More Media Coverage of Danger that the Ford Government’s Critical Medical Care Triage Poses for Ontarians with disabilities, But the Government Claims Protocol Does Not Come From the Government – So Does The Government Believe It Comes From Some Rogue Group Issuing Directions to Ontario’s Hospitals?

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/

More Media Coverage of Danger that the Ford Government’s Critical Medical Care Triage Poses for Ontarians with disabilities, But the Government Claims Protocol Does Not Come From the Government – So Does The Government Believe It Comes From Some Rogue Group Issuing Directions to Ontario’s Hospitals?

January 20, 2021

            SUMMARY

Finally, the Ford Government’s deeply worrisome plans for rationing or “triage” of life-saving critical medical care are starting to get more media attention, including some focus on concerns from the disability community that those plans create the real danger of disability discrimination against some patients with disabilities. We here give you some examples, and our feedback. In most of these articles, the AODA Alliance was quoted.

As the following shows, the Government repeatedly claims the January 13, 2021 triage protocol is not a critical care triage protocol, and that it does not come from the Government. Yet a look at reveals that it certainly is a critical care triage protocol, authorized by the Government’s own Ontario Critical Care COVID Command Centre. If it doesn’t come from the Government, does it come from some rogue individual or group appointing themselves to dictate who lives and who dies if critical care must be triaged? What happened to the Ford Government’s promised openness and transparency when it comes to its response to the COVID-19 pandemic?

  1. On Thursday, January 14, 2021, CBC TV’s flagship national news program “The National” included, as its second news item, a report on plans for triage of critical care in Quebec and Ontario. The story included two quotations from AODA Alliance Chair David Lepofsky, identifying some of our major concerns on this front. You can watch it on Youtube at https://www.youtube.com/watch?v=_tySXRTHIGQ&feature=youtu.be We have also posted it with captioning at https://youtu.be/-LRyewJOKNQ
  1. On Tuesday, January 19, 2021, Toronto’s Zoomer Radio 740 Fight Back program hosted by Libby Znaimer included a half hour radio interview on the critical care triage protocol issue with AODA Alliance Chair David Lepofsky and Bioethicist Kerry Bowman. The audio of this is available as a podcast at https://zoomerradio.ca/podcasts/fight-back-on-zoomer-radio-podcast/the-provinces-directive-for-life-saving-care-january-19-2021/
  1. QP Briefing, a very influential publication of the Toronto star based at Queen’s Park, included an article dated January 18, 2021 on disability concerns with the January 13, 2021 triage protocol. That article reports, among other things:

“But the government said it’s only a draft, and hasn’t been approved or endorsed by the Ministry of Health.”

To the contrary, the January 13, 2021 triage protocol states that it is approved by the Ontario Critical Care COVID Command Centre. This appears to be the Government-designated body which is making the key decisions in this area. The Government has not told us who is on it, or what it’s mandate is. We’ve asked weeks ago!

The Government has not let us meet with the Ontario Critical Care COVID Command Centre. This body is, as far as we can tell, doing its life-and-death decision-making behind closed doors, with no public accountability. There is no showing that it has legal authority to make life-and-death policy for Ontario.

This news report gives a rare response on this issue from the Ford Government – one that is deeply disturbing. The article states:

“A source in Elliott’s office said the document “was not issued by the province and is guidance for the sector by the sector.”

The Ministry of Health said the province’s Bioethics Table has created separate guidelines that were “developed through rigorous review of existing and emerging academic literature and published policy statements on critical care triage in the COVID-19 pandemic, consultation with clinical, legal, and other experts, as well as community stakeholders, including disability rights organizations. Recent revisions include a more robust human rights and equity framing of the central issues,” ministry spoksperson David Jensen said in an email.

The document in question “has not been activated and has been released only for planning purposes to prepare for the possibility of a major surge in care, as an option of last resort, to be invoked only when all existing local and regional critical care resources have been used, all reasonable attempts have been made to move patients to or resources from areas with greater critical care resource availability, and only for as long as the major surge lasts,” Jensen said.

He said the ministry expects the Bioethics Table to keep consulting with stakeholders on the triage guidance.

Elliott’s office directed further questions to Dr. Andrew Baker, the critical care chief at St. Michael’s Hospital and incident commander of the Ontario Critical Care COVID-19 Command Centre. Baker did not respond to a request for comment.”

As for the Government’s misleading claims of ongoing consultations, the Government-appointed external Bioethics Table has had no contact with us or, to our knowledge, with others in the disability community advocating on this issue, since its rushed December 17, 220 roundtable. Since then, the following all took place in secret, with no consultation of us, and no disclosure to us:

  1. a) On January 6, 2021, the Government’s internal Ontario Critical Care COVID Command Centre secretly approved the all-important checklist for doctors doing triage, replete with deployment of the disability-discriminatory Clinical Frailty Scale.
  1. b) On January 12, 2021, the external advisory Bioethics Table sent the Government a new revised secret report on critical care triage. We have not seen it. Neither the Government nor the Government’s advisory Bioethics Table told us about it.
  1. c) On January 13, 2021, just as the Bioethics Table’s Dr. James Downar was telling The Agenda with Steve Paikin and all Ontarians that they are now consulting on this issue, the Government’s internal Ontario Critical Care COVID Command Centre secretly approved the January 13, 2021 triage protocol which was that day sent to all Ontario hospitals.

