if Hospital Overloads Require Critical Care Triage, Will the Ford Government Agree to Tell the Public the Daily Numbers of Patients Refused Life-Saving Critical Care They Need?

Accessibility for Ontarians with Disabilities Act Alliance Update

United for a Barrier-Free Society for All People with Disabilities

Web: www.aodaalliance.org Email: aodafeedback@gmail.com Twitter: @aodaalliance Facebook: www.facebook.com/aodaalliance/

if Hospital Overloads Require Critical Care Triage, Will the Ford Government Agree to Tell the Public the Daily Numbers of Patients Refused Life-Saving Critical Care They Need?

April 27, 2021

            SUMMARY

The AODA Alliance just wrote the Ford Government to request that key information about its critical care triage plans be immediately made public. That letter is set out below. The possibility that life-saving critical care will have to be rationed or “triaged” gets closer as ICUs get fuller and fuller.

We asked the Ford Government to release any critical care triage protocols for doctors to use for adult patients, for patients under 18, and for any patient if the Government tries to give doctors the terrifying power to remove critical care from patients without their consent.

We ask for any directions or draft directions for ambulance crews on whether or when they should refuse life-saving care to a patient needing it when called to an emergency. We ask for results of practice drills run by Ontario hospitals on how they’d decide who gets refused life-saving critical care. The public should know how differently each hospital would deal with this.

Every day, the Government makes public statistics on the number of new COVID-19 cases, the number of patients in ICUs, and the number of COVID-19 deaths. We ask the Ford Government to commit that if critical care triage must take place, the Government will make public the number of patients each day who are refused critical care they need due to triage. The public has a right to know this and all the information we seek.

Our requests build in part on a very disturbing article in the April 26, 2021 Globe and Mail by reporter Jeff Gray. We set that article out below and quote it in our letter to the Ford Government.

Will the Ford Government answer this letter, provide the information we seek, and have its officials speak to us about our concerns? As the letter explains, the Government refused to answer any of the eight earlier well-researched letters that we sent on this topic. Its officials, all the way up to the Health Minister, have not met with us or spoken to us about our concerns. The Premier’s Office has been no better.

We keep hearing from people with disabilities that they are frightened and angry about the Ford Government’s approach to this critical care triage issue. This is so especially after they have had to put up with a year of suffering disproportionately from the COVID-19 pandemic and from the Ford Government’s ongoing failure to effectively address their urgent needs in its emergency planning. The Ford Government’s relentless secrecy in this area fuels that anger and fear.

We deeply appreciate the hard work of our front-line health professionals and all health care workers who are trying to cope with the ICU overload that keeps spiraling out of control. We believe that doctors don’t want to have to undertake critical care triage. We also believe that they don’t want the Ford Government to set them up to engage in disability discrimination if that critical care triage must take place.

To learn more about this issue, visit the AODA Alliance’s health care web page.

            MORE DETAILS

April 26, 2021 AODA Alliance Letter to Ontario Health Minister Christine Elliott

Accessibility for Ontarians with Disabilities Act Alliance

United for a Barrier-Free Society for All People with Disabilities      Web: www.aodaalliance.org Email: aodafeedback@gmail.com Twitter: @aodaalliance Facebook: www.facebook.com/aodaalliance/

April 26, 2021

To: The Hon. Christine Elliott, Minister of Health

Via email: Christine.elliott@ontario.ca

Ministry of Health

5th Floor

777 Bay St.

Toronto, ON M7A 2J3

Dear Minister,

Re: Ontario’s Plans for Medical Triage of Life-Saving Critical Care in the Event Hospitals Cannot Handle All COVID-19 Cases

We are in a crisis. Ontario is very close to having to ration or triage life-saving critical care. This is because hospitals have record-breaking demands on intensive care units.

For over a year, people with disabilities have disproportionately suffered from the pandemic’s worst hardships. Under Ontario’s critical care triage plans, they are in danger of also suffering from disability discrimination in access to life-saving critical care. Disability discrimination fatally infects the January 13, 2021 Critical Care Triage Protocol.

For example, if a cancer patient needs critical care, they will be deprioritized if a patient is “Completely disabled and cannot carry out any self-care; totally confined to bed or chair”. As another example, if a patient needing critical care is over 65 and has a progressive disease (like MS, arthritis or Parkinson’s), their access to critical care is reduced depending on how few of eleven activities of daily living they can perform without assistance. This includes dressing, bathing, eating, walking, getting in and out of bed, using the telephone, going shopping, preparing meals, doing housework, taking medication, or handling their finances. That is disability discrimination, pure and simple.

