Scope of treatment and clinical-decision making in the older patient with COVID-19 infection, a European perspective.

PURPOSE: Older patients were particularly vulnerable to severe COVID-19 disease resulting in high in-hospital mortality rates during the two first waves. The aims of this study were to better characterize the management of older people presenting with COVID-19 in European hospitals and to identify national guidelines on hospital admission and ICU admission for this population. METHODS: Online survey based on a vignette of a frail older patient with Covid-19 distributed by e-mail to all members of the European Geriatric Medicine Society. The survey contained questions regarding the treatment of the vignette patient as well as general questions regarding available services. Additionally, questions on national policies and differences between the first and second wave of the pandemic were asked. RESULTS: Survey of 282 respondents from 28 different countries was analyzed. Responses on treatment of the patient in the vignette were similar from respondents across the 28 countries. 247 respondents (87%) would admit the patient to the hospital, in most cases to a geriatric COVID-19 ward (78%). Cardiopulmonary resuscitation was found medically inappropriate by 85% of respondents, intubation and mechanical ventilation by 91% of respondents, admission to the ICU by 82%, and ExtraCorpular Membrane Oxygenation (ECMO) by 93%. Sixty percent of respondents indicated they would consult with a palliative care specialist, 56% would seek the help of a spiritual counsellor. National guidelines on admission criteria of geriatric patients to the hospital existed in 22 different European countries. CONCLUSION: This pandemic has fostered the collaboration between geriatricians and palliative care specialists to improve the care for older patients with a severe disease and often an uncertain prognosis.

Documento de consenso y recomendaciones sobre cuidados paliativos en insuficiencia cardiaca de las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología / Consensus document and recommendations on palliative care in heart failure of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology

La insuficiencia cardiaca es una entidad compleja, que conlleva elevada morbilidad y mortalidad y cuyo curso y evolución son inciertos y difíciles de predecir. Este trabajo, impulsado por las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología, aborda los diferentes aspectos relacionados con los cuidados paliativos en el campo de la insuficiencia cardiaca, vía final común de la mayoría de las enfermedades cardiovasculares. También establece un consenso y una serie de recomendaciones con el objetivo de reconocer y comprender la necesidad de implementar y aplicar, de modo progresivo, este tipo de cuidados a lo largo del curso de la enfermedad, y no únicamente en sus estadios avanzados, para mejorar la atención que reciben los pacientes y su calidad de vida. La finalidad es mejorar y adecuar los tratamientos a las necesidades y los deseos de cada paciente, que debe contar con información adecuada y ser partícipe de la toma de decisiones

Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making

Consensus document and recommendations on palliative care in heart failure of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology.

Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making.

En busca de respuestas al reto de la complejidad clínica en el siglo xxi: a propósito de los índices de fragilidad / The challenge of clinical complexity in the 21st century: could frailty indexes be the answer?

Estamos ante un reto colosal tanto para los sistemas de salud como para los profesionales: el de una eclosión epidemiológica de personas con complejidad clínica y necesidades de atención complejas. Frente al incremento de situaciones de complejidad —habitualmente relacionadas con la incertidumbre en el diagnóstico situacional y las dificultades para la toma de decisiones—, los profesionales necesitarán de nuevos marcos conceptuales y de nuevas herramientas que sean pragmáticas y eficientes. Es factible pensar que el paradigma de la fragilidad ofrezca una excelente oportunidad para revisar y universalizar los principios de la valoración geriátrica; también es probable que los índices de fragilidad sean la respuesta más plausible al desafío del diagnóstico de precisión, punto de partida necesario para una atención auténticamente centrada en la persona (AU)

The number of older people with complex clinical conditions and complex care needs continues to increase in the population. This is presenting many challenges to healthcare professionals and healthcare systems. In the face of these challenges, approaches are required that are practical and feasible. The frailty paradigm may be an excellent opportunity to review and establish some of the principles of comprehensive Geriatric Assessment in specialties outside Geriatric Medicine. The assessment of frailty using Frailty Indexes provides an aid to the ‘situational diagnosis’ of complex clinical situations, and may help in tackling uncertainty in a person-centred approach (AU)

[The challenge of clinical complexity in the 21st century: Could frailty indexes be the answer?] / En busca de respuestas al reto de la complejidad clínica en el siglo xxi: a propósito de los índices de fragilidad.

