Setting Goals or Shifting Goalposts: Role of Frailty for Critical Care Decisions During COVID-19
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© Serdi and Springer Nature Switzerland AG 2020
J Frailty Aging 2020;9(4)246-247 Published online September 2, 2020, http://dx.doi.org/10.14283/jfa.2020.46
LETTER TO THE EDITOR SETTING GOALS OR SHIFTING GOALPOSTS: ROLE OF FRAILTY FOR CRITICAL CARE DECISIONS DURING COVID-19 Dear Editor, Frailty is characterized by a loss of physiological reserves leading to increased susceptibility to adverse outcomes with stressor events (1). With healthcare resources worldwide overstretched by the unprecedented COVID-19 pandemic, there is intense interest in reliable assessment tools to inform patient prioritization for scarce intensive care resource. Not surprisingly, frailty tools have been thrust into the spotlight as the panacea to age-based criteria for critical care triage decisions. However, detractors worry that rigid and indiscriminate application of frailty tools may ironically exacerbate the deprioritising of older adults and other vulnerable populations. Herein, we describe the 3F approach to guide thinking about the role of frailty in critical care decisions for older adults during the COVID-19 pandemic. Framing Setting goals of care versus shifting goalposts of care Frailty captures the health status of an older person and predicts adverse outcomes in the community and acute inpatient care settings. Over the years, geriatricians have promoted frailty as part of a patient-centred approach to assessment that is the cornerstone for rational contextappropriate goals of care (2). On this basis, there is keen interest in the development and broad uptake of convenient screening and assessment tools to assist in frailty identification amongst older people who access the healthcare system (1). Its utility in predicting adverse outcomes have also been examined in the intensive care unit (ICU) setting. Whilst the multidimensional measure of frailty such as Clinical Frailty Scale (CFS) and Frailty Index (FI) generally predict higher hospital mortality, longer length of stay, poor functional outcome and institutionalisation, these findings are not uniform across all studies (3). Notably, there are no outcome studies that examine the effectiveness of frailty for ICU triaging purposes. Using frailty for such a purpose would be akin to shifting goalposts of care with current knowledge. Framework Right instrument for the right purpose While frailty has value in allocation of scarce health resources, it also has limitations. Frailty does not invariably lead to adverse outcomes in older adults. In fact, a recent study demonstrated that the outcomes for frail patients more Received June 15, 2020 Accepted for publication June 23, 2020
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than 80 years of age can be good, with 91% surviving ICU admission, 82% surviving to hospital discharge, and fewer than 5% discharged to new nursing home care (4). Within the spectrum of frailty, the mildly frail have better outcomes than the moderately or severely frail, even in the oldest-old, and should not be excluded from ICU care. Moreover, as frailty has never been validated for ICU triaging
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