1018342

research-article2021
PMJ0010.1177/02692163211018342Palliative MedicinePiers et al.

Short Report

Palliative Medicine

Early resuscitation orders in hospitalized oldest-

2021, Vol. 35(7) 1288­–1294
© The Author(s) 2021
Article reuse guidelines:
old with COVID-19: A multicenter cohort study sagepub.com/journals-permissions
DOI: 10.1177/02692163211018342
https://doi.org/10.1177/02692163211018342
journals.sagepub.com/home/pmj

Ruth Piers1,2 , Eva Van Braeckel2,3, Dominique Benoit2,4

and Nele Van Den Noortgate1,2

Abstract
Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is
essential to assist patient autonomy and prevent non-beneficial medical interventions.
Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19.
Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with
COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians.
Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the
geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in
474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher
frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty
(p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1%
in persons who developed respiratory failure vs 16.7% in patients without respiratory failure (p < 0.001)). Of 104 patients without
early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to
intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%.
Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider
intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of
conservative treatment.

Keywords
COVID-19, resuscitation orders, aged, 80 and over, in-hospital mortality, advance care planning, multicenter study, cohort study,
intensive care unit

What is already known?

•• Oldest old with COVID-19 are at increased risk of mortality.
•• The outcome is related to the level of premorbid frailty.
•• Goals of care conversations are desired by patients and are feasible but often neglected in acute care settings.

What this paper adds?

•• Oldest old admitted with COVID-19 were frequently co-managed by geriatricians in Belgian hospitals.
•• Early resuscitation orders were taken in two thirds of the cohort.
•• The degree of anticipatory treatment limitation was associated with the degree of premorbid frailty.
•• More than half of hospitalized oldest old with an early decision not to consider intensive care treatment survived by
means of conservative treatment.

1Department of Geriatric Medicine, Ghent University Hospital, Ghent, Corresponding author:

Belgium Ruth Piers, Department of Geriatric Medicine, Ghent University
2Department of Internal Medicine and Pediatrics, Ghent University, Hospital, C. Heymanslaan 10, Ghent 9000, Belgium.
Ghent, Belgium Email: ruth.piers@uzgent.be
3Department of Respiratory Medicine, Ghent University Hospital, Ghent,

