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

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.

Metadata

Item Type:	Article
Authors/Creators:	Straw, S https://orcid.org/0000-0002-2942-4574 McGinlay, M Drozd, M https://orcid.org/0000-0003-0255-4624 Slater, TA Cowley, A Kamalathasan, S Maxwell, N Bird, RA Koshy, AO Prica, M Patel, PA Relton, SD https://orcid.org/0000-0003-0634-4587 Gierula, J Cubbon, RM https://orcid.org/0000-0001-7844-3600 Kearney, MT Witte, KK https://orcid.org/0000-0002-7146-7105
Copyright, Publisher and Additional Information:	© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Keywords:	COVID-19; Resuscitation; Advanced care planning; Comorbidity; Elderly; Geriatrics
Dates:	Accepted: 3 January 2021 Published (online): 11 January 2021 Published: 11 January 2021
Institution:	The University of Leeds
Academic Units:	The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Medicine (Leeds) > Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM) > Clinical & Population Science Dept (Leeds) The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Medicine (Leeds) > Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM) > Discovery & Translational Science Dept (Leeds) The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Medicine (Leeds) > Leeds Institute of Health Sciences (Leeds) > Centre for Health Services Research (Leeds)
Depositing User:	Symplectic Publications
Date Deposited:	29 Jan 2021 10:16
Last Modified:	25 Jun 2023 22:33
Status:	Published
Publisher:	BMC
Identification Number:	10.1186/s12904-021-00711-8
Open Archives Initiative ID (OAI ID):	oai:eprints.whiterose.ac.uk:170409

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

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