What consent to vaccination against Covid-19 for elderly people living in institutions?
Press release of the National Academy of Medicine
December 24, 2020
No medical act can be performed without the consent of the concerned person. This principle applies unreservedly to vaccination: on the basis of clear, fair and accessible information provided by the doctor, it is up to each person to decide freely whether or not to be vaccinated.
According to the most recent data from Santé Publique France, 31% of deaths by Covid-19 occurred among elderly people living in a residential establishment for dependent elderly people (EHPAD) or a medical-social establishment (EMS). On the basis of this observation, the High Authority for Health (HAS) recommended allocating the first vaccination resources to this vulnerable population, the most exposed to serious forms of infection, and to vaccinate, in an initial phase (January and February 2021), people residing in EHPADs and long-term care units (USLDs) .
From 27 December 2020, the field teams in charge of deploying this vaccination strategy will be faced with three major difficulties:
– messenger RNA vaccines, based on a new technology, still have areas of uncertainty, particularly with regard to medium- and long-term efficacy and safety, which explains the hesitation expressed by many elderly people;
– It is estimated in France that 57% of the residents of the 7400 EPHADs and 70% of the residents of the 600 USLDs suffer from moderate to severe cognitive disorders. Many of these people are isolated and have no family;
– the launch of this first phase of vaccination in a very short time is a logistical challenge that requires the implementation of an organisation adapted to each type of establishment.
In the particular conditions of an epidemiological situation that is still worrying, it is important to remember a few principles to be observed before proceeding with vaccination against SARS-CoV-2
– No one should be vaccinated against his or her will; before vaccinating an elderly person, it is first necessary to assess his or her degree of lucidity. If this diagnosis has not been made previously, it must be established collectively by the health care team and recorded in the person’s medical file.
– When the degree of lucidity is deemed compatible with the understanding of the vaccine offer, each person must be informed during a pre-vaccination consultation, followed by other individual interviews if necessary, that his/her age, and possibly, state of health, make him/her a priority for vaccination, taking into account a very favourable benefit/risk ratio.
– A dialogue should be established, using simple and understandable terms, adapted to each individual case, to ensure that the vaccination proposal has been understood.
– As the vaccination campaign is due to start very soon, it is urgent to begin this information phase prior to the collection of consents.
– The response to the request for consent must be mentioned in each person’s medical file, but there is no need to authenticate it by signature, as this could generate anxiety and worry and as no other usual medical procedure requires such a conduct towards the residents. The entry in the medical file, specifying the medical examinations and preliminary interviews as well as the decision taken, will suffice to establish the reality of the care provided.
In view of these considerations, the National Academy of Medicine recommends:
not to exclude from vaccination against Covid-19 any elderly person residing in institutions, as only a medical contraindication or a refusal by the person concerned can justify abstention from vaccination;
to ensure that complete information on the new Covid-19 vaccines and on their mode of administration is distributed immediately to each establishment caring for the elderly;
to provide the elderly, even when their lucidity is diminished, with complete, sincere and appropriate information, if possible in a collegial manner, during the pre-vaccination consultation, renewing the dialogue as much as necessary;
to consider that preserving the lucidity of elderly persons residing in institutions guarantees the value of free and informed consent. A medical diagnosis of lack of lucidity should lead the health care team to consult the opinion of a trusted person or a close relative, in order to express the wishes of the person concerned;
not to require the signature of a document attesting to consent;
in the event of a total lack of lucidity observed medically, to carry out all possible research to try to find out the person’s wishes regarding the vaccination in order to take a concordant decision;
to search in the medical file of the person concerned all medical and relational elements concerning the acceptance or refusal of vaccinations;
to ensure that each establishment has a permanent system of medical care, hiring for example a local health professional, doctor or nurse, who is constantly available, to ensure the best possible follow-up of the consequences of the vaccination.
Vaccination strategy against Sars-Cov-2, preliminary recommendations on the strategy for prioritising the populations to be vaccinated, 27 November 2020