Belgium
4Department of Intensive Care Medicine, Ghent University Hospital,

Ghent, Belgium
Piers et al. 1289
Implications for practice, theory or policy
•• Geriatricians frequently and timely think about the ceiling of treatment in oldest old with COVID-19. Maximum conserva-
tive supportive treatment can save lives, while also taking palliative care principles like advance care planning into account.
Introduction
COVID-19 is characterized by a broad spectrum of disease
severity, including severe pneumonia with high risk of
developing respiratory failure requiring oxygen therapy,
non-invasive ventilation or invasive mechanical ventila-
tion in the intensive care unit (ICU).
The older patient seems to have a higher susceptibility
for SARS-CoV-2 infection, a higher risk of developing
severe COVID-19 and of COVID-19 related mortality.1,2 A
meta-analysis gathering data from China, Italy, Spain, UK
and New York found that persons aged 80 or older had a
six-times higher risk of dying compared to younger
patients, with case fatality rates varying between 14.8%
(China) and 53.7% (New York).3 The level of frailty, defined
as the level of reduction in ability to withstand acute
stress situations, is known to be a robust risk factor for
adverse outcome in older adults in different settings.4,5
Recent studies confirm the relation between frailty and
outcome in COVID-19.6,7
Clinicians should always carefully balance benefits and
harms in deciding whether or not to escalate care, also in
COVID-19.8,9 In-hospital, the level of supportive care may
range from pursuing all life-sustaining therapies including
mechanical ventilation to comfort-directed care. The deci-
sion as to which level is most appropriate for an older indi-
vidual is based on the interplay between the estimated
outcome and the patient’s goals of care.8 Timely, honest
and compassionate conversations may help frail patients
and their families to prepare for uncertain but possible
adverse outcome.9,10 Acute hospitals are known to be
places where advance care planning is often lacking.11,12
However, there is evidence that a majority of patients
who know they are at the end of their life want to avoid
ICU13,14 and that goals of care conversations during the
COVID-19 pandemic are feasible even in acute care
settings.15
To the best of our knowledge, transparent description
of early resuscitation orders in COVID-19 is lacking in lit-
erature.16 This study aimed to describe early resuscitation
order decisions in relation to premorbid frailty in oldest-
old admitted with COVID-19.
Methods
Design, participants, settings
This is a multicentre retrospective cohort study of patients
aged 80 years and older who were admitted to the acute
hospital in March and April 2020 with COVID-19.
Recruitment was performed through means of an existing
network of geriatricians working in 10 different hospitals
(convenience sample) who collected the data retrospec-
tively by means of an electronic case report form. In
Belgium, patients aged 80 years and older admitted to
acute hospitals are mainly hospitalized in geriatric beds
and treated by geriatricians.
Inclusion criteria were being 80 or older at the time of
hospital admission and having been diagnosed with
COVID-19 (based on SARS-CoV-2 PCR positivity and/or
based on characteristic anomalies on chest computed
tomography, biochemistry and suggestive signs and symp-
toms, and/or consensus on COVID-19 diagnosis within
multidisciplinary team meeting).
Ethics
The study was approved by the central ethics committee
(Ghent University Hospital, Belgian Registration number
BC-07858) and all local ethics committees. Informed con-
sent was waived because of the retrospective and non-
interventional nature of the study and because strict
anonymity during data processing was guaranteed. The
treating geriatricians looked into their medical files and
delivered the anonymized data through a secure web
application REDCap (https://www.project-redcap.org).
Data collection and measures
Participating geriatricians filled out a short survey on the
resuscitation order policy in their ward (consultation of
patients, families, nursing team and other medical spe-
cialties in making up the resuscitation order in March and
April 2020).
The total number of octogenarians admitted to their
hospital was retrieved through the official registration
data for the government. The geriatricians collected data
from those patients with whom they had a therapeuthical
relationship. Socio-demographic information, premorbid
level of frailty, comorbidities, respiratory characteristics of
the peak of the COVID-infection during admission, resus-
citation orders and in-hospital mortality were collected
from the medical record after patient discharge. All data
were collected before August 2020, in order to minimize
recall bias.
An ‘early’ resuscitation order was defined as a treat-
ment limitation decision taken within 72 h after hospital
1290 Palliative Medicine 35(7)
admission. The resuscitation orders were predefined into
