Doctors could face bleak choices in deciding who gets care in pandemic
'Complete shift in the way that we're supposed to practise medicine,' says Dr. Michael Warner
As COVID-19 numbers continue to rise, some provinces in Canada are facing the prospect of intensive care units being overwhelmed by critically ill patients. Should that happen, doctors will be forced to make difficult choices about who gets critical care and who does not.
"We're supposed to ... evaluate each patient based on what is called their short-term mortality risk," said Dr. Michael Warner, medical director of critical care at Toronto's Michael Garron Hospital.
"We're supposed to estimate the likelihood the patient will be alive 12 months after their critical illness."
Last week, hospitals in Ontario were given ICU triage protocols from the Ministry of Health. A similar document was given to hospitals in Quebec earlier this month. These documents contain guidelines to help doctors decide how likely it is that a patient may live or die in the short term. Depending on the circumstance, ICU doctors may be forced to use these guidelines, and not offer critical care to patients who are unlikely to survive. The more strained the system becomes, the more drastic the decisions ICU doctors will need to make.
Dr. Brian Goldman, host of White Coat, Black Art, spoke with Dr. Michael Warner and Dr. Marco Vergano, an anesthesiologist and ICU doctor in Turin, Italy. Dr. Vergano was forced to make these difficult choices during the first wave of the COVID-19 pandemic in March 2020.
Here is part of their conversation.
Dr. Michael Warner, based on the proposed guidelines you've seen so far ... walk me through what would happen when a patient is proposed for admission to the intensive care unit. How will you assess them?
Warner: There are tools that we're supposed to use: checklists to evaluate from an objective basis the likelihood the patient will survive a year from their critical illness. And if the patient is not offered critical care, it's not like they're left with nothing.
They're supposed to be offered palliative care, or some other form of care in hospitals so that when they ultimately die, they can die in a comfortable, dignified way.
You and I know that there's a difference between theory and reality. How confident are you that emergency physicians like me can assimilate these new rules and use them accurately in a chaotic and stressful environment like the emergency department?
Warner: On a good day, the [emergency department] can be bananas. And if we're ever at the point where this policy becomes something that we have to use, I think the situation will be where you're running around just trying to keep people alive.
It's hard to know how we would be able to effectively use a tool where two doctors have to verify someone's mortality risk, and then decide on what to do if there are patients everywhere, potentially dying.
I think we need something written down on paper so that all these stakeholders can review it and provide their input. But at the end of the day, if we ever have to use it, we may have to improvise.
Dr. Marco Vergano, rationing critical care in this kind of situation, which most of us have not faced, isn't just about deciding whether or not to admit someone to the ICU, it's also about ending critical care. Did you feel as if you were deciding who would live and who would die?
Vergano: Sometimes, yes, it was like that.
If we admitted patients who were probably a little bit borderline with limited chances of survival and if they failed the first days of ICU treatment, we were forced to shift to crisis standards of care and free that bed for other patients.
What impact did that have on you and your colleagues emotionally?
Vergano: I think that it was quite a significant impact. It was hard, because it took two or three months to go back to normal. And then we had the relatively quiet summer. And then we faced the second wave since the end of September.
But I think that we didn't properly recover and decompress from the first wave. And we were exhausted after the first wave.
When you have a lot of severe cases and your emergency departments fill up with COVID patients, in a certain sense, the battle is already lost.- Dr. Marco Vergano
So I and many of my colleagues experienced a lot of burnout.
We recovered a little bit. And now we are exhausted again emotionally.
Dr. Michael Warner, how are you reacting as you're hearing Marco talk about this?
Warner: When I think about being a physician, I've never had to determine the care I provide to a patient based on externalities. And the externalities here are the demand for that same bed. I've never had to do that before. That's really what triage is. That's a complete shift in the way that we're supposed to practise medicine.
In fact, in the protocol that's been proposed, if you have two patients that are matched in terms of their short-term mortality risk, you're supposed to go to a website and use a random number generator to determine which one gets critical care. That's completely foreign. And I think that's something that they had to do in Italy, where they had to almost put patients against each other, and measure them.
And you have to think about things, you know, to remove your implicit bias. You shouldn't actually know what the patient's name is, in case you have some version of what a specific name means in terms of race or ethnic background, etc. I mean, there's all these things you need to consider when you're going to put patients against each other in a triage protocol.
Dr. Marco Vergano, what's your advice to Michael and other ICU doctors here who might soon face these impossible choices?
Vergano: When you have a lot of severe cases and your emergency departments fill up with COVID patients, in a certain sense, the battle is already lost. Because only a real lockdown can prevent things from going worse.
You must also work to transfer patients [to other hospitals] and increase your capacity. But bear in mind that when you give resources to the treatment of COVID patients, you subtract resources from other things like elective surgery, so you will increase your non-COVID mortality. So in the second wave, we've been less prone to cancel non-urgent surgery and to divert resources because we realized that the death toll of non-COVID patients was really high as well.
Dr. Michael Warner, I'll give the last word to you. How do you react as you prepare for the next month?
Warner: I do agree that there's an epidemic of non-COVID care that is probably not counted in this pandemic. And all those patients waiting for non-COVID care weigh heavily on me.
Marco was right, if you have a bunch of patients coming to the emergency department with COVID-19, you have already lost, which is why I think some of the moral distress physicians feel … is that many of us have have said what we thought needed to be done outside the hospital to prevent or avoid us from becoming overwhelmed, and prevent us from having to ration care. And some of those things haven't been done in my view in a timely manner. And by the time all the patients come, it is too late.
So I hope we never need to use this triage protocol. I think it's wise to have one in place now, for us to become socialized to. I think that disability and other advocates should definitely educate us on how this policy may not meet the needs of all patients so that it can be fair and equitable.
Q&A edited for length and clarity.
Written by Jeff Goodes. Produced by Jeff Goodes and Willow Smith.