Pediatricians in Alberta are bracing for the possibility of having to decide which critically ill children will be eligible for care should a surge in COVID-19 cases push the province into its highest level of triage protocol.
The uncomfortable reality comes as the presidents of Alberta’s largest health care unions and largest worker advocacy group urge Premier Jason Kenney to immediately request federal assistance to deal with the province’s overwhelmed hospitals.
As of Sunday morning, provincial critical-care capacity was at 84 per cent, according to Alberta Health Services (AHS). Without additional surge spaces, capacity would be at 160 per cent. About 75 per cent of surgeries at all hospitals have been cancelled, including at children’s hospitals, so that staff can be redeployed to respond to COVID-19 patients at other sites.
“It is our assessment that Alberta’s health care system is not just ‘on the verge’ of collapse – we believe it’s actually collapsing in front of our eyes,” a Sept. 18 letter to Mr. Kenney from the union presidents reads.
AHS last week began sharing with staff its framework for critical care triage during a pandemic or disaster – a road map to follow as an “absolute, absolute last resort,” president and chief executive officer Verna Yiu said.
The introduction to the 52-page document says the protocols “create an objective process to guide health care professionals in making the difficult determination of how to allocate resources to critically ill adult and pediatric patients when there are not enough critical care resources for everyone.”
The protocol, which has not yet been activated, would begin with a number of measures including patient transfers, redeployment of medical staff and extended work hours. Phase 1 triage would then be triggered when provincial occupancy of all available critical-care surge beds surpassed 90 per cent. Under this phase, only patients with a greater than 20 per cent probability of surviving the next year would be eligible for critical care.
At 95 per cent occupancy, the province would move to Phase 2, in which only adults with a greater than 50 per cent probability of surviving the next year would be eligible for critical care. Pediatric triage would also be considered at this stage; children with complex chronic illnesses, for example, may not be able to receive critical care that they would have under normal circumstances. Care could also be discontinued for patients already in the ICU.
Samina Ali, a pediatric emergency physician at Stollery Children’s Hospital in Edmonton, said she is hopeful that such a scenario can be avoided, but that even the need to consider the idea of triaging children for care in Canada is shocking.
“Never in my life training did I ever think I would have to read something like that,” she said of the triage document. “Never in my career did I think I’d have to consider those factors in making decisions. And I hope to high heavens that I never have to talk to a family about that, ever.”
Dr. Ali added that the framework can be traced back to ablest biases in society.
“I know these are absolutely not the intentions of people who I’m sure worked with heavy hearts to create these policies, but when you say chronic conditions and likelihood to survive influence your decision making, that includes a lot of children who are not neurotypical or have life-limiting conditions,” she said. “And that hurts me to the core.”
Dr. Ali said while the primary concern is for patients and their families, she is equally troubled by the effect on health care workers who may be asked to make these decisions.
“There will be so much moral distress and conflict,” she said. “I’m very worried about post-traumatic stress disorder and burnout and quitting.”
Tehseen Ladha, an Edmonton-based pediatrician with a master’s in public health, similarly believes Phase 2 can be avoided, but said “it is certainly a shock to be in a situation where this document is even on the table.”
Dr. Ladha is among a number of physicians calling for a full lockdown to halt the rapid spread of the virus in the province. It’s a move that would go beyond the measures announced by the Alberta government last Wednesday, which have been called confusing and come with a number of exemptions and exceptions.
“It’s important to make clear that we have not called for a lockdown until this point, and the reason we haven’t is because there were opportunities to still be pro-active and put in sensible public-health measures that would have prevented this,” Dr. Ladha said.
“But now it’s far too late. Because we’re in a reactive stage, we really need to shut down all non-essential services and businesses to get that exponential rise down sufficiently.”
In their letter, the heads of groups including the United Nurses of Alberta, the Alberta Union of Provincial Employees, the Health Sciences Association of Alberta the Canadian Union of Public Employees and the Alberta Federation of Labour urge Mr. Kenney “in the strongest possible terms” to call on Ottawa to immediately deploy the military, Red Cross and all available medical staffing resources from other provinces.
“The tank is empty. The well is dry,” the letter said. “Our members have been going above and beyond for 19 months, but they are worried that this wave of the pandemic is the one that will crush them.”
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