To date, the SARS-CoV-2 pandemic has infected 11 million individuals and caused over 540,000 deaths. 1 At its beginning, mounting healthcare demands threatened to inundate critical care surge capacities.
This led to critical care resources being rationed in countries such as Italy, at times based on arbitrary age cut-offs. 2 Subsequently, score-based rationing protocols were proposed to allocate intensive care unit (ICU) beds swiftly and in a consistent manner while under time and situational pressure. As countries globally flatten their epidemic curves, there may be a short reprieve before lifting of social restrictions leads to successive waves of infection. It is now timely to review the prevailing emphasis on score-based rationing. This approach, rooted in disaster triage, enabled frontline clinicians to avoid challenging conversations in some instances. However, such approaches fail to address the humanistic issues magnified by this crisis, such as those concerning perceived burden of treatment, acceptable quality of life, and antecedent decision-making.
These are particularly pertinent when deliberating ceiling-of-care for older populations. In the United States, individuals aged 65 and above make up 45% of hospitalisations, 53% of ICU admissions and 80% of all deaths from SARS-CoV-2. 3 By nature of their physiological vulnerability, older adults are a group likely to require critical care, but for who the benefits of ICU care remain uncertain.
Two questions must be answered before triaging the older people with COVID- 
informed and shared decision-making -a process where patients and care-providers openly weigh benefits against burden of critical care, in relation to the patient's unique values, concerns and social set-up.
The UK Intensive Care National Audit and Research Centre (ICNARC) reported SARS-CoV-2 to carry a mortality rate twice as high as that seen in other viral pneumonias (48.6% vs 22%). 4 Advanced age is associated with more severe disease. Based on data from China, only 1% of individuals in their 20s required hospitalisation, as compared to 11% of those in their 60s and 18% of patients aged above 80. 5 Similarly, in-hospital mortality is higher at older ages. Amongst 5700 patients from New York City, hospital deaths were reported to be 16% for those aged 60-69; 32% for those aged 70-79; and 54% for those aged 80 and over. 6 Survival outcomes of the older people remains poor despite critical care. Of 5139 ICU patients in the UK, mortality rates were 40% for patients in their 50s, 55% for those in their 60s
and near 65% for patients in their 70s and 80s. 4 Emerging evidence suggests a close association between greater mortality and overwhelmed healthcare infrastructures. In China, survival rate improves across all age-groups as the point of analysis shifts away from the epicenter at Wuhan. 7 Similarly, South Korea's early success at outbreak containment likely contributed to its significantly lower age-adjusted case-fatality than China and Italy. 8 Nonetheless, current epidemiological evidence shows poor outcomes, particularly for the oldest old.
However, age-stratified epidemiological data should never be indiscriminately extrapolated to individuals in place of bedside risk-stratification. Physicians, advocating for their patient's best interest, must discern the subgroup of robust older people who may survive if offered critical care. To do so, clinicians will need accurate prognostic tools -unfortunately, none of the COVID-19 triage protocols had
underwent scientific validation. In fact, recent studies have cast serious aspersions over their validity. As an example, several triage standards included the Sequential Organ Failure Assessment (SOFA) score as a measure of multi-organ dysfunction and set arbitrary cut-offs for the purpose of rationing. However, COVID-19 patients presented with predominately isolated respiratory failure leading to low SOFA scores that fell below designated thresholds, rendering these protocols unhelpful. 9 Perhaps more importantly, current protocols weight their component variables empirically, often with a disproportionate emphasis on chronological age. This is exemplified by NHS's COVID-19 decision-support tool. 10 Under this empirical framework, patients aged seventy and above would only be borderline candidates for ICU care, regardless of physiological reserves. Any further functional deficit or comorbidity would be likely to render them ineligible.