five levels: (1) full code: pursue all life-sustaining treat-
ments including mechanical ventilation in case of respira-
tory failure; (2) do-not-resuscitate only: pursue all
life-sustaining treatments excluding cardiopulmonary
resuscitation (CPR); (3) do-not-intubate: pursue all life-
sustaining treatments including non-invasive ventilation
but excluding mechanical ventilation and CPR; (4) ward-
based medical treatment only: pursue all life-sustaining
treatments excluding, CPR, intubation, non-invasive venti-
lation; (5) comfort-directed care: no life-sustaining treat-
ments, only treatment supporting comfort of the patient.
Throughout the article these five levels are dichotomized:
one to three consider intensive care versus four and five:
do not consider intensive care admission.
The Clinical Frailty Scale (CFS) is often put forward as a
preferred tool for assessing frailty in older adults to be
used for timely ICU admission decisions.17,18 The CFS© was
used with official permission to assess premorbid frailty
and was scored by the geriatrician.19 The CFS ranks frailty
from 1 (very fit) to 9 (terminally ill). A patient with CFS 7 is
severely frail without limited prognosis, and patients with
CFS 8 and 9 have a life expectancy lower than 6 months.
As geriatricians are experts in comprehensive geriatric
assessment, they are best placed to score CFS.
Severity of COVID-19: criteria for respiratory failure
were predefined as follows: PaO2 ⩽ 60 mmHg and/or low
SpO2 (⩽ 90% with supplemental oxygen or ⩽88% without
supplemental oxygen) and/or in need of more than 5 L/
min oxygen supplementation at any moment during hos-
pital stay.
Statistical analysis
Descriptive statistics and Chi Square test for association
between the degree of treatment limitation and patient
characteristics were computed using IBM SPSS Statistics
software version 25 (IBM Corp., Armonk, NY, USA). The
exact p-values are reported, with statistical significance
defined as p⩽0.05.
Results
Hospital resuscitation order policy
characteristics
Concerning the resuscitation order policy on their wards,
geriatricians informed their patients and/or families
‘always’ in 70% of hospitals and ‘often’ in 30%. Consultation
with the nursing team occurred ‘always’ in 50% of hospi-
tals, ‘often’ in 40% and ‘occasionally’ in 10%. Consultation
with other colleagues occurred in 30% of hospitals with
the general practitioner, emergency physician and pulmo-
nologist, in 20% of hospitals with the intensive care
physician.
Participants
Overall, 766 octogenarians were admitted of whom 49
patients were not included because there was no thera-
peutic relationship with the geriatrician. Additionally, six
cases were excluded because of incomplete case report
form, leaving 711 cases for the study. In Table 1, premor-
bid characteristics are shown. Premorbid CFS was filled
out by the treating geriatrician post-hoc for study purpose
in 68%. Mean premorbid CFS was 5.44 (95% CI [5.32–5.55]
on a scale that ranges from 1 (very fit) to 9 (terminally ill)).
Early decisions not to consider admission in the ICU
were taken in 474 (66.7%) patients. This subgroup was
characterized by significantly higher age, more comorbid-
ity, more often coming from a nursing home and higher
premorbid CFS (Table 1). There was a significant associa-
tion between the degree of anticipatory treatment limi-
tation and the degree of premorbid CFS (p < 0.001)
(Figure 1).
In-hospital mortality was 41.6% in 474 patients in
whom an early decision not to consider ICU admission
was made. Half of patients with a decision not to consider
ICU admission developed respiratory failure (234/474); in
those persons who developed respiratory failure, in-hos-
pital mortality was 67.1% (157/234) versus 16.7% (40/240)
in patients who did not develop respiratory failure
(p < 0.001).
In-hospital mortality was 20.7% in 237 patients with-
out early decision not to consider ICU. Of 104 patients
without early decision not to consider ICU admission but
who developed respiratory failure, 59 were eventually not
transferred to ICU, and of those 15 (25.4%) died on the
regular ward. About 45 were transferred to the ICU, of
whom 64.4% died in the ICU.
Discussion
Main findings
The majority of oldest old admitted in 10 acute Belgian hos-
pitals with COVID-19 were treated by a geriatrician.
Anticipatory decision-making was frequent with an early
decision not to consider ICU admission in case of respiratory
failure in two thirds of the cohort. The degree of anticipa-
tory treatment limitation was associated with the degree of
premorbid frailty. The group with early decision not to con-
sider ICU admission was characterized by significantly higher
age, more comorbidity, and higher level of premorbid frailty.
The mortality was 20.7% in patients without early decision
and 41.6% in the group with early decision not to consider
ICU admission.
Strengths and limitations
To the best of the author’s knowledge, this is one of the
first studies openly describing anticipatory resuscitation
Piers et al. 1291

