Improving goal-concordant care in the hospital for patients with dementia in the COVID-19 era.

At this point in the COVID‐19 pandemic, we are well‐versed in mortality risk factors for COVID‐19 infection, such as older age and medical comorbidities, including dementia. In this context, advance care planning (ACP) among patients who are at high risk for developing severe COVID‐19 and death is critical, even if it has not been prioritized on a national level. Among older adults, ACP discussions and documents have been associated with decreased in‐hospital death and increased hospice utilization. Importantly, for patients with dementia, aligning care plans with patients and families can be complex given limitations or uncertainty around patient cognition and capacity.

In April 2022 issue, Stefan et al. present findings from a retrospective cohort study examining patient characteristics of adults over age 50 with COVID‐19 infection who died while hospitalized. While some patients died unexpectedly due to COVID‐19, approximately 60% had a serious or advanced illness with a potential prognosis of less than 12 months in the absence of COVID‐19 infection. Among the patients in this study, over 40% had a diagnosis of dementia, and almost half (47%) were admitted from skilled nursing or long‐term care facility. However, patients in this cohort received aggressive care. For example, among patients with serious or advanced illness, almost 40% were full code at admission and less than 6% received a palliative care consult in the prior 12 months. In addition, among patients with serious or advanced illness, a majority (67%) developed delirium, and 17% received mechanical ventilation prior to their deaths.

The discordance between high expected mortality during hospitalization and the high proportion of patients who received invasive interventions highlights the opportunity for serious illness communication to occur early and often. Many patients with serious or advanced illness and their family members express that the patient would not want aggressive measures in the setting of a high acuity illness and would prefer to die at home. , Thus, these study findings suggest an opportunity to improve planning for expected illness severity and trajectory among patients with advanced illness. Furthermore, rates of some aggressive treatments (such as mechanical ventilation) have been increasing in patients with advanced dementia without a meaningful improvement in patient outcomes.

ACP is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. Unfortunately, overall participation in ACP by persons with dementia remains low and has been difficult to implement, underscoring unique challenges in this population. Further work is needed to understand how to implement both effective and culturally‐appropriate ACP across diverse populations, including those with dementia.

In the hospital setting, we are challenged by caring for patients with acute and potentially reversible illnesses, and goals of care may be dynamic. Several approaches can support goal‐concordant care. First, the presence and severity of dementia (which may be overlooked by hospital clinicians) must be recognized and incorporated into goals of care conversations. Second, we should continue to clarify and refine best practices to promote family engagement in goals of care conversations (including the use of virtual family meetings during pandemic‐related restrictions). Third, while inpatient palliative care teams have been associated with more patients with dementia referred to hospice, further work is needed to clarify exactly which patients may benefit from specialty palliative consultation. Finally, we should explore novel system‐based interventions like automated/triggered specialty palliative care consultations to use hospitalizations as an opportunity to improve goal‐concordant care for patients with dementia. As we enter into the next phase of the COVID‐19 pandemic, additional prioritization of both ACP and serious illness communication can help provide goal‐concordant care for our patients who enter the hospital with dementia and/or severe comorbidities.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.