As ICUs fill up, doctors confront grim choice of who gets life-saving care
Ontario's protocol for critical-care triage worries disability rights advocates
Hospitals are shifting critically ill patients around, looking for any empty bed. Nurses and doctors are putting in exhaustion-defying amounts of overtime. Some provinces are opening new intensive care unit capacity.
But it may not be enough to stave off a point no one wants to reach in the pandemic — when only a handful of ICU beds remain but a greater number of patients need those spots.
That point is drawing perilously close in Ontario and possibly parts of Saskatchewan, even as some other provinces don't have a single hospitalized COVID-19 patient.
It means some of the hardest decisions health-care providers ever face will have to be made: who gets potentially life-saving care and who doesn't.
"There are people who could be saved by critical care who aren't going to get it," said Dr. James Downar, a palliative and critical-care physician in Ottawa who co-wrote Ontario's ICU protocol for when that awful moment strikes.
He hopes the protocol won't be needed.
"It's a difficult, difficult job to make such a call ... and I hope it doesn't happen."
Decisions about how to ration life-saving care are never easy, Downar said — and this one has been not only arduous but controversial. Bioethicists and human rights groups have raised concerns that Ontario's protocol discriminates against people with disabilities.
Downar says any protocol is better than none, which could leave decisions vulnerable to doctors' unconscious biases — or an even cruder determination: first come, first served.
Level 1 triage could come in weeks
Ontario's protocol is a work in progress and hasn't officially been published, but the latest 32-page draft to be widely circulated among doctors looks like this:
- Two physicians will independently assess any patient needing an ICU bed for their "short-term mortality risk" or STMR — their likelihood of death within 12 months.
- At the lowest level of triage, Level 1, anyone with short-term mortality risk greater than 80 per cent is de-prioritized for an ICU bed.
- If the COVID-19 situation worsens and triage moves to Level 2, anyone with an STMR over 50 per cent is "not prioritized for critical care."
- If ICUs get even more strained and go to Level 3, only people with a less than 30 per cent risk of dying within the next year would be prioritized for a spot.
Level 1 triage might be reached within Ontario in the next two weeks if current trends continue.
I cannot see a situation where some degree of ICU triage does not happen in Ontario. <br><br>Demand will outstrip supply of staffed beds.<br><br>In addition to being cruel and unfair to our future patients, this will break the back of healthcare workers.<br><br>We tried to warn you.—@drmwarner
Quebec has a similar ICU protocol in place, inspired by Ontario's, that also contemplates bands of mortality risk at 80, 50 and 30 per cent.
Withdrawal of care would need government approval
An even more drastic scenario, contemplated but not yet a possibility, is that doctors could take people off life support to free up ICU space for someone deemed to have a higher chance of survival. For that to happen, the provincial government would have to enact new regulations.
That hasn't happened yet, but one Ottawa woman says she already worries critical-care physicians are under increasing pressure from having to treat so many ICU patients.
Nadine Tabbara said her 74-year-old father, Souheil, contracted COVID-19 and was admitted to the Ottawa Hospital intensive care ward Feb. 1 and put on a ventilator. He can't speak or move his limbs.
Tabbara said doctors told her they want to withdraw life support because he is not getting better, but she worries the worsening COVID situation might be affecting his care.
"The ICU is full and the doctors are overwhelmed," she said. "And I think they may be rushing to decisions like this."
The hospital told the family its decision was medically motivated and it would have recommended the same approach even without COVID-19.
"Hospital capacity during the COVID-19 pandemic has not influenced access to critical care at all and does not influence decisions on moving to palliative care," Ottawa Hospital said in a statement. "The decision to move patients from critical care to palliative care is one that no health-care worker takes lightly."
WATCH | Doctors prepare to possibly triage ICU care:
Protocol violates human rights, groups allege
One major problem with the province's ICU decision-making protocol, a number of human rights groups and bioethics experts say, is that it risks only deepening inequities in health care.
Some of the more fiercely contested criteria for mortality risk, to be used in assessing critically ill COVID-19 patients with cancer or seniors suffering from a condition known as "frailty," consider things like whether a patient is "capable of only limited self-care" or can dress, bathe, eat or walk without assistance, and whether they can handle their finances or go shopping.
"The only way to describe this is as raging, cruel disability discrimination, by doctors who say this is science and government that won't even answer," said lawyer and disability rights activist David Lepofsky, chair of the AODA Alliance, which has been campaigning to reform the Ontario ICU protocol since an early version emerged last spring.
"It explicitly makes having a disability count against you, and that is flagrantly contrary to the human rights code and the Canadian Charter of Rights and Freedoms."
Pandemic made 'exponentially scarier'
Lepofsky said doctors' decisions on who lives and who dies won't be subject to appeal, which denies patients and their families a fundamental right.
"If we had the death penalty, you'd have right to trial and due process," he said.
Vivia Kay Kieswetter, a seminary student at Trinity College in Toronto and advocate for people with disabilities who has an autoimmune disorder, said reading Ontario's ICU triage protocol has made the pandemic "exponentially scarier" for her.
"This is something that has been a source of additional stress and anxiety for those with disabilities over the course of this pandemic," she said.
Six of the bioethicists on the panel that helped draft the protocol published a dissent last week. They say the protocol doesn't properly recognize that people with disabilities, Indigenous patients or people of colour could disproportionately be scored at a higher short-term mortality risk because of pre-existing inequities in society that weigh on their health "well before people are brought to the doors of an ICU."
"Judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to ... [consider] social disadvantage," the dissenting bioethicists wrote.
'Absolutely not ... based on disability'
Ottawa's Downar, one of the numerous doctors and ethicists behind the drafting of the protocols, replies that no one is being discriminated against based on a disability. Rather, the triage protocols try to save the most lives possible, he said, by prioritizing scarce ICU resources on patients who are most likely to survive.
The criteria that reference dressing or bathing oneself or going shopping, Downar said, do so only for patients with certain underlying conditions — in this case, cancer or frailty syndrome — who fall critically ill with COVID-19. And that's because those kinds of assessments have been shown in research studies to be strong predictors of whether people with those underlying conditions will survive in the ICU, he said.
"People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it's absolutely not a triage based on disability," Downar said.
Protocols in both Ontario and Quebec have explicit language that doctors are not to rely on someone's disability in assessing their mortality risk. A frailty syndrome assessment is excluded, for instance, for people with "long-term disabilities (e.g. cerebral palsy), learning disabilities or autism."
Still, Downar acknowledged that the effect of using short-term mortality risk to triage patients for ICU care "is going to necessarily affect some demographic groups more than others."
"What we lack is a way to correct for it that would be fair, objective and that everybody would agree on. It's not that we haven't looked.... But so far we have yet to see one that would be fair."