are usually not permitted. Several patients of even more difficult for families. advanced age with severe infection have died alone in the hospital or in nursing homes. Conclusion COVID-19 in elderly patients raises some ethical issues; however, most The suffering of the family does not end there, as containment of these issues are similar to ethical problems in other conditions, measures also apply in the context of mourning, which adds trauma such as heart failure.17–19 The correct prioritisation for the allocation of to that of death itself. Corpses are considered potentially infectious, scarce resources should be based on various factors relating to the so are deposited as soon as possible in a body bag that will never be individual. Chronological age should not be the only factor that reopened. During the peak of the outbreak in Madrid, we had so many influences the decision-making process. This is essential to good deaths that an ice rink had to be used as a provisional morgue. It was clinical practice. EUROPEAN CARDIOLOGY REVIEW 3 COVID-19 1. Foreman KJ, Marquez N, Dolgert A, et al. Forecasting life receive when they are old. BMJ 2012;344:e77. https://doi. (SEMICYUC). Recomendaciones éticas para la toma de expectancy, years of life lost, and all-cause and cause-specific org/10.1136/bmj.e77; PMID: 22228700. decisiones en la situación excepcional de crisis por mortality for 250 causes of death: reference and alternative 7. Emanuel EJ, Persad G, Upshur R, et al. 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