Age and grit in prioritising intensive care: - a mixed-methods approach of normative challenges

Intensive care unit (ICU) admissions among older patients are increasing, posing significant challenges to already strained healthcare systems. Decision-making around ICU admission in times of limited resources may provide important knowledge about difficult prioritisations, particularly for older patients. Thus, the aim was to investigate ICU-admission decisions for older patients with COVID-19.

A mixed-methods approach. We audio-recorded ten COVID Rounds and nine Moral Case Deliberations for 34 patients across three Swedish hospitals during the pandemic, and collected data from medical records of 329 patients aged ≥ 65 diagnosed with COVID-19. Data were analysed using qualitative content analysis and multiple regression.

Among 239 patients with documented decisions in medical records, 56% included explicit justifications. The justifications included considerations of medical benefit (not-too- ill/too-ill), general condition (good/frail), age (not-too-old/high age), professional duty (benefit of the doubt/do no harm) and "worth giving it a go" (grit and will to live/lack of will and coping). A minority (31%) of decisions favoured ICU admission. Justifications supporting admission were predominantly drawn from discussions in COVID Rounds and MCDs, where patient grit was a recurring argument. In regression analyses, age ≥ 80 years was the only factor significantly associated with not being admitted to ICU and having a documented justification. Few decisions explicitly referred to COVID-19-specific factors.

Our findings reflect patterns similar to pre-pandemic ICU decision-making, suggesting continuity in clinical reasoning. However, the limited documentation of justifications-especially in favour of admission-warrants attention, emphasising the need for clearer reasoning in medical records. Our findings identify chronological age as a key triage factor, normatively supported by the ethical principles of non-maleficence, justice, and Sweden's legal priority-setting principle of Needs and Solidarity-which emphasises care only when benefit is likely. We therefore advocate for national (and potentially international) guidance on triage systems that support a palliative approach for very old patients. While grit may be relevant to ICU admission due to its link to potential benefit, its use raises ethical concerns, particularly in relation to Needs and Solidarity and Human Dignity. We recommend its cautious application pending further research.