Transcriber: Eunice Tan Reviewer: Tanya Cushman
We have all had to change the way we work over the past few months
due to COVID-19.
As a geriatrician working in an acute hospital,
my team and I saw huge changes implemented really quickly
to our working practice.
Multidisciplinary teams pulled together
to get COVID-19 wards ready for our patients.
Delivery of training on all aspects of care for our patients
occurred at a rate never previously experienced.
There was a great sense of camaraderie
mixed with apprehension
about what the care for our patients would look like in practice.
Data from other countries ahead of the pandemic,
such as Italy and Spain,
showed the prognosis for our usual cohort of frail, elderly patients was shocking.
We were psychologically prepared for our crisis,
the potential rationing of ventilators,
and the possibility of our hospitals running out of palliative care drugs.
When we looked at reports from China, the USA, Italy, for example,
we saw that older people
and those with underlying health conditions
did particularly badly if exposed to COVID-19.
All of our patients are older,
and most of them have several underlying health conditions,
such as hypertension, COPD, diabetes, heart disease.
So the prognosis looked particularly poor for our patients.
Many of our patients are also frail.
This means they are less resilient and have depleted reserves.
By definition,
it also means that they have underlying health conditions.
As we age, our immune system becomes less effective also.
And this means that older people are more susceptible
to developing infection in the first place,
and if they do develop it,
they're less able at fighting it effectively.
This issue of reduced immunity
is especially important when we consider coming out of lockdown.
Many people over 70 are annoyed at being called 'older'
when, in fact, they feel very fit and well.
This issue of biological rather than chronological age is important,
but reduced immunity
also has to be factored into the equation.
As a result of COVID-19,
some of our practices in hospital have changed,
and some of these have been beneficial.
Any patient admitted with COVID-19 has an advance care plan drawn up,
and this is regardless of age.
We discuss with the patient
what they would like to happen should they deteriorate on the ward.
Would they like non-invasive ventilation?
Would they like to be considered for ICU? Etc.
We also discuss these wishes with their family if it is appropriate.
And resuscitation wishes are also documented.
The patient is then discussed with the multidisciplinary team
and with the intensive care team if it is appropriate.
These very formalised means of communication
are an excellent way for the multidisciplinary team
to know what the plan is for each exact patient on the ward.
I hope that something like this can continue beyond the pandemic.
The issue of frailty is also discussed on each patient.
We document how frail a patient is according to the Clinical Frailty Scale -
this was devised by Rockwood et al.
There is evidence that patients who are even just mildly frail -
and these are these patients who need help with managing bills
or managing medication, for example -
do not do well in an ICU setting.
With mortality rates of 50% in ICU even in selected patients,
we have to ensure
that we are providing ICU admissions
for patients who are most likely to benefit from it.
An ICU admission is expensive, but it can also be very distressing.
So the potential futility of ICU treatment needs also to be considered.
Beyond COVID-19,
I also hope that people consider their long-term wishes
more readily and more openly with their families.
This anticipatory, or advance care, planning
usually only occurs when a crisis point is reached
and usually in a hospital setting and an emergency.
Many of our patients, however,
have long-term underlying health conditions,
such as dementia, heart failure, cancer, etc,
and many needless hospital admissions occur towards the end of a patient's life.
We all have difficulty accepting our own mortality,
but if people have more open and honest conversations
about what they would like to happen towards the end of their life,
maybe some of these admissions,
which can be distressing for patients and their families,
can be avoided.
During this pandemic,
care homes have been particularly hard hit
and care home deaths may outstrip hospital deaths -
a fact we would have found very difficult to fathom
before the stark reality hit.
Many care home residents, however,
are choosing to remain in their care home, with COVID-19,
rather than be admitted to an acute hospital setting.
GPs, community geriatric teams, and care home assistants
have really stepped up
to provide holistic, patient-centred care where the patient wants it.
I also hope this can continue beyond the pandemic,
when it is appropriate.
Thankfully, in Northern Ireland,
we have not seen the hospital deaths we had been anticipating at all.
Care homes have been particularly hard hit, as mentioned.
Many patients in care homes, however, are reaching the end of their lives
and have underlying health conditions, such as dementia, frailty, etc.
We have a duty to ensure that we provide the right treatment to the right patient
at the right time and in the right place.
And for many care home residents,
this will mean good palliative care in their own home.
I would suggest a good, well-planned palliative care
is something that we should all strive for towards the end of our lives.