Ontario has prepared a plan for hospitals to determine who should and should not receive life-saving care if medical facilities become overstretched by the novel coronavirus pandemic.
In the most severe phase – if hospitals are at double their capacity for a sustained period – anyone with less than a 70-per-cent chance at surviving would not qualify for the medications and machines that keep them alive, according to the report prepared for Ontario Health. This group includes those who have metastatic cancer, those in cardiac arrest and those with severe and moderate cognitive impairment caused by a progressive illness.
The guidelines in the report apply to life-saving treatment of all kinds, not just to COVID-19. People who are already receiving life-saving treatment could be removed from supports in favour of individuals with better odds of surviving.
The document, which is titled Clinical Triage Protocol for Major Surge in COVID Pandemic and dated March 28, carries the insignia of Ontario Health, a government agency. It has not been made public. James Downar, an Ottawa bioethicist, led the drafting of the protocol, overseen by an ethics committee of Ontario’s centralized COVID-19 supervisory group.
Kayla Iafelice, a spokeswoman for the Premier Doug Ford’s office, said Thursday night the report is only a draft and has to go through a number of approval processes, including the highest level of government. “We have not authorized the protocol.”
While the protocol in the report does not apply directly to children, they could be denied life-saving treatment out of what the protocol describes as fairness. When adult hospitals are at their most severe triage level, it says, hospitals may consider triage for children “in order to respect the principles of utility and fairness populationwide.” It says doctors should first consider “the moral distress inherent in removing a child from life support, or denying its application.”
An ethicist involved in the development of a similar protocol, yet to be finalized, in New Brunswick, called Ontario’s protocol a bold model for other provinces as they move to “pandemic ethics.”
“When you change from normal clinical ethics to pandemic ethics, the goals have to change, to save as many lives as possible,” said Timothy Christie, regional director of ethics services for Horizon Health Network in New Brunswick. (The Globe and Mail sent him a copy of the document.)
The result, he acknowledged, is that people will die who otherwise would live.
“It means there are going to be a lot of people we would be able to save under normal circumstances that we’re not going to be able to right now. That is the unfortunate reality of the situation we’re in.”
The Ontario document offers doctors a script for how to talk to patients and their families about the new rules on who receives life-saving care.
“Normally, when somebody develops critical illness, the medical team would offer them intensive care (a combination of medications and machines to support their vital organs), provided that the medical team felt that they had a reasonable chance of survival,” the document says. “However, because of the COVID outbreak, we are currently unable to offer intensive care to everyone who is critically ill … ”
The decision to start triage would be made by regional authorities, not individual hospitals, according to the document: When an individual hospital reaches capacity, regional authorities must try to transfer patients to other sites for life-saving care. The protocol would take effect only when all hospitals are past capacity. Currently, many Ontario jurisdictions are at 70-per-cent capacity in surgery, because of aggressive attempts to postpone elective surgeries and other procedures, said Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians.
Decisions on whether an individual receives care would involve the physician responsible for the patient’s care, a triage doctor and a hospital triage committee, which should include a doctor, an ethicist and an administrator responsible for bed allocation, the protocol says.
The guiding principles are utility (those who derive maximum benefit receive the care); proportionality (the number harmed by the protocol should not exceed the number harmed under a first-come, first-served approach); and fairness (“priority should not be given to anyone on the basis of socio-economic privilege or political rank”).
The triage contains three levels. The first, when the system reaches 200-per-cent capacity, would deny life-saving treatment to those with more than an 80-per-cent chance of death from trauma, and those who are unable to perform daily tasks because of a severe cognitive impairment from a progressive illness. The wording suggests that some individuals with dementia would be denied life-saving care, but that individuals with developmental delays not caused by progressive illness would still qualify for such care.
The second level denies life-saving treatment to those with more than a 50-per-cent chance of death. The third level applies to those with more than a 30-per-cent chance of death.
Michael Bryant, head of the Canadian Civil Liberties Association, said he is concerned about the protocol not being made public. He said his biggest concern is that in practice, unconscious biases against individuals with mental illness or addictions might be expressed, or errors in assessing these individuals could be made, when doctors exclude people who appear to have cognitive impairments.
In B.C., a coronavirus task force released three documents Saturday for health-care workers that offer guidance on their duty to help patients, how the use of protective equipment needs to be prioritized and a higher-level framework for making ethical decisions if the virus brings a potential crisis of hospital resources. B.C. has left the five regional health authorities in charge of releasing more details.
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