The COVID-19 crisis has increased the need for wise decisions on the level of treatment depending on the patient's underlying health condition, the seriousness of the infection and the patient's desires and vulnerability. The guidelines for opting out of treatment are in accordance with the recommendations of the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed). Link: Recommendations of the Danish Patient Safety Authority.
In Denmark, we have no specific directions limiting the scope of treatment of COVID-19. Age alone is not a desired criteria, and the question of hospitalisation will always depend on an individual assessment. We need a recognised patient vulnerability assessment tool, but it is possible to look to the British Clinical Frailty Scale (CFS) prepared by the NHS Specialised Clinical Frailty Network (3). It is the assessment of the National Institute for Health and Care Excellence (NICE) that it is doubtful whether persons with a CFS score equal to or greater than five will benefit from intensive care (4). Many patients at assisted living facilities will benefit from remaining in their usual place of residence.
Generally, nursing staff should talk to patients and/or their relatives at an early point about their expectations of treatment in case of a novel coronavirus infection or cardiac arrest.
Patients and/or relatives having a special desire for treatment are suggested to contact the doctor. The actual decision on the level of treatment is made during the period of disease, either when the patient tests positive for COVID-19 or earlier if the patient's condition has already deteriorated.
A COVID-19 patient who can understand the consequences of his or her decision has the right to opt out of treatment and refuse hospitalisation/intensive care. The assessment of whether a patient making such a decision is of sound mind must be made by a doctor.
If a patient and/or his or her relatives have a strong desire for active treatment, the doctor can consult a physician at the hospital or in that situation admit the patient to hospital or direct the patient to a COVID‑19 assessment centre.
If the doctor makes the judgement that hospital treatment would be futile, the doctor could have the following dialogue with the patient and/or his or her relatives:
'I do hope that we can help your mother/father/wife/husband through the coronavirus infection, but if xx's condition deteriorates, we will not hospitalise him/her, and we will not resuscitate him/her in case of cardiac arrest. The reason is that the treatment offered in connection with hospitalisation and resuscitation will not have the desired effect when the body is so weakened by the serious illness (cancer, severe cardiac disorder, lung disease, renal disease, neurological disorder).'
Give information about the course of a COVID-19 infection in weak multiple-disease patients and the trajectory of cognitive decline.
'I want to be sure that you know that we will continue the treatment as long as it remains effective and we will relieve pain. We will also find a way for you to be with your dear one during his/her last days.'
When it is the doctor's judgement that hospital treatment would be futile, the doctor must also consider the need for palliative care, see paragraph 2). When the final decision has been made to opt out of treatment, the doctor must always confirm this in writing:
a) The patient is of sound mind and does not want to be hospitalised/receive ventilator treatment for the current novel coronavirus infection.
b) Due to the patient's overall health condition (including dementia), the patient is NOT to be hospitalised, but must be treated and given symptom relief at the nursing home, unless there is a clear purpose of admitting the patient to hospital that cannot be achieved at the local nursing home. Do-not-resuscitate order.'