Table 1. Premorbid clinical characteristics in 711 hospitalized oldest-old COVID-19 patients: comparison between patients without
versus with early decision not to consider ICU admission.

Characteristic Total no. (%) Patients in whom early Patients in whom p-Value
decision to consider ICU early decision NOT
in respiratory failure (%) to consider ICU (%)
Age category
 80–84 299 (42.1) 153 (64.6) 146 (30.8) <0.001
 85–89 271 (38.1) 68 (28.7) 203 (42.8)
 ⩾90 141 (19.8) 16 (6.8) 125 (26.4)
Gender
 Female 401 (56.4) 124 (52.3) 277 (58.4) 0.128
 Male 310 (43.6) 113 (47.7) 197 (41.6)
Residency before hospital admission
 At home 447 (62.9) 192 (81.0) 255 (53.8) <0.001
 Not at home 264 (37.1) 45 (19.0) 219 (46.2)
 Assisted-living facility 43 (6.0) 15 (6.3) 28 (5.9)
 Nursing home 221 (31.1) 30 (12.7) 191 (40.3)
Comorbidity
 Malignancy 192 (27.0) 51 (21.5) 141 (29.7) 0.020
 Metastatic solid tumor or progressive 38 (5.3) 1 (0.4) 37 (7.8) <0.001
hematological malignancy
 Cardiovascular 582 (81.9) 195 (82.3) 387 (81.6) 0.918
 Hypertension 439 (61.7) 61 (67.9) 278 (58.6) 0.018
 Coronary artery disease 197 (27.7) 67 (28.3) 130 (27.4) 0.859
 Carotid artery disease 66 (9.3) 13 (5.5) 53 (11.2) 0.013
 Heart failure 195 (27.4) 52 (21.9) 143 (30.2) 0.021
 Cerebrovascular accident 126 (17.7) 40 (16.9) 86 (18.1) 0.755
 Peripheral arterial disease 84 (11.8) 23 (9.7) 61 (12.9) 0.267
 Chronic lung condition 129 (18.1) 43 (18.1) 86 (18.1) 1.000
 Asthma 28 (3.9) 12 (5.1) 16 (3.4) 0.308
 Chronic obstructive pulmonary disease 101 (14.2) 31 (13.1) 70 (14.8) 0.571
 Obstructive sleep apnea 11 (1.5) 3 (1.3) 8 (1.7) 0.760
 Immunosuppressiona 30 (4.2) 8 (3.4) 22 (4.6) 0.554
 Chronic kidney disease 291 (40.9) 72 (30.4) 219 (46.2) <0.001
 End-stage renal failure of hemodialysis 21 (3.0) 8 (3.4) 13 (2.7) <0.001
 Chronic liver diseaseb 19 (2.7) 5 (2.1) 14 (3.0) 0.626
 Metabolic disease 260 (36.6) 88 (37.1) 172 (36.3) 0.869
 Obesity (BMI ⩾ 30) 98 (13.8) 31 (13.1) 67 (14.1) 0.118
 Diabetes mellitus 201 (28.2) 66 (27.9) 135 (28.5) 0.233
 Dementia 283 (39.8) 39 (16.5) 244 (51.5) <0.001
Number of affected organs/systemsc
 Mean (95% CI) 2.5 (2.4–2.6) 2.11 (1.97–2.26) 2.71 (2.60–2.82) <0.001
Clinical frailty scale
 Mean (95% CI) 4.42 (4.21–4.62) 5.95 (5.83–6.07) <0.001

ICU: intensive care unit.

aImmunosuppression includes HIV, organ transplant, chronic intake of immunomodulatory medication or systemic corticosteroids.
bChronic liver disease includes cirrhosis or chronic hepatitis.
cNumber of comorbidities was determined by calculating in how many of the eight organ systems there was at least one disease.

orders in patients with COVID-19. Another main strength
is its multicentre design. However, there are some limita-
tions. The main limitation is that we lack information on
patient level about the decision-making process (varying
from explicit individual preferences of the patient, over
shared decision-making to unilateral medical decision).
Second limitation is the retrospective nature of the study;
in 68% the CFS was filled-out post-hoc by the geriatrician
on basis of the comprehensive geriatric assessment by
the multidisciplinary team which is standard practice.
Last, in order to really perform a causal analysis, we lacked
detailed and longitudinal data on severity of illness and
lacked data associated with the resuscitation order such
as preference of the patient. As such, we can neither
1292 Palliative Medicine 35(7)

Figure 1. Early resuscitation orders in relation to premorbid Clinical Frailty Scale score.
p < 0.001 (Chi-Square);
There was one missing value on Clinical Frailty Scale (CFS); CFS was known during hospital admission in 32%; CFS was filled out post-hoc for study
purpose in 68%. The CFS ranks frailty from 1 (very fit) to 9 (terminally ill). A patient with CFS 7 is severely frail without limited prognosis, and patients
with CFS 8 and 9 have a life expectancy lower than 6 months.
There are five levels of resuscitation orders: Full code: pursue all life-sustaining treatments (LST) including mechanical ventilation in case of respira-
tory failure; Do-not-resuscitate only: pursue all LSTs excluding cardiopulmonary resuscitation (CPR); Do-not-intubate: pursue all LST including non-
invasive ventilation but excluding mechanical ventilation and CPR; Ward-based medical treatment only: pursue all LSTs excluding, CPR, intubation,
non-invasive ventilation; Comfort-directed care: no LST, only treatment supporting comfort of the patient.
Throughout the article these five levels are dichotomized to decisions to (not) consider intensive care unit (ICU) admission.