The Ontario Government’s pervasive secrecy over its critical care triage plans has made many people with disabilities terrified, angry and distrustful. The parts of the Ontario critical care triage plan that have leaked to the public make that fear and distrust justified.

The public has a right to know what the Government is planning or considering for critical care triage. We ask you to make those critical care triage plans, draft plans, not-yet-approved plans, and options all public now, such as the following:

  1. Please make public the current version of the Ontario critical care triage protocol that has been sent to Ontario hospitals. The Government has never made it public. In contrast, we publicly posted the January 13, 2021 Critical Care Triage Protocol, which was leaked. Please advise if it has been altered since January 13, 2021, or if a more recent version has been sent to hospitals.
  1. The April 26, 2021 Globe and Mail included a report by Jeff Gray, confirming that a second critical care triage protocol has also been developed. That report states:

“The other protocol is referred to as the “Critical Care Triage Protocol.” According to a document summarizing it and obtained by The Globe and Mail, it is largely the same, but assumes that cabinet issues an executive order overriding the province’s Health Care Consent Act and allowing existing ICU patients to be disconnected from life support without consent.”

Please give us a copy of that second critical care triage protocol i.e. one that is meant to be used if the Cabinet or Legislature were to suspend the operation of the Health Care Consent Act (even if that second protocol is a draft or has not yet been approved). That second protocol would apply if the Government tried to give doctors the power to unilaterally take critical care away from a patient who is already receiving it and who does not consent to its withdrawal. We are on record opposing the Government giving any such powers to doctors. We have cautioned that any doctor would do so, or would use the January 13, 2021 Critical Care Triage Protocol at their peril.

  1. In a January 23, 2021 webinar to train front-line doctors on how to use the January 13, 2021 Critical Care Triage Protocol, it was suggested that Ontario may have given a direction or draft direction to ambulance crews and related emergency services, and/or would be doing so, on EMTs or other ambulance crews undertaking some form of critical care triage on patients even before they arrive at hospital. In our February 25, 2021 letter to you, we asked (referring to the AODA Alliance’s February 25, 2021 report on Ontario’s critical care triage plans):

“This new report also reveals that instructions may have been given or may be given to Ontario emergency services and EMTs on the possibility of not starting critical care supports in some situations for an emergency patient who needs and wants them, before reaching the hospital, if critical care triage has been directed for Ontario. This would be done so that hospitals don’t feel obligated to continue giving that patient critical care. We ask you to let us know if any such instructions have been given or have been designed or contemplated, by whom and to whom, with and with what authority? If so, we ask you to give us a copy of those instructions, past or present, and any draft instructions being considered.”

Your Government never answered that letter. You also did not answer this question when you were asked in the Legislature during Question Period on April 21, 2021.

Please give us any directions or draft directions that have been sent to any ambulance or emergency services or emergency medical technicians (EMTs), or that are prepared for or are being considered for distribution to them, on the possibility of their taking part in any form of critical care triage on patients before the patient gets to hospital.

  1. We understand that in addition to the January 13, 2021 Critical Care Triage Protocol (which applies to adult patients), a different critical care triage protocol was developed for patients under the age of 18. We have never seen it or been consulted on it. We have been told nothing about its contents. Could you please give us any protocol or draft protocol now in circulation or prepared for circulation on critical care triage for patients under age 18?
  1. If critical care triage is directed or takes place, will your Government commit to swiftly and daily make public the number of people who are denied critical care, or from whom it is withdrawn without the patient’s consent? The public deserves to know this on an immediate basis, along with the other important COVID-19 statistics that are made public each day.
  1. The April 26, 2021 Globe and Mail also reported that some Ontario hospitals have been conducting practice drills or simulations with critical care triage. This is to develop experience and familiarity in case critical care triage becomes necessary. On February 25, 2021, we made public the fact that Ontario hospitals were urged to do so.

Is the Government tracking those simulations? Will you make public the results of these drills or simulations, including the hypothetical cases that are used in these drills. The public has a right to know how consistently or inconsistently critical care triage would be handled, depending on which hospital is doing it. The public also deserves to know who would live and who would die as a result of critical care triage, according to these simulations.

Minister, in the past days, your Government has substantially reconsidered and changed its policy in a number of important areas concerning the COVID-19 pandemic. It is urgent for you to now do the same with Ontario’s plans and protocol for critical care triage, so that Ontario is ready in the event that such triage becomes necessary.

