Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data
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.
Figure 1
Figure 2
Figure 3
Posted 12 Jan, 2021
On 11 Jan, 2021
On 30 Dec, 2020
On 29 Dec, 2020
On 13 Nov, 2020
Received 13 Nov, 2020
On 11 Nov, 2020
Invitations sent on 08 Nov, 2020
On 28 Oct, 2020
On 27 Oct, 2020
On 13 Oct, 2020
On 01 Oct, 2020
Received 27 Sep, 2020
On 22 Sep, 2020
Received 22 Sep, 2020
On 20 Sep, 2020
Invitations sent on 18 Sep, 2020
On 24 Aug, 2020
On 23 Aug, 2020
On 23 Aug, 2020
On 20 Aug, 2020
Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data
Posted 12 Jan, 2021
On 11 Jan, 2021
On 30 Dec, 2020
On 29 Dec, 2020
On 13 Nov, 2020
Received 13 Nov, 2020
On 11 Nov, 2020
Invitations sent on 08 Nov, 2020
On 28 Oct, 2020
On 27 Oct, 2020
On 13 Oct, 2020
On 01 Oct, 2020
Received 27 Sep, 2020
On 22 Sep, 2020
Received 22 Sep, 2020
On 20 Sep, 2020
Invitations sent on 18 Sep, 2020
On 24 Aug, 2020
On 23 Aug, 2020
On 23 Aug, 2020
On 20 Aug, 2020
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.
Figure 1
Figure 2
Figure 3