The number of older people with complex clinical conditions and complex care needs continues to increase in the population. This is presenting many challenges to healthcare professionals and healthcare systems. In the face of these challenges, approaches are required that are practical and feasible. The frailty paradigm may be an excellent opportunity to review and establish some of the principles of comprehensive Geriatric Assessment in specialties outside Geriatric Medicine. The assessment of frailty using Frailty Indexes provides an aid to the 'situational diagnosis' of complex clinical situations, and may help in tackling uncertainty in a person-centred approach.

Palliative peritoneal dialysis: Implementation of a home care programme for terminal patients treated with peritoneal dialysis (PD).

Terminal-stage patients on peritoneal dialysis (PD) are often transferred to haemodialysis as they are unable to perform the dialysis technique themselves since their functional capacities are reduced. We present our experience with five patients on PD with a shortterm life-threatening condition, whose treatment was shared by primary care units and who were treated with a PD modality adapted to their circumstances, which we call Palliative Peritoneal Dialysis.

Diálisis peritoneal paliativa: implantación de un programa de atención domiciliaria a enfermos tratados con diálisis peritoneal (DP) en situación terminal / Palliative peritoneal dialysis: Implementation of a home care system for patients treated with peritoneal dialysis in terminal situations

Los pacientes en Diálisis peritoneal (DP) en situación terminal suelen ser transferidos ahemodiálisis ya que son incapaces de realizarse la técnica dialítica a consecuencia de que sus capacidades funcionales están disminuidas. Presentamos nuestra experiencia con5 pacientes en DP con patología que amenazaba su vida a corto plazo, cuyo tratamiento fue compartido por las unidades de atención primaria y fueron mantenidos en una modalidad de DP adaptada a sus circunstancias a la que hemos denominado Diálisis Peritoneal Paliativa (AU)

Patients undergoing peritoneal dialysis (PD) in a terminal situation are generally transferred to haemodialysis, given that they are incapable of carrying out the dialysis technique due to the fact that their functional capabilities are diminished. We present our experience with5 patients undergoing PD with pathology that constituted short-term threat to their lives. Their treatment was shared by the primary attention units and they were maintained in a PD mode adapted to their circumstances, which we have called Palliative Peritoneal Dialysis (AU)

Home Palliative Care for Patients with Advanced Chronic Kidney Disease: Preliminary Results.

Healthcare for patients with advanced chronic kidney disease (ACKD) on conservative treatment very often poses healthcare problems that are difficult to solve. At the end of 2011, we began a program based on the care and monitoring of these patients by Primary Care Teams. ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor and nurse, under the coordination of the Palliative Care Unit and the Nephrology Department. During 2012, 2013, and 2014, 76 patients received treatment in this program (mean age: 81 years; mean Charlson age-comorbidity index: 10, and mean glomerular filtration rate: 12.4 mL/min/1.73 m²). The median patient follow-up time (until death or until 31 December 2014) was 165 days. During this period, 51% of patients did not have to visit the hospital's emergency department and 58% did not require hospitalization. Forty-eight of the 76 patients died after a median time of 135 days in the program; 24 (50%) died at home. Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care Teams.

