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Id Subject Object Predicate Lexical cue
T1 0-93 Sentence denotes Ethical Issues in Decision-making Regarding the Elderly Affected by Coronavirus Disease 2019:
T2 94-111 Sentence denotes An Expert Opinion
T3 114-122 Sentence denotes Abstract
T4 123-236 Sentence denotes The coronavirus disease 2019 (COVID-19) pandemic is resulting in ethical decisions regarding resource allocation.
T5 237-361 Sentence denotes Prioritisation reflects established practices that regulate the distribution of finite resources when demand exceeds supply.
T6 362-467 Sentence denotes However, discrimination based on sex, race or age has no role in prioritisation unless clearly justified.
T7 468-610 Sentence denotes The risk posed by COVID-19 is higher for elderly people than for younger people, so older adults should be prioritised in preventive measures.
T8 611-731 Sentence denotes In the case of people who already have COVID-19, healthcare professionals might prioritise those most likely to survive.
T9 732-904 Sentence denotes Making decisions based on chronological age alone is not justified; in addition to age, other aspects that determine theoretical life expectancy must be taken into account.
T10 905-1020 Sentence denotes Individualised correct prioritisation in the allocation of scarce resources is essential to good clinical practice.
T11 1022-1111 Sentence denotes Nearly every country is now affected by the coronavirus disease 2019 (COVID-19) pandemic.
T12 1112-1230 Sentence denotes The disease is spreading rapidly and is taxing the global healthcare system, particularly intensive care units (ICUs).
T13 1231-1352 Sentence denotes Physicians are faced with ethical decisions regarding the allocation of these precious resources, especially ventilators.
T14 1353-1544 Sentence denotes Although only a few of those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) require admission to intensive care, the burden on healthcare systems is unprecedented.
T15 1545-1651 Sentence denotes This article focuses on ethical issues in decision-making regarding COVID-19, particularly in the elderly.
T16 1652-1749 Sentence denotes Madrid has been one of the cities with the higher number of COVID-19 cases and casualties so far.
T17 1750-1843 Sentence denotes We have suffered from limited resources and lived with these ethical issues on a daily basis.
T18 1844-1998 Sentence denotes Also, Spain is experiencing population ageing at a rate that is unprecedented in Europe and COVID-19 infection is particularly severe in the elderly.[1,2]
T19 2000-2014 Sentence denotes Prioritisation
T20 2015-2110 Sentence denotes Prioritisation for the allocation of scarce resources is not confined to the COVID-19 outbreak.
T21 2111-2327 Sentence denotes Transplant organs are examples of scarce resources where prioritisation criteria for allocation are common and physicians have to make a case-by-case evaluation in order to establish which patient receives the organ.
T22 2328-2462 Sentence denotes Prioritisation reflects established practices that regulate the distribution of finite resources when demand happens to exceed supply.
T23 2463-2640 Sentence denotes Discrimination based on sex, race or age has no role in prioritisation unless clearly justified, for example sex mismatch might influence the outcome of a heart transplant.[3,4]
T24 2641-2749 Sentence denotes Prioritisation does not mean that one life is more valuable than another, as all lives are equally valuable.
T25 2750-2888 Sentence denotes When resources are insufficient to save all those in need, prioritisation means allocating the available assets in the most effective way.
T26 2889-2987 Sentence denotes This method allows priority treatment of patients more likely to benefit from the scarce resource.
T27 2988-3089 Sentence denotes Prioritisation should be as objective as possible but also flexible to changes in clinical situation.
T28 3090-3296 Sentence denotes Transparent mechanisms to determine which patients will receive a specific resource are desirable and should be explained to patients who finally receive an organ, to those who are denied and to the public.
T29 3298-3304 Sentence denotes Ageism
T30 3305-3408 Sentence denotes Ageism encompasses stereotyping, prejudice and discrimination against people on the basis of their age.
T31 3409-3511 Sentence denotes Ageism is widespread and an insidious practice that has harmful effects on the health of older adults.
T32 3512-4083 Sentence denotes A recent systematic review showed that the significant adverse relationship between ageism and health is even more consistent than the relationships found in systematic reviews of the effects of racism on health.[5] Moreover, European doctors worry about the care they will receive when they are old, with 80% of healthcare professionals anxious about how they would be treated, suggesting they realise that ageism is very common.[6] Paradoxically, increasing numbers of elderly people are remaining healthy and some of them have important international responsibilities.
T33 4084-4171 Sentence denotes For instance, Pope Francis is now 83 years old and Queen Elizabeth II is 94 (Figure 1).
T34 4172-4181 Sentence denotes Figure 1:
T35 4183-4275 Sentence denotes Queen Elizabeth II and Pope Francis Queen Elizabeth II, aged 94, and Pope Frances, aged 83.
