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Research article
Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data
Klaus K Witte
University of Leeds
Corresponding Author
ORCiD: https://orcid.org/0000-0002-7146-7105
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Palliative Care.
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
COVID-19, resuscitation, advanced care planning, comorbidity, elderly, geriatrics.
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CURRENT STATUS: Published
Version 3
Posted 12 Jan, 2021
Published
On 11 Jan, 2021
No community comments so far
Submission checks complete
On 30 Dec, 2020
Editorial decision: Accept
On 29 Dec, 2020
No comments provided
Reviewer #2 agreed
On 13 Nov, 2020
Review #2 received
Received 13 Nov, 2020
Reviewer #1 agreed
On 11 Nov, 2020
Reviewers invited
Invitations sent on 08 Nov, 2020
Editor assigned
On 28 Oct, 2020
Editor invited
On 27 Oct, 2020
Submission checks complete
On 13 Oct, 2020
No comments provided
Editorial decision: Major revision
On 01 Oct, 2020
Review #1 received
Received 27 Sep, 2020
Reviewer #2 agreed
On 22 Sep, 2020
Review #2 received
Received 22 Sep, 2020
Reviewer #1 agreed
On 20 Sep, 2020
Reviewers invited
Invitations sent on 18 Sep, 2020
Editor assigned
On 24 Aug, 2020
Submission checks complete
On 23 Aug, 2020
Editor invited
On 23 Aug, 2020
First submitted
On 20 Aug, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Anesthesiology & Pain Medicine
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This preprint is under consideration at BMC Palliative Care. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data
Klaus K Witte
University of Leeds
Corresponding Author
ORCiD: https://orcid.org/0000-0002-7146-7105
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 3
Posted 12 Jan, 2021
Published
On 11 Jan, 2021
No community comments so far
Submission checks complete
On 30 Dec, 2020
Editorial decision: Accept
On 29 Dec, 2020
No comments provided
Reviewer #2 agreed
On 13 Nov, 2020
Review #2 received
Received 13 Nov, 2020
Reviewer #1 agreed
On 11 Nov, 2020
Reviewers invited
Invitations sent on 08 Nov, 2020
Editor assigned
On 28 Oct, 2020
Editor invited
On 27 Oct, 2020
Submission checks complete
On 13 Oct, 2020
No comments provided
Editorial decision: Major revision
On 01 Oct, 2020
Review #1 received
Received 27 Sep, 2020
Reviewer #2 agreed
On 22 Sep, 2020
Review #2 received
Received 22 Sep, 2020
Reviewer #1 agreed
On 20 Sep, 2020
Reviewers invited
Invitations sent on 18 Sep, 2020
Editor assigned
On 24 Aug, 2020
Submission checks complete
On 23 Aug, 2020
Editor invited
On 23 Aug, 2020
First submitted
On 20 Aug, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Anesthesiology & Pain Medicine
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Palliative Care.
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