Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth—length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
Highlights
Critical care is a limited healthcare resource
If the justification for using frailty in rationing is its relationship with probability of survival or duration of survival, it would potentially be a mistake to exclude from intensive care admission patients with stable long-standing disability. (While patients with underlying stable disability might have reduced survival post-intensive care, the relationship is likely to be less than the impact of frailty.) In response to this criticism, National Institute for Health and Care Excellence (NICE) amended its guidance to indicate that the Clinical Frailty Scale” (CFS) should only be used in patients over the age of 65, and should not be used for groups of patients with stable chronic disabilities (NICE 2020)
Frailty might be almost a perfect Intensive Care Units (ICU) rationing criterion—potentially attractive according to multiple different theories of rationing, and in combination identifying patients who are less likely to survive, likely to survive for a shorter period, and with greater functional impairment
Summary
Critical care is a limited healthcare resource. In many countries, adult Intensive Care Units (ICU) often operate at close to capacity and must decline a number of patients referred for possible admission (Rhodes et al 2012). In the VIP1 study, there were more than 100 emergency intensive care admissions of patients over 80 years assessed as “very severely frail” (with an expected life expectancy of
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