T36 4276-4342 Sentence denotes Would they receive optimal management if they had severe COVID-19?
T37 4343-4351 Sentence denotes Sources:
T38 4352-4406 Sentence denotes Cubankite/Shutterstock.com and AM113/Shutterstock.com.
T39 4407-4415 Sentence denotes Table 1:
T40 4417-4505 Sentence denotes Therapeutic Planning Checklist for Elderly Patients Admitted to Hospital due to COVID-19
T41 4507-4531 Sentence denotes COVID-19 and the Elderly
T42 4532-4767 Sentence denotes The risk posed by COVID-19 is higher for elderly people than for younger people.[2] For this reason, medical and political authorities should offer older adults strict preventive measures to minimise the risk of exposure and infection.
T43 4768-4945 Sentence denotes In the event that an effective vaccine for SARS-CoV-2 is developed, priority should be given to vaccination of the elderly, with the aim of maximising the number of lives saved.
T44 4946-5049 Sentence denotes This is also true for other preventive measures, such as possible pre- or post-exposure prophylaxis.[7]
T45 5050-5114 Sentence denotes In the case of people with COVID-19, the situation is different.
T46 5115-5275 Sentence denotes When allocating resources in these scenarios, healthcare professionals might prioritise those most likely to survive over those with remote chances of survival.
T47 5276-5338 Sentence denotes Making a decision based on chronological age is not justified.
T48 5339-5443 Sentence denotes In addition to age, other aspects that determine theoretical life expectancy must be taken into account.
T49 5444-5559 Sentence denotes Biological age and the use of frailty scales and comprehensive geriatric assessment are essential for this purpose.
T50 5560-5935 Sentence denotes The recent statement of the Executive Board of the European Geriatric Medicine Society insists that advanced age alone should not be a criterion for excluding patients from specialised hospital units.[8] If an elderly patient is dismissed from a specialised hospital unit for any reason, access to medical attention, symptomatic treatment and palliative care must be ensured.
T51 5936-6126 Sentence denotes This last point is essential, as palliative care is frequently suboptimal in elderly patients with other conditions, such as heart failure, and this is probably the case in COVID-19.[2,9,10]
T52 6128-6175 Sentence denotes Therapeutic Adaptation after COVID-19 Admission
T53 6176-6364 Sentence denotes In patients with advanced age who are admitted to hospital due to a severe SARS-CoV-2 infection, it is very important to establish a therapeutic adaptation plan from the time of admission.
T54 6365-6627 Sentence denotes This plan should be clearly documented in the clinical history, making it clear whether or not the patient is a candidate for mechanical ventilation and, in case of their condition worsening, when to propose the withdrawal of life-sustaining therapies (Table 1).
T55 6628-6794 Sentence denotes Decisions that maximise survival to hospital discharge, the number of years of life saved and the possibility of living each of the stages of life can be prioritised.
T56 6795-6974 Sentence denotes In this regard, patients with minimal expected benefit should not be admitted to ICU and the admission of patients with a life expectancy <1–2 years should be carefully evaluated.
T57 6975-7012 Sentence denotes This applies to patients of all ages.
T58 7013-7107 Sentence denotes A utilitarian mentality should be applied, which should prevent prejudice against the elderly.
T59 7108-7327 Sentence denotes For example, a frail elderly patient might have a low chance of surviving the prolonged intubation required to recover from COVID-19 pneumonia, but this is also the case for young patients with severe comorbidities.[11]
T60 7329-7350 Sentence denotes The Madrid Experience
T61 7351-7481 Sentence denotes During the peak of the outbreak, more than two-thirds of beds in most hospitals in Madrid were occupied by patients with COVID-19.
T62 7482-7850 Sentence denotes Figure 2 depicts the official numbers of patients admitted to hospital, admitted to ICUs, who died and who recovered in Spain between mid-March and the middle of April.[12] Non-invasive ventilation was attempted frequently, even using improvised alternative strategies like the modified Easybreath diving mask to administer continuous positive airway pressure therapy.
T63 7851-8130 Sentence denotes Invasive ventilation was often necessary and, in spite of tremendous efforts by the hospitals (for example Gregorio Marañón University Hospital opened ICUs in operating rooms and in the library), there were not enough ICU beds for all the critically ill patients who needed them.
T64 8131-8302 Sentence denotes The limited availability of ventilation support was even more problematic due to the prolonged intubation – often more than 3 weeks – that many of these patients required.
