A woman waits at a COVID-19 testing clinic in Montreal on Jan. 19, 2021.Ryan Remiorz/The Canadian Press
If the pandemic gets much worse in Canada’s hardest-hit provinces, grading systems developed by doctors and approved by provinces will help physicians decide who gets potential lifesaving treatment and who does not.
The purpose of the grading systems, filled with scores, scales and categories, is to establish a ranking of patients in need of critical care – including COVID-19 patients – with the aim of determining who will get access to increasingly scarce critical care beds, ventilators and ICU staff. The pandemic critical care triage protocol scores patients on severity of injury or illness, likelihood of immediate survival, and one-year prognosis beyond the intensive care unit.
Another objective, to limit bias and to depersonalize who will receive care, is spelled out at the top of each of the nine pages of the Quebec version of the Intensive Care Access Form. “Do not write the name,” it says.
“Our usual way to work is we treat the patient in front of us, one person at a time. This says we have to start thinking about what’s best for the largest number of people,” said Dr. Paul Warshawsky, chief of critical care at Montreal’s Jewish General Hospital. “It’s to help us select patients in a way that is fair and equitable, not based on how loudly a family is advocating.”
Across the country, medical systems are already triaging tens of thousands of patients who need scheduled surgeries but must wait as COVID-19 taxes resources. Intensive care triage is the next major step for hospital life-and-death decisions.
Critical care triage protocols are circulating in several provinces, including hard-hit Ontario and Alberta. Only Quebec has so far made its final triage form public, along with a 48-page explainer.
Ontario’s full, official protocol, similar to Quebec’s, is expected to be publicly released soon, according to Dr. James Downar, a specialist in critical care at The Ottawa Hospital who drafted Ontario’s protocol. It is not clear if Alberta will make its protocol public.
No Canadian medical system has had to invoke formal critical care triage during the pandemic. New York hospitals invoked “crisis standards of care” in the first wave, but doctors complained the triage guidelines were more theoretical than practical. They often ended up improvising who received care. Los Angeles County put protocols in place this month but has yet to formally start triage.
“If you run out of resources, you have three options: First-come first-serve, which is deeply unfair and brings a lot of extra mortality. A pure lottery random system has lower risk of inequity, but would lead to a lot of preventable death,” Dr. Downar said. “They’re not morally defensible.”
“You are left with option three: Try your very best to come up with criteria that can be applied consistently and explicitly, based on evidence. Avoid criterion that would assign value to a human being, but just assign probability they would live.”
If the protocol is invoked, doctors in Quebec would fill out the ICU access form for every patient in critical care or waiting for it. A team of two doctors and an ethicist for each hospital would receive them, rank patients and make the final calls.
The Quebec form would decide who gets into ICU but also who could be removed from ventilators if patients with a higher probability of survival need them. It is not clear if Ontario’s final protocol will contain this piece.
In Quebec, the intensive care protocol is supposed to kick in once the province reaches 200 per cent of normal ICU capacity. Most ICUs in Quebec are not full, but some in Montreal are above 100 per cent. Critical patients in Toronto are being moved to hospitals across Southern Ontario.
“It’s scary, we’re not at the doorstep of the protocol but we’re near it,” Dr. Warshawsky said. The Jewish General ICU is “currently running at 130 per cent. I’m not sure we can get to 200 per cent.”
Intensive care has two main functions when dealing with an influx of COVID-19 patients. One is constant monitoring – each nurse is in charge of no more than two patients in Quebec. The other is breathing assistance, where ventilators pump oxygen into a patient’s lungs.
Most intensive care triage plans set out three crisis stages. At the first stage, patients with only a 20 per cent chance or less of survival within a year would be denied intensive care. Two other stages with survival rates of 50 per cent and 70 per cent, respectively, kick in if the situation deteriorates.
Then, patients are sorted. In the Quebec form, physicians complete a trauma- and injury-severity score if the patient needs care for a major accident.
With cardiac arrest, organ failure and metastatic cancer patients, a number of indicators are used for the first two stages. At stage three, the existence of these afflictions alone would prevent treatment in the ICU.
Patients over 60 years old with burns over 40 per cent or more of their bodies would be denied any ICU care.
The form’s final pages rank conditions that make recovery from assisted breathing less likely, such as dementia and frailty, raising alarm among disability advocates. Weight and muscle loss, diminished ability to walk are among clinical frailty symptoms.
“The tools they use conflate disability with frailty,” said Mariam Shanouda, a lawyer with the Toronto’s ARCH legal clinic, who represents people with disabilities. “We already know there are demographic sectors more affected by COVID-19. Black people, other racialized minorities, Indigenous people, people with disabilities … they will inevitably be most affected by this protocol and they have not been sufficiently consulted.”
The Quebec protocol was reviewed by committees involving dozens of medical professionals, lawyers and ethicists, but a handful of patients. “I don’t know why this wasn’t examined prior to the pandemic as part of pandemic preparedness,” said Vardit Ravitsky, a professor of bioethics at the University of Montreal. “Public consultation on something involving life-and-death decisions like this should be as inclusive as possible.”
Judging frailty or dementia could discriminate against both the elderly and disabled, said David Lepofsky, chairman of advocacy group Accessibility for Ontarians with Disabilities Act Alliance. He warned the protocol will turn triage doctors “into a law unto themselves.”
Mr. Lepofsky, an adjunct professor at the University of Toronto’s law school, has written to Ontario Health Minister Christine Elliott to demand the protocol be scrapped and a process launched for a full debate and legislation. “They have had 11 months to figure this out,” Mr. Lepofsky said. “And they haven’t.”
Dr. Downar said the protocols “will not exclude people on the basis of disability. No iteration of the protocol would do that, and our protocols explicitly exclude it.”
Dr. Downar added doctors and nurses left with “impromptu triage practices” would create far greater risk of bias. But, he acknowledged, “even a system that controls subjectivity and implicit bias and is purely focused on mortality risk will still affect some groups more than others. Mortality risk is not evenly distributed in society.”
The final page of Quebec’s protocol outlines criteria for resolving ties, putting a priority on younger people and workers in the health care system, elements not part of Ontario’s draft protocol.
In both Ontario and Quebec, if all else is equal, random chance will be used for the final selection of critical care patients.
With a report from Jeff Gray in Toronto.
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