Geriatric frailty, therapeutic failure, and the ethics of end-of-life care
Nursing home residents are polypathological patients: cardiovascular diseases (hypertension, atherosclerosis, heart failure), metabolic disorders (diabetes, hepatic and renal insufficiency), neurodegenerative diseases (Parkinson’s, Alzheimer’s), malnutrition and muscle wasting. These chronic conditions have had time to cause lasting damage to the body.
Median length of stay in nursing homes is approximately 2 years and 7 months. These are end-of-life patients whose organisms are weakened and exhausted. In a COVID-19 context, they present all comorbidities associated with severe forms of the disease.
Nursing home patients’ prescriptions stack treatments upon treatments for side effects. The geriatrician’s first task is to simplify these prescriptions to focus on essentials. Pharmacokinetics in these patients is substantially altered: kidneys filter poorly (accumulation of active molecules), liver metabolizes poorly (potentially toxic precursors), intestines absorb poorly.
The result is an unstable equilibrium that any complication — an infection, a new treatment — can collapse through a cascade of decompensation.
In non-nursing-home patients, COVID-19 causes profound asthenia and marked apathy. In nursing home patients already at the end of their reserves, this fatigue can be so profound that they literally die of exhaustion, without classic signs of severity: no obvious sepsis, discrete dyspnea, predominantly intestinal or urinary symptoms. They “fade away in silence,” making detection and intervention particularly difficult.
For those who develop acute respiratory distress, deterioration is even faster than in younger patients — sometimes 2 to 3 hours between the first signs and the need for intubation.
Pharmacokinetic analysis of hydroxychloroquine reveals major contraindications in geriatric patients: digestive absorption disrupted by COVID-19 intestinal symptoms, very long half-life with accumulation risk, hepatic and renal tropism (organs already failing), and critically a cardiac risk (QT segment prolongation) in patients already suffering from heart failure. Adding drug interactions with existing prescriptions transforms the prescription into a perilous exercise.
Facing a highly unfavorable risk-benefit ratio for intensive resuscitation in these patients — sedation, endotracheal intubation, vasopressors, crystalloids, dobutamine, insulin, hydrocortisone, rhAPC — with an expected mortality approaching 100%, and an even heavier ECMO procedure (50% failure rate in the general population), we face therapeutic failure.
Palliative care is not euthanasia. The intentionality is fundamentally different: to relieve anguish, suffering, and respiratory distress, to accompany the end of life on a path of dignity. The decree authorizing injectable Rivotril falls within the framework of the Claeys-Leonetti law (2016) on end of life, supervised by the French Society for Palliative Care (SFAP) protocols.
This article, written in the urgency of April 2020, aimed to respond to accusations of euthanasia leveled against healthcare workers. It recalls that it is the disease that kills — not the palliative management of suffering — and that end-of-life care by profoundly humane teams is an irreplaceable medical act.