Preparing For That Worst-Case Scenario ...

"[Ontario should ensure] liability protection for all those who would be involved in implementing the Proposed Framework ... including an Emergency Order related to any aspect requiring a deviation for the Health Care Consent Act."

"[ICU doctors should regularly reassess people admitted to ICU to consider withdrawal of life support] through a shared decision-making process with SDMs [substitute decision-makers] if a patient does not appear to be improving." 

COVID-19 Bioethics Table, Ontario

Dr.James Downar:  Ottawa Hospital Research Institute/CP

"It's really important to be clear here -- this is not about how long you're likely to live, it's not a lifespan question. It's your probability of being alive 12 months after developing critical illness."

"We're suggesting, out of a principle of fairness, the same approach should apply to people inside the ICU. It would be unfair to treat people differently depending on the timing that they presented."

Nobody likes the idea of ever withdrawing life-support on somebody without their permission, without their consent. But in a triage scenario, we're talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole, and trying to maximize the number of people who will survive an overwhelming surge [of COVID hospitalizations]."

"We are hopeful that, as part of the state of emergency, should we need it, that there will be an executive order allowing us to withdraw."

Dr.James Downar, head, palliative care, University of Ottawa, member Bioethics Table

"We are going to say, 'By the way, we are taking your family member off the ventilator in lieu of another patient who we feel has a better prognosis, given this pandemic condition. Do you agree'?"

"I think that if we did that we would not get consent. Nobody is going to give us consent."

Dr.Peter Goldberg, head, critical care, McGill University Health Centre

"It's difficult to imagine how troubling that would be, that we would actually have to suspend the consent act."

"[However, should hospitals become unable to handle a rush of people in the ICU who are unable to benefit from critical care, who are likely to die] -- If we don't have the tool to provide equitable access to care, that will create a lot of distress on the system."

Dr.Andrea Frolic, director, Program for Ethics and Care Ecologies, Hamilton Health Sciences

An ICU health-care worker shown inside a negative pressure room cares for a COVID-19 patient on a ventilator at the Humber River Hospital during the COVID-19 pandemic in Toronto  THE CANADIAN PRESS/Nathan Denette

 

In the event that the current situation of burgeoning COVID infections persists and accelerates, the Province of Ontario government has been approached with a request to temporarily suspend the law that requires doctors to obtain consent of patients they are treating or their families prior to withdrawing a ventilator or any other life-sustaining treatment in the case of patients facing a grim end-of-life prognosis, should the feared crushing of hospitals' capability to treat an onrush of patients eventuate.

 

Specifically, Ontario's COVID-19 Bioethics Table, a group of health professionals tasked to forge a method by which the province would be able to handle the epidemic of virus infections most capably, is recommending that the province issue an Executive Order suspending the province's Health Care Consent Act for withdrawal of treatment in the ICU in the possible event of the situation becoming untenable. An enabler to smooth the way for doctors to assess patients' likely outcomes and acting accordingly.

 

The provinces are in the process of protocol preparations determining who should benefit from critical care, and who might be left without, should hospitals become flooded with critically ill COVID patients.As it stands, the Health Care Consent Act requires doctors to obtain prior agreement from patients before they have life-support withdrawn on the advice of attending physicians, any resulting disputes to be resolved by the Consent and Capacity Board, an independent tribunal. 

 COVID-19 vaccine  Carlos Osorio/AFP via Getty Images

An "emergency standard of care" alert was issued this week by the Ontario Critical Care COVID     Command Centre, for hospitals to prepare for the worst-case scenario, somewhat akin to what Italy experienced in its overwhelming demand surge for critical care, when hospitals there were forced by such circumstances to make those wretched life-and-death decisions over who they deemed could be saved by ICU treatment and who would obtain least benefit from it, given the depth of their medical condition.

The document stressed its over-arching objective, to "save the most lives in the most ethical manner possible". Recommending that a critical-care triage be considered as an option of last resort, to be taken only once all other reasonable efforts have been taken to move people to other hospitals where space might be available and appropriate staff present to care for them -- and then only for as long as the surge might go on. Minimizing deaths, minimizing risk of discrimination and "unconscious bias" against people with disabilities, racialized communities and other vulnerable groups, and minimizing "moral injury and burnout", the ultimate stated goal.

Priority, the document made clear, was to be prepared to give patients with the greatest likelihood of surviving any conditions bringing them to hospital, whether it be COVID-19, heart attack, a bleed in the brain, or any other life-threatening illness. Any patients presenting with a steep likelihood of expiring within a year -- from whichever critical condition they present with -- would receive a lower priority rating for an ICU bed.

"This is literally life and death and to not only give doctors that power to operate outside [the act] but to insulate them from any liability whatsoever, that is not something to be taken lightly."

Mariam Shanouda, lawyer, ARCH Disability Law Centre, Toronto