Programa de atención domiciliaria a pacientes con enfermedad renal crónica avanzada. Experiencia de dos años / Home care programme for patients with advanced chronic kidney disease. A two-year experience

Introducción: La atención sanitaria de los pacientes con enfermedad renal crónica avanzada (ERCA) bajo tratamiento conservador plantea con gran frecuencia problemas asistenciales de difícil solución. Muchos de ellos son enfermos añosos, con dificultad de movilidad, en los que los desplazamientos al centro hospitalario suponen una gran dificultad. A finales del año 2011 iniciamos un programa basado en la asistencia y el control de estos enfermos por los equipos de Atención Primaria. Material y métodos: A los pacientes con ERCA que han elegido tratamiento conservador, se les ofrece la posibilidad de recibir una asistencia fundamentalmente domiciliaria por el médico de Atención Primaria, bajo la coordinación de la Unidad de Cuidados Paliativos y del Servicio de Nefrología. Resultados: Durante los años 2012 y 2013, 50 enfermos recibieron tratamiento en este programa. Edad media: 81 años, índice edad-comorbilidad de Charlson: 10, y filtrado glomerular medio 11,8 ml/min/1,73 m². El tiempo de seguimiento medio por enfermo (hasta el fallecimiento o hasta el 31/12/2013) fue de 184 días. Durante este período, el 44 % de los enfermos no tuvo que acudir al Servicio de Urgencias del hospital, y el 58 % no precisó ingreso hospitalario. Fallecieron 29 de los 50 enfermos, tras un tiempo medio de permanencia en el programa de 163 días; en 14 de ellos (48 %), el sitio de fallecimiento fue su domicilio. Conclusiones: Nuestra experiencia indica que con soporte de la Unidad de Cuidados Paliativos y del Servicio de Nefrología, el paciente con ERCA no candidato a diálisis puede ser controlado en su domicilio por Atención Primaria (AU)

Introduction: Healthcare for patients with advanced chronic kidney disease (ACKD) on conservative treatment very often poses healthcare problems that are difficult to solve. Many patients are elderly and have mobility problems, and it is very difficult for them to travel to hospital. At the end of 2011, we began a programme based on the care and monitoring of these patients by Primary Care teams. Material and method: ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor, under the coordination of the Palliative Care Unit and the Nephrology Department. Results: During 2012 and 2013, 50 patients received treatment in this programme. Mean age: 81 years, Charlson age-comorbidity index: 10 and mean glomerular filtration rate: 11.8ml/min/1.73.m². The mean patient follow-up time (until death or until 31/12/2013) was 184 days. During this period, 44% of patients did not have to visit the hospital’s Emergency Department and 58% did not require hospitalisation. 29 of the 50 patients died after a mean time of 163 days on the programme; 14 (48%) died at home. Conclusions: Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care (AU)

Home care programme for patients with advanced chronic kidney disease. A two-year experience.

INTRODUCTION:  Healthcare for patients with advanced chronic kidney disease (ACKD) on conservative treatment very often poses healthcare problems that are difficult to solve. Many patients are elderly and have mobility problems, and it is very difficult for them to travel to hospital. At the end of 2011, we began a programme based on the care and monitoring of these patients by Primary Care teams.  MATERIAL AND METHOD:  ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor, under the coordination of the Palliative Care Unit and the Nephrology Department.  RESULTS:  During 2012 and 2013, 50 patients received treatment in this programme. Mean age: 81 years, Charlson age-comorbidity index: 10 and mean glomerular filtration rate: 11.8ml/min/1.73.m². The mean patient follow-up time (until death or until 31/12/2013) was 184 days. During this period, 44% of patients did not have to visit the hospital’s Emergency Department and 58% did not require hospitalisation. 29 of the 50 patients died after a mean time of 163 days on the programme; 14 (48%) died at home.  CONCLUSIONS:  Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care.

Drug therapy optimization at the end of life.

Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.

End-stage heart disease in the elderly.

