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The Stockholm Region guideline, which was applied since March 20 to provide the appropriate level of care to patients with covid-19, used an international scale, the Clinical Fragilty Scale, which estimates the frailty of the elderly and which Ekuriren was the first to describe.
The guideline adopted in March states that people who were between 1 and 4 on the nine-point scale were prioritized for hospital care. For the elderly who cannot cope with everyday life on their own, hospital care would only be relevant for emergency procedures, such as surgical procedures. Each case would be assessed individually, but the goal was to relieve emergency hospitals and care for the elderly at home.
According to the scale it is estimated an older person who is at a vital 1 while a four is fragile but still manages everyday life on his own. Five on the scale means that a person is “slightly frail” and needs help coping with everyday tasks, such as shopping, cooking, and light housework, and nine are terminally ill.
In the Swedish instructions on the scale, there are references on how the scale should be used when estimating people with dementia. The fact that people between 5 and 9 on the scale were downgraded meant that no dementia was prioritized for hospital care, says Anders Wimo, a professor emeritus, family physician and specialist in general medicine who researches dementia.
– If you have a dementia illness, you basically belong to categories 5-8, which should not be prioritized for hospital care. All patients with dementia in special housing were affected by the control document, says Anders Wimo.
About two thirds of all those living in special housing have dementia, according to Wimo.
– The wording of the guideline was discriminatory for people with dementia, then there was a reservation that everyone should be evaluated individually. Ivo’s review may well show how it was applied.
Maria Eriksdotter, professor of geriatrics at Karolinska Institutet, says she reacted to the design of the guidance document.
– They have used this CFS scale that deals with how vulnerable you are. Based on the scale, numerical values were established for different levels of care that were a little too low. It didn’t go well. An assessment based on a frailty scale cannot be used that way.
She picks up that the wording of the document, in addition to the scale, that doctors must make an individual assessment of medical needs, in the situation can be forgotten.
– Sometimes when it becomes stressful, there is a risk that the assessment will focus more on numerical values.
Maria Eriksdotter, a professor of geriatrics, reacted to the priority guideline for older people in the Stockholm region. The scale was removed after her accusations.
Photo: Susanne Kronholm
Maria Eriksdotter claims that she contacted the chief physician for the Stockholm region in May and felt she was being listened to.
– I understood that the issue was already under discussion, and in the next version the numerical values for the different levels of care disappeared. It is really important that the writing has changed.
In that version Instead, the guideline developed on May 22 states that the CFS scale can be used “as a guide in the physician’s assessment,” for medical needs and benefit of care, “if you have sufficient knowledge and experience of the tool”.
Johan Bratt, the region’s chief physician, says CFS is a quick and easy way for healthcare professionals to describe a patient’s condition, but confirms that the guideline was changed in May in the wake of the KI accusations.
– We receive comments that we take into account. We wanted to avoid that those who had no knowledge and experience of the tool felt the need in this pressure situation to begin to acquire knowledge about the scale. Therefore, it was toned down in the May release.
All hospital care for dementia has been avoided by prioritizing between 1 and 4 on the scale, according to the researchers. What do you say about that?
– What has always stood out in the different versions is the individual medical assessment. No one at SÄBO will be disqualified from receiving hospital or geriatric care without a general medical evaluation.
How do you see the risk of negative consequences for older people who were at the top of the scale?
– That is what we are going to assess now, in the regional assessment of deaths in SÄBO. And Ivo is doing his research. We will analyze the outcome of the guidelines in individual cases.