The need for your Government to end its secrecy on this issue of life and death is all the more pressing since the Government’s own advisory Bioethics Table has called for openness. As well, fully six members of that Bioethics Table have publicly criticized your Government’s plans regarding critical care triage. Their voices supplemented the concerns voiced by the Ontario Human Rights Commission.

The Government has left it to one of the critical care triage protocol’s authors to publicly defend the Ontario protocol. Defences offered in its defence are transparently meritless.

That protocol’s explicit disability discrimination, described above, is incorrectly and baldly denied. It was argued in its defence that this is not disability discrimination, since some disabilities are not deprioritized for critical care under it. That is like arguing that an employer who refuses to hire Muslims does not discriminate based on religion, because that employer is nevertheless willing to hire Jews.

In the protocol’s defence, it was argued as well that the protocol can’t be disability discriminatory, because under it, two people with the same disability might not be assessed the same during triage. That argument rests on the bogus idea that the policy must discriminate against all people with disabilities with equal cruelty before it is disability discrimination against any people with disabilities. See further the April 20, 2021 AODA Alliance Update.

We ask you to answer this letter, and to meet with us and others from Ontario’s disability community, in this urgent situation. Neither you nor your Government’s officials who are making decisions in this area have met with us to discuss our concerns, despite our requests.

You have not answered any of our eight earlier letters to you over the past seven months. Those letters detail serious and well-researched objections to disability discrimination in Ontario’s critical care triage plans, including the AODA Alliance‘s September 25, 2020 letter, its November 2, 2020 letter, its November 9, 2020 letter, its December 7, 2020 letter, its December 15, 2020 letter, its December 17, 2020 letter, its January 18, 2021 letter and its February 25, 2021 letter to you.

Please stay safe.

Sincerely,

David Lepofsky CM, O. Ont

Chair Accessibility for Ontarians with Disabilities Act Alliance

CC:

Premier Doug Ford premier@ontario.ca

Helen Angus, Deputy Minister of Health helen.angus@ontario.ca

Raymond Cho, Minister of Seniors and Accessibility Raymond.cho@ontario.ca

Denise Cole, Deputy Minister for Seniors and Accessibility Denise.Cole@ontario.ca

Mary Bartolomucci, Assistant Deputy Minister for the Accessibility Directorate, Mary.Bartolomucci@ontario.ca

Todd Smith, Minister of Children, Community and Social Services todd.smithco@pc.ola.org

Janet Menard, Deputy Minister, Ministry of Children, Community and Social Services Janet.Menard@ontario.ca

Ena Chadha, Chief Commissioner of the Ontario Human Rights Commission cco@ohrc.on.ca

Robert Lattanzio, Executive Director, ARCH Disability Law Centre lattanr@lao.on.ca

Globe and Mail April 26, 2021

Originally posted at https://www.theglobeandmail.com/canada/article-ontario-doctors-prepare-for-worst-case-covid-19-triage-decisions/?cmpid=rss&utm_source=dlvr.it&utm_medium=twitter

News

Ontario doctors prepare for worst-case triage calls

By JEFF GRAY

Staff

Ontario doctors have been taking part in virtual training sessions on the province’s worst-case scenario COVID-19 emergency triage protocol, using role-play to practise telling families their loved ones are ineligible for life-support.

The triage protocol would employ a series of metrics to score incoming patients on their likelihood of survival in 12 months. If COVID-19’s growth outstrips all current efforts to expand the intensive-care system, transfer patients to other hospitals across the province and draft in extra staff, the protocol would reserve scarce ICU beds for those deemed more likely to survive.

The province’s rapidly swelling intensive care units were home to a record 851 COVID-19 patients as of Sunday and some hospitals were still familiarizing their staff with the complex triage system that could be enacted.

Erin O’Connor, deputy medical director of the emergency departments in the University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said her simulation team has been running role-play training sessions on the protocol since the second wave. But now, she is fielding calls from other hospitals that are trying to prepare for the worst.

“Honestly, it’s terrifying for all of us,” Dr. O’Connor said. “And we are all just trying to brace ourselves and prepare ourselves as well as we possibly can to deliver the best care we can in a situation where we don’t have unlimited resources.”

Ontario has ramped down all non-emergency surgeries and procedures to try to accommodate the current COVID-19 surge.

It is trying to encourage the shifting of elderly patients from hospitals into empty spaces in longterm care. It has also been moving hundreds of critical-care patients a week – by helicopter, ambulance and even a retrofitted bus – from packed hotspot hospitals in the Greater Toronto Area to ICUs as far away as Kingston.