Without a validated triaging tool, critical care may be inequitably allocated according to random chance or on a first-come, first-serve basis. However, stewarding ICU resources based on arbitrary chronological age cut-off is ageist and signals moral indifference towards older people. 11, 12 Age has been too often conflated with frailty, disability and multi-morbidity -which by themselves independently predict adverse outcomes. In particular, the Clinical Frailty Score (CFS) has recently been demonstrated to better predict disease outcome in older patients with COVID-19, than age or comorbidity. 13 We applaud the inclusion of CFS into the NICE rapid critical care guidelines, but share concerns that non-selective application beyond the older population will disadvantage patients with non-progressive long-term disabilities. 10 Considering the disproportionate morbidity and mortality seen in the infected older patients, there is a pressing need to construct and validate a multi-component and weighted prognostic index, specific to the critically ill older patients with COVID-19 and ideally incorporating disease-specific indicators for non-COVID-19 conditions, frailty, comorbidity and functional disabilities. Such a tool will be important to inform shared decision-making, but cannot replace these crucial conversations between clinicians, patients and their families.
Putting together the genuine prospects of poorer outcomes, as well as existing challenges in accurate prognostication, physicians must engage older patients in honest discussions, that weigh the likelihood of achieving the quantitative benefit (prolonging survival), against the impact of critical care on the patients' quality of life. Such dialogues must go beyond conveyance of survival probabilities and extend to elucidating patient-centered values that should always play a central role in therapeutic goal-setting.
ICU survival is often not the fundamental concern for older persons, who may accept greater risks of dying if critical care promises a return to an acceptable level of function, albeit over substantial time.
The reverse is equally pertinent.
Qualitative studies consistently report that older adults value cognitive autonomy, functional independence and meaningful engagement in community activities. 14 The subjectivity tied to trade-offs between conflicting goals of longevity and quality of life frequently deters physicians from engaging in such discourses. Yet, no conversation regarding survival probability can be complete without an accompanying discussion regarding the longer-term disabling process consequent to critical illnesses. 
COVID-19 patients typically deteriorate two weeks from the onset of the infection, leaving a critical 5day period from admission to point of inexorable decline. 17 Beyond this, critically ill patients may no longer be able to engage in meaningful communication. Goals-of-care discussion must be woven into daily consultations during this narrow window of opportunity. Such discussions are rare pre-COVID, and will remain so unless they are prioritized as an indispensable element in the care of all older people, both in pandemic times and after the pandemic has passsed. 18 COVID-19 is here to stay, hence goals-ofcare discussions cannot remain opportunistic, but must be brought to the forefront as a policy-driven clinical norm. Undoubtedly, there will be impediments to these conversations, such as the mandatory use of face masks and personal protection equipment, as well as restricted visiting policies. However,
these can be circumvented through video-conferencing platforms that have become increasingly accessible owing to the availability of smartphones in the general population.
Conversely, evading these conversations is ethically indefensible. Leaving treatment escalation decisions until a time of crisis deprives patients of an informed choice and risks family members demanding overaggressive treatment in the heat of the moment. During these dialogues, physicians must truthfully convey the emergent clinical reality, discern therapeutic goals and discuss the feasibility of achieving them. A measured and shared decision to forgo ICU treatment will be far less emotionally burdensome for families than one that involves withdrawing life-sustaining treatment, although the two entities are deemed ethically and legally the same. On the other hand, should the patient stand to benefit and is keen for critical care, their physician should take the opportunity to manage their expectations by framing ICU admission as a trial of treatment rather than the endpoint in care. Palliative care must always be offered as an option, without which patients and families may be misled into demanding critical care out of fear that they would otherwise be forsaken. We enclose an institutional strategy encompassing these key points, that facilitates an expedient bedside conversation. (Figure 1 ).
One major hindrance to these antecedent discussions is the belief that a besieged healthcare system lacks the luxury of time for such lengthy dialogues. Paradoxically, avoiding them earlier in the disease trajectory will lead to more emotionally-charged disputes when ventilators need to be withdrawn, be this due to treatment futility or a failure to reach a triage threshold. Appropriate ceilings-of-care will also prevent medically inappropriate cardiopulmonary resuscitation, reduce contagion exposure to healthcare professionals and streamline ICU resources towards treating patients who want and would benefit from critical care.
As the pandemic slowly turns the corner, we should bring the focus back to having these goals-of-care conversations with our patients. Complex, value-centric decisions are best made conjointly between 