CMA President says COVID-19 means we need to think not just about healthcare, but pandemic palliative care
The Canadian Medical Association has responded to several outbreaks in its lifetime — the Spanish flu in 1918, SARS in 2003 and H1N1 in 2009. Dr. Sandy Buchman is leading the organization's efforts in one of the toughest challenges it has had to face in recent years.
Buchman has practised comprehensive family medicine for more than 20 years, with special interests in primary care, cancer care, palliative care, HIV/AIDS, global health and social accountability.
He spoke with The Sunday Edition's host Michael Enright about how to increase hospital capacity and support frontline healthcare workers, and what the outbreak means for vulnerable populations in Canada, such as homeless people.
Here are highlights from their conversation. Dr. Buchman's comments have been edited for length and clarity.
Whether Canada has enough healthcare workers to face this crisis
In non-COVID-19 times, we're dealing with a shortage of physicians and other healthcare professionals. During the federal election campaign, we let the government know that there were five million Canadians without a family doctor. So at the best of times we have a shortage.
During this surge, people are really coming forward. Retired physicians are coming out to help people. But it is concerning whether we will have enough staff. I know of cases where physicians specifically have already contacted COVID-19 and are in isolation. They are doing well, but it is already happening, so that is a factor that may limit our workforce.
The other thing that I am concerned about is that there's potential burnout of healthcare workers. They are already being overworked, and I'm worried that there'll be both physical and mental exhaustion from the ongoing demands, and also the difficulty we're going to have in facing some of the emotional and challenging decisions that we're going to have to make about who gets treatment and who doesn't.
Palliative care during the COVID-19 pandemic
I'm a palliative care physician. I'm used to doing home-based care. I also work with the homeless. As we face difficult decisions as to who gets ventilated and who doesn't — because that could happen — we're also going to have a huge need for palliative care of people who are now at the end of life, who are dying. To me, it would be unethical to not provide this kind of palliative care to patients who will not survive ventilation, or have been selected not to receive ventilation, if it comes to that.
In the best scenario, again, only up to about 30 per cent of patients have access to palliative care. We still have the same number of people who need this care with other serious conditions, from cancer to heart failure to chronic obstructive lung disease. And then we're going to be hit with this surge of severely ill, actively dying patients who are suffering.
We're really focused here on trying to prevent illness, prevent death and dying. With all the energy going into that, we haven't really looked at the dying part of it. We need to look at the palliative care needs. In addition, people receiving aggressive care may also have the symptoms that we in palliative care are good at addressing, such as severe shortness of breath. We're good at that. We can do that. So, even if people are being aggressively treated, it's not mutually exclusive that they should receive really good palliative care symptom management.
Deciding who gets treated when there's limited resources
I hope this doesn't happen, but I think we have to be prepared for this. This is currently what they are facing in Italy. There's often a kind of utilitarian approach, where those who will obtain the maximum benefit should be the ones that receive the treatment. Hence, it's happening that if you're over 65 years of age, or if you have other illnesses such as diabetes, asthma, chronic obstructive lung disease or hypertension, it is very possible that you would not be allowed to be ventilated. So this is a serious ethical dilemma. Intensive care physicians have to face this, but it's occasional. Now they'll be met with a surge of patients [and] they'll have to decide very, very quickly.
In palliative care, we've often called for goals-of-care conversations or advance-care planning. In other words, when you're not in crisis, to have the discussion with your physician and with your loved ones and your substitute decision makers as to what you would want in certain scenarios.
COVID-19 and vulnerable populations, like the homeless
Social distancing is an oxymoron for this population. When you are on the street, if you're lucky enough to get a shelter bed, you are often housed with countless other people in the same room, dormitory style. People [are] crowded into waiting areas, or into dining room areas. So there is no possibility of social distancing of practising isolation.
Most of these people are carrying multiple other illnesses that can also make them very vulnerable to the effects of COVID-19. So we actually expect that we're going to see quite significant illness amongst this population and a lot of deaths coming through that.
I have seen some encouraging work in Toronto, where planning has been for people who will get tested to have an isolation shelter, where there are single rooms and single bathrooms, where they will be kept for 48 hours.
This is a really important issue for shelter workers, for those frontline workers who need personal protective equipment, and at this point have not yet received it. If they're not able to go to work, then I think all bets are off.
It's very important to visit the home and to understand the home environment. But once we've established that personal relationship, that intimacy, then many other visits can be done virtually. We can have equipment and technology that allows me to listen to a person's chest while I'm at home wearing earphones, getting all their important vital signs and biometric information. That's all possible these days and in a very cost-effective way.
These things are happening now, and I'm hopeful that this unfortunate opportunity of COVID-19 will actually propel us into the 21st century and improve the efficiency and delivery of care and, in particular, access to care. This is one of the equalizers for equity of access for remote and rural Canadians and for Indigenous populations. So it's really important that we see this through, and maximize the ability of virtual care to serve Canadians.
What gives him hope
I do see hopeful signs, and actually I'm optimistic that we will flatten the curve. We have this kind of golden moment, this opportunity to change the course and not face what Italy is facing. I think we will have the capacity to handle this crisis, as long as we all come together and are practising those public health techniques — social distancing, isolation, regular handwashing.
We hope for the best and plan for the worst. So some of this may have come across as talking about the worst case scenarios. But I believe that all that planning for the worst case scenarios is helping us provide that kind of reduction of the disease severity over time. I think it helps us get control and and I think for most of us it provides confidence that we are prepared.
I'm encouraged, too, by what I see happening all around me, and how people are working so hard to get this right. I've never seen anything like it. I lived through SARS as a doctor on the front line, but I've never seen anything quite like how people are coming together now. To me that is also an incredibly optimistic message, because it gives us passion to continue this fight.
Click 'listen' above to hear the full interview.