confirm nor reject if early resuscitation orders and ICU
treatment selection caused excess mortality. However, we
found two recent publications showing that ICU admis-
sion was not associated with improved outcome.6,20
What this study adds
Treatment limitation decisions have been made all over
the world in the older population with COVID-1916,21 but
were seldom discussed openly. We observed a prevalence
of 66.7% of early decisions not to escalate treatment in
case respiratory failure would occur. This is transcending
the prevalence of hospital resuscitation orders taken in
non-COVID times with prevalence ranging from 20% to
40%.22–24 A possible explanation may be that COVID
patients are expected to have a higher need for ICU refer-
ral, a longer duration of mechanical ventilation followed
by much longer and as consequence less successful reha-
bilitation process, compared to non-COVID patients.
These facts reflect more urge to discuss treatment limita-
tion in patients with COVID. This is also reflected in a
report of a Dutch cohort of 100 COVID-patients with an
average age of 68 years, admitted on non-ICU wards, in
which 39% had an early do-not-intubate order.20 Also in
accordance with our findings, Lee et  al.15 showed that
after palliative care consultation focusing on goals of care
conversations in seriously ill patients during the COVID-19
pandemic, 78% of hospitalized patients and their surro-
gates opted to forego mechanical ventilation. In a study
performed on an acute geriatric ward before the pan-
demic, 74% of SPICT identified patients had a resuscita-
tion order, which is a similar prevalence as found in this
study.25 This reflects that geriatrician value to discuss
timely the treatment plan in frail patients with a life-
threatening disease. In line with De Bock et al.,25 the
degree of treatment limitation was related to the degree
of premorbid frailty as (mostly retrospectively) assigned
by geriatricians also in this study. Geriatricians affirmed
that patients and/or families were consulted concerning
the treatment limitation decision, as required by Belgian
law.
Importantly, more than half of hospitalized patients
with an early resuscitation order survived by means of
conservative treatment on the regular ward by geriatri-
cians. This under scribes that maximum conservative sup-
portive treatment can save lives, while also taking
palliative care principles like advance care planning into
account. This might support that geriatricians are in the
right place to take care of oldest old with COVID-19, also
because they are experts in assessing the level of frailty, a
major risk factor for poor outcome in the oldest old.6
When a palliative care approach is integrated early in
the appropriate patients, more attention can be given to
symptom control and (online) connection with loved ones
Piers et al. 1293
and saying goodbye when death is apparent, in order to
safeguard what is deemed important by patients and
families.26–28
Authors’ note
Part of the content of this paper was presented at the EUGMS
2020 online conference.
Acknowledgements
The authors thank all certified geriatricians who also helped
with the data collection: Celine Van de Vyver, Wim Janssens,
Katrien Cobbaert, Eva De Raes, Inge Pattyn, Veerle Mouton,
Véronique Ghekiere, Ranjini D’Souza, Pieter Samaey, Ine
Westhovens, Marie Louise Van Leeuwen, Charlotte De Clercq,
Nele Schalck, Han Martens, David Dedecker, Elke Steen, Katrien
Van Puyvelde, Veerle Immegeers, Sandra Maertens, Vinciane
Guyssens, Hilde Baeyens, Kyri Van Hecke, Griet Buyck.
Author contributions
The authors confirm that the manuscript has been read and
approved by all the named authors and that there are no other
persons who satisfied the criteria for authorship but are not
listed. The order of authors listed in the manuscript has been
approved by all the authors. Study conception and design: Piers,
Van Braeckel, Benoit, Van Den Noortgate. Acquisition of data:
Piers. Analysis and interpretation of data: Piers, Van Braeckel,
Benoit, Van Den Noortgate. Drafting of manuscript: Piers.
Critical revision: Van Braeckel, Benoit, Van Den Noortgate.
Data management and sharing
Data can be requested by contacting ruth.piers@uzgent.be
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Research ethics and patient consent
The study was approved by the central ethics committee (Ghent
University Hospital, Belgian Registration number BC-07858) and
all local ethics committees. Informed consent was waived
because of the retrospective and non-interventional nature of
the study and because strict anonymity during data processing
was guaranteed.
ORCID iD
Ruth Piers https://orcid.org/0000-0001-5261-220X
Supplemental material
Supplemental material for this article is available online.
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