More Steps Needed to Manage Current Care of Older Adults

The COVID-19 pandemic is a critical time to think about how best to manage the care of older adults, both for their sake and for the near- and longer-term costs and stresses to the health care system, according to a new commentary by a UC San Francisco clinician.

“If we ignore age, we too often provide costly, ineffective care,” said author Louise Aronson, MD, professor of geriatrics at UCSF and a UCSF Health geriatrician, in a New England Journal of Medicine Perspective appearing online April 7, 2020.

“But if we make age the sole criterion for rationing, we take a giant step toward overt valuing of some lives over others,” Aronson said. “Not only does that approach defy the core tenets of medicine, but a glance at the U.S. Department of Health and Human Services definition of ‘special populations’ reveals that it would put most of us at risk for second-class care. We must do everything possible to avoid the first step down that slippery slope.”

So far, during the COVID-19 pandemic, an estimated 80 percent of U.S. deaths have been in adults over age 65, and it especially affects those over 80 with underlying health conditions. However, health leaders and clinicians may be too busy saving lives to consider how to prevent the hazards of hospitalization for elders or ensuring that elders get the care needed to feel their lives are worth living after discharge.

In the NEJM Perspective, Aronson recommends several additions to current pandemic management. To start, stick to the facts, and harness the expertise and person-power of the many clinicians and researchers who cannot currently do their usual work to develop crisis-related protocols for ambulatory, institutionalized, homebound and hospitalized patients. Special attention should be paid to elders and other populations with high health care needs.

Health care systems also should acknowledge the particular presentations, needs and risks of elders in protocols and planning. Most medical centers have protocols for children and adults, but nothing for elders, and basic standards of health equity demand protocols with elder-specific diagnostic, treatment and outcome-prediction tools, Aronson said.

Further, by prioritizing advance care planning of older adults, the rationing of care can be prevented or delayed. The absence of planning for aggressive, supportive or palliative care increases suffering at the end of life, while its use allows elders to live and die according to their personal priorities, Aronson said.