This document was produced by the Spanish Society of Cardiology Section on Geriatric Cardiology "End-stage heart disease in the elderly" working group. Its aim was to provide an expert overview that would increase understanding of the last days of life of elderly patients with heart disease and improve treatment and clinical decision-making. As elderly heart disease patients form a heterogeneous group, thorough clinical evaluation is essential, in particular to identify factors that could influence prognosis (e.g., heart disease, comorbid conditions, functional status and frailty). The evaluation should be carried out before any clinical decisions are made, especially those that could restrict therapy, such as do-not-resuscitate orders or instructions to deactivate an implantable cardioverter-defibrillator. Elderly patients with terminal heart disease have the right to expect a certain level of care and consideration: they should not suffer unnecessarily, their freely expressed wishes should be respected, they should be fully informed about their medical condition, they should be able to express an opinion about possible interventions, and they should be entitled to receive psychospiritual care. After an incurable disease has been diagnosed, the aim of palliative care should be to control symptoms. It should not be used only when the patient is close to death. Although palliative care is relatively undeveloped in heart disease, its use must be borne in mind in elderly patients with advanced heart failure. The main aims are to make the patient as comfortable as possible in all senses and to optimize quality of life in the patient's final days, while avoiding the use of aggressive treatments that consume health-care resources without providing any benefits.

El anciano con cardiopatía terminal / End-stage heart disease in the elderly

El objetivo de este documento del Grupo de Estudio «El anciano con cardiopatía terminal», de la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología, es aportar un punto de vista experto que permita un mejor conocimiento de la situación y una mejora en el manejo y la toma de decisiones en los últimos días de vida del paciente de edad avanzada que sufre una cardiopatía. Los cardiópatas ancianos constituyen un grupo heterogéneo y es necesaria una valoración exhaustiva, especialmente de los factores que condicionan el pronóstico (cardiopatía, comorbilidad, situación funcional y datos de fragilidad) antes de tomar decisiones, sobre todo aquellas que conlleven limitación del esfuerzo terapéutico como las órdenes de no reanimar o la desactivación de desfibriladores automáticos implantables. Los ancianos con cardiopatías terminales tienen derecho a disponer de una serie de cuidados y atenciones, entre ellos no sufrir inútilmente, respeto a su libertad de conciencia, conocer su situación, opinar sobre posibles intervenciones y recibir asistencia psicoespiritual. Los cuidados paliativos deben dirigirse al control de los síntomas tras el diagnóstico de la enfermedad incurable y no iniciarse únicamente en la fase de agonía. Estos cuidados están poco desarrollados en las cardiopatías y deben de tenerse presentes en los ancianos con insuficiencia cardiaca avanzada. Su objetivo es conseguir el máximo bienestar para el paciente desde un punto de vista integral, mejorar su calidad de vida antes del fallecimiento y evitar el empleo de tratamientos agresivos que consumen recursos sin resultados (AU)

This document was produced by the Spanish Society of Cardiology Section on Geriatric Cardiology “Endstage heart disease in the elderly” working group. Its aim was to provide an expert overview that would increase understanding of the last days of life of elderly patients with heart disease and improve treatment and clinical decision-making. As elderly heart disease patients form a heterogeneous group, thorough clinical evaluation is essential, in particular to identify factors that could influence prognosis (eg, heart disease, comorbid conditions, functional status, and frailty). The evaluation should be carried out before any clinical decisions are made, especially those that could restrict therapy, such as do-not-resuscitate orders or instructions to deactivate an implantable cardioverter-defibrillator. Elderly patients with terminal heart disease have the right to expect a certain level of care and consideration: they should not suffer unnecessarily, their freely expressed wishes should be respected, they should be fully informed about their medical condition, they should be able to express an opinion about possible interventions, and they should be entitled to receive psychospiritual care. After an incurable disease has been diagnosed, the aim of palliative care should be to control symptoms. It should not be used only when the patient is close to death. Although palliative care is relatively undeveloped in heart disease, its use must be borne in mind in elderly patients with advanced heart failure. The main aims are to make the patient as comfortable as possible in all senses and to optimize quality of life in the patient’s final days, while avoiding the use of aggressive treatments that consume health-care resources without providing any benefits (AU)