In addition to military-style tents set up alongside hospitals, the province is installing makeshift ICUs in operating rooms and recovery rooms. And ICU nurses are working with teams of redeployed, less-experienced staff to oversee more patients, said Chris Simpson, executive vice-president of Ontario Health, the government agency that oversees the health system, and a Kingston cardiologist.

Modelling from the province’s COVID-19 Science Advisory table predicted a peak of at least 1,500 virus cases in ICUs by the first week of May, and possibly as many as 2,000. That’s as many ICU beds as Ontario has now in total, filled with more than 800 COVID-19 patients and about 1,200 non-COVID-19 patients.

Theoretically, with the existing ICU system running all out, it could accommodate a maximum of 2,300. On top of that, Ontario Health has told hospitals to find staff and space for more than 1,000 additional beds, many of which would be ICU-like beds operated with fewer staff.

If the system can manage all that expansion, and do it fast enough, officials hope the worst can be avoided. But nobody knows if this is doable – or how long it could be sustained. And everyone agrees that at these numbers, the quality of care would be severely compromised.

Most agree it already is.

“I think that’s kind of a stretch goal where we think we could get,” Dr. Simpson said, adding that every corner of every hospital is being scoured for space and staff. “If it does come to using the triage tool, I think we need to be able to say we have absolutely maximized and done everything we possibly could.”

If the system as a whole, or a hospital or a regional group of hospitals, completely runs out of space but faces a queue of critically ill patients – whether they are suffering from COVID-19, or car collisions, or heart attacks – drastic decisions may need to be made.

There are actually two protocols, neither of which has been formally made public. Ontario Health Minister Christine Elliott has said repeatedly that no protocols have been approved and refused to release them. Disability rights groups and the Ontario Human Rights Commission have raised concerns about potential discrimination against the disabled.

According to a leaked copy of one protocol, known as the “Emergency Standard of Care” and circulated to hospitals in January, two doctors would evaluate each incoming patient, using a set of criteria to determine their chances of survival. A webbased calculator may also be used to plug in the data about a patient’s condition. Ties could see a randomizer website make the final call.

It would be phased in: At Level 1 triage, all patients with more than an 80-per-cent chance of death after 12 months would be “deprioritized” for ICU beds and instead receive palliative care. At Level 2, the cutoff becomes a more than 50-per-cent chance of death at one year. At Level 3, it moves to just 30 per cent.

According to the leaked copy of the Emergency Standard of Care, it is up to the Ontario-wide Critical Care COVID-19 Command Centre to declare when to use it.

The other protocol is referred to as the “Critical Care Triage Protocol.” According to a document summarizing it and obtained by The Globe and Mail, it is largely the same, but assumes that cabinet issues an executive order overriding the province’s Health Care Consent Act and allowing existing ICU patients to be disconnected from life support without consent. Such an order, some doctors say, would save more lives, as those in ICUs with little hope of survival could be removed to make way for new patients with better chances.

Whether the system can surge enough to avoid either scenario, doctors say, also depends on how quickly the province’s stay-athome order and retail and restaurant shutdowns – and its hotzone vaccination push – can start to push down infection numbers.

But ICU numbers, which lag those daily new infection counts, are expected to keep rising in the near term. Plus, those who end up in ICU with COVID-19 are now staying longer.

Ontario registered 3,947 new infections on Sunday, pushing the seven-day average down slightly to 4,051 – below the more recent worst-case projections.

There were 24 deaths.

Whatever happens, many doctors warn the system is already triaging by another name.

Everything from cancer procedures to heart surgeries are being postponed. Plus, crowded, understaffed makeshift ICUs will result in more deaths for both COVID-19 and non-COVID-19 patients, said James Downar, a specialist in critical care at the Ottawa Hospital who was involved in drafting the triage protocols. Whether it makes sense depends on how long the surge lasts, he said.

“The question isn’t, ‘When do we start triage?’ It’s ‘When do we change the way we are triaging?’ ” he said.

Already, reports of the surge’s collateral damage are surfacing.

Nir Lipsman, a neurosurgeon at Toronto’s Sunnybrook Hospital, posted on Twitter last week that a young patient with head trauma was left without an operating-room slot as the hospital was jammed with COVID-19 patients.

After rearranging some patients and bringing in extra nurses, his team was able to make this surgery happen.

“This is the domino effect, the downstream effect, of this wave that we are experiencing,” Dr.

Lipsman said.