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Observational Study
. 2021 Jan 11;20(1):10.
doi: 10.1186/s12904-021-00711-8.

Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data

Sam Straw  1 , Melanie McGinlay  2 , Michael Drozd  1 , Thomas A Slater  1 , Alice Cowley  2 , Stephe Kamalathasan  2 , Nicholas Maxwell  3 , Rory A Bird  3 , Aaron O Koshy  1 , Milos Prica  2 , Peysh A Patel  2 , Samuel D Relton  4 , John Gierula  1 , Richard M Cubbon  1 , Mark T Kearney  1 , Klaus K Witte  5
Affiliations
Observational Study

Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data

Sam Straw et al. BMC Palliat Care. .

Erratum in

Abstract

Background: Observational studies investigating risk factors in coronavirus disease 2019 (COVID-19) have not considered the confounding effects of advanced care planning, such that a valid picture of risk for elderly, frail and multi-morbid patients is unknown. We aimed to report ceiling of care and cardiopulmonary resuscitation (CPR) decisions and their association with demographic and clinical characteristics as well as outcomes during the COVID-19 pandemic.

Methods: Retrospective, observational study conducted between 5th March and 7th May 2020 of all hospitalised patients with COVID-19. Ceiling of care and CPR decisions were documented using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. Unadjusted and multivariable regression analyses were used to determine factors associated with ceiling of care decisions and death during hospitalisation.

Results: A total of 485 patients were included, of whom 409 (84·3%) had a documented ceiling of care; level one for 208 (50·9%), level two for 75 (18·3%) and level three for 126 (30·8%). CPR decisions were documented for 451 (93·0%) of whom 336 (74·5%) were 'not for resuscitation'. Advanced age, frailty, White-European ethnicity, a diagnosis of any co-morbidity and receipt of cardiovascular medications were associated with ceiling of care decisions. In a multivariable model only advanced age (odds 0·89, 0·86-0·93 p < 0·001), frailty (odds 0·48, 0·38-0·60, p < 0·001) and the cumulative number of co-morbidities (odds 0·72, 0·52-1·0, p = 0·048) were independently associated. Death during hospitalisation was independently associated with age, frailty and requirement for level two or three care.

Conclusion: Ceiling of care decisions were made for the majority of patients during the COVID-19 pandemic, broadly in line with known predictors of poor outcomes in COVID-19, but with a focus on co-morbidities suggesting ICU admission might not be a reliable end-point for observational studies where advanced care planning is routine.

Keywords: Advanced care planning; COVID-19; Comorbidity; Elderly; Geriatrics; Resuscitation.

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Conflict of interest statement

There are no competing interests for any of the authors.

Figures

Fig. 1
Fig. 1
Bar charts showing a age, b ethnicity, c Clinical Frailty Scale and d co-morbidities in patients deemed appropriate for level one, two or three care. Patients in the present study were often elderly, frail and were multi-morbid
Fig. 2
Fig. 2
Forrest plot showing unadjusted odds ratios of appropriateness of level three care associated with demographic and clinical variables. There were associations between treatment escalation decisions and age, frailty and burden of co-morbidities
Fig. 3
Fig. 3
Bar charts showing outcomes of patients appropriate for level one, two or three care. Patients appropriate for level three care were the most likely to be discharged and least likely to have died during admission. p-value < 0·05*, < 0·01**, < 0·001***
See this image and copyright information in PMC

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