T65 8303-8535 Sentence denotes The news that prioritisation criteria were being applied in Spanish hospitals sparked widespread controversy and triggered a debate about the right of every individual, particularly the elderly, to access specialised healthcare.[13]
T66 8537-8563 Sentence denotes Use of Off-label Therapies
T67 8564-8974 Sentence denotes Effective therapies for this novel coronavirus are needed urgently and several clinical trials are now underway.[14] Meanwhile, the use of use of off-label therapies based on in vitro data and early clinical experience with COVID-19 has increased dramatically; examples include remdesivir, lopinavir, ritonavir, interferon, chloroquine, hydroxychloroquine, azithromycin, tocilizumab, steroids and cyclosporine.
T68 8975-9153 Sentence denotes To date, no therapies have been shown to be effective.[15] Moreover, some of these drugs have frequent and potentially life-threatening side-effects, particularly in the elderly.
T69 9154-9236 Sentence denotes Most are known to prolong the QT interval and can have a proarrhythmic effect.[16]
T70 9238-9250 Sentence denotes Confinement:
T71 9251-9264 Sentence denotes Pros and Cons
T72 9265-9448 Sentence denotes Confinement is an effective way to decrease SARS-CoV-2 transmission and is a way to win time until effective therapies are developed and/or an effective and safe vaccine is available.
T73 9449-9541 Sentence denotes However, the stay-at-home policy has negative effects in those with advanced age (Figure 3).
T74 9542-9693 Sentence denotes The psychological risk of confinement is particularly high among vulnerable populations, such as those in a situation of dependence or that live alone.
T75 9694-9779 Sentence denotes The negative consequences are multifaceted, with physical, mental and social aspects.
T76 9780-9912 Sentence denotes Staying at home for long periods of time facilitates sedentary behaviours and might worsen previous frailty or pre-frail conditions.
T77 9913-10030 Sentence denotes At the time of writing this article, our parents/grandparents (aged 82 and 78) have not left their home for 2 months.
T78 10031-10080 Sentence denotes We are certainly concerned about their situation.
T79 10081-10229 Sentence denotes Moreover, confinement is extremely negative for the economy and the elderly might end up suffering the consequences of a severe economic depression.
T80 10230-10296 Sentence denotes Finally, the legal situation varies a lot from country to country.
T81 10297-10409 Sentence denotes New laws have created legal frameworks that frequently restrict or prohibit the movement of people and vehicles.
T82 10410-10494 Sentence denotes Some countries have severe penalties for those who do not comply with the new rules.
T83 10496-10515 Sentence denotes Family and Mourning
T84 10516-10602 Sentence denotes The COVID-19 pandemic has isolated the elderly not only at home but also in hospitals.
T85 10603-10636 Sentence denotes Visits are usually not permitted.
T86 10637-10744 Sentence denotes Several patients of advanced age with severe infection have died alone in the hospital or in nursing homes.
T87 10745-10898 Sentence denotes The suffering of the family does not end there, as containment measures also apply in the context of mourning, which adds trauma to that of death itself.
T88 10899-11025 Sentence denotes Corpses are considered potentially infectious, so are deposited as soon as possible in a body bag that will never be reopened.
T89 11026-11147 Sentence denotes During the peak of the outbreak in Madrid, we had so many deaths that an ice rink had to be used as a provisional morgue.
T90 11148-11237 Sentence denotes It was frequently impossible for families to see their deceased loved ones one last time.
T91 11238-11247 Sentence denotes Figure 2:
T92 11249-11400 Sentence denotes Official Daily Evolution of the Number of Patients Admitted to Hospital, Admitted to Intensive Care Units, who Died and who Recovered in Spain Source:
T93 11401-11429 Sentence denotes Ministerio de Sanidad et al.
T94 11430-11439 Sentence denotes 2020.[12]
T95 11440-11449 Sentence denotes Figure 3:
T96 11451-11653 Sentence denotes Confinement – the Stay-at-home Policy – has Positive and Negative Effects in Individuals of Advanced Age The rules of social distancing put in place by the health authorities applies also at funerals.
T97 11654-11842 Sentence denotes Services must be limited to close family members only (with a maximum of three people), usually with video recording and streaming for those who wish to attend the funeral from a distance.
T98 11843-11908 Sentence denotes Finally, the vast majority of older people in Spain are Catholic.
T99 11909-12010 Sentence denotes The fact that public masses have been cancelled makes the situation even more difficult for families.
T100 12012-12022 Sentence denotes Conclusion
T101 12023-12321 Sentence denotes COVID-19 in elderly patients raises some ethical issues; however, most of these issues are similar to ethical problems in other conditions, such as heart failure.[17–19] The correct prioritisation for the allocation of scarce resources should be based on various factors relating to the individual.
T102 12322-12414 Sentence denotes Chronological age should not be the only factor that influences the decision-making process.
T103 12415-12459 Sentence denotes This is essential to good clinical practice.