If the January 13, 2021 triage protocol was not sent to Ontario hospitals by the Government or on its behalf, who was the rogue person or group that has been sending it around the province? Why hasn’t the Government rescinded it, just as it belatedly rescinded the earlier March 28, 2020 critical care triage protocol?

Moreover, if this was not circulated by or on behalf of the Ford Government, that means there is no authoritative protocol for critical care triage in place. With the need for triage now “close” according to the Bioethics Table’s Dr. James Downar, it means doctors are left with no directions at all. This further risks each triage doctor being a law unto themselves, further endangering people with disabilities.

  1. A January 18, 2021 article by the Canadian Press’s Liam Casey was posted by various news outlets. The post of it in the January 18, 2021 St. Catherins Standard is set out below. That article includes this:

“Dr. Andrew Baker, the head of the critical care COVID-19 command centre and director of critical care at St. Michael’s Hospital, said the triage protocol contains information and tools that are a standard way for physicians to conduct an assessment for a patient upon arrival at an emergency department.

“They were shared with the critical care community as background only and to ensure a common approach across the sector, so physicians and other health professional staff can learn how to quickly operationalize an emergency standard of care for admission to critical care, if ever needed,” he said.

Baker said an emergency standard of care is not in place, but will be enacted if needed.”

This furthers the confusing double-talk emanating from the Government on this issue. The January 13, 2021 triage protocol embodies serious dangers of disability discrimination, as the AODA Alliance’s unanswered January 18, 2021 letter to Ontario Health Minister Christine Elliott. By circulating this document, the Government or its representatives are embedding improper discriminatory triage practices in the front lines of our health care system, to be ready for deployment should the COVID-19 pandemic require critical care triage. This must be rectified now!

  1. In a detailed January 18, 2021 report on CBC News online, the Government again tried to distance itself from the January 13, 2021 triage protocol without withdrawing it or offering to speak to any of us in the public about it. This article includes no feedback on concerns from the disability community, such as those from the AODA Alliance. That article included this:

“This morning, the Ontario NDP released a document they say is the province’s triage protocol. However, a spokesperson for the Minister of Health later said in an email to CBC News Monday that it is not a triage protocol but rather “guidance that originated from experts in the sector, for use by the sector.”

Dated Jan. 13, the 32-page document outlines the details and critical elements of the triage process should there be a major surge in COVID-19 patients requiring hospital care.

The documents say this should be considered only “as an option of last resort,” prioritizes care for those “with the greatest likelihood of survival.” It emphasizes the need for protection of individual human rights, non-discriminatory decision making and accountability.

The spokesperson said as of Monday, nothing has been issued or approved by the Ministry of Health.

“The expectation of the Ministry of Health is for the Bioethics Table to continue its engagement in consultations and discussions with various stakeholder groups,” the statement from the ministry reads.

In a news release, the NDP said the document “shows that the crisis in hospitals is out of control” while accusing Premier Doug Ford and his government of trying to keep it out of public view.

“Had physicians not reached out to the Official Opposition and others, the directive that was written in secret, without consultation, would remain a secret,” the NDP said.”

  1. In an earlier January 15, 2021 article on TVO. org Journalist Sarah Trick gave a good background to this issue pre-dating our chance to receive and review the leaked January 13, 2021 triage protocol. This otherwise excellent article inaccurately states that the Ford Government’s earlier March 28, 2020 triage protocol “was circulated to hospitals and community organizations for their feedback. “…the Government had it circulated to hospitals for feedback but most certainly did not circulate it to community groups for their feedback. It only reached the disability community last spring due to it being leaked to them.

In addition to the preceding news coverage, we have witnessed the following important step forward this week on this issue. On Monday, January 18, 2021, NDP Leader Andrea Horwath and NDP Disabilities critic Joel Harden released a helpful strong public statement about the January 13, 2021 triage protocol. It condemned that protocol, and explicitly endorsed the AODA Alliance’s concerns about it.

If you want more background on this issue, check out the following:

  1. The new January 13, 2021 triage protocol which the AODA Alliance received, is now making public, and has asked the Ford Government to verify. We have only acquired this in PDF format, which lacks proper accessibility. We gather some others in the community now have this document as well.
  1. The AODA Alliance’s January 18, 2021 news release on the January 13, 2021 triage protocol.
  1. The panel on critical care triage, including AODA Alliance Chair David Lepofsky, on the January 13, 2021 edition of TVO’s The Agenda with Steve Paikin.
  1. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.
  1. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.

            MORE DETAILS

 QP Briefing January 18, 2021

Disability advocates sound alarm over draft triage guidelines

Jack Hauen

As COVID-19 patients pack Ontario hospitals, disability advocates say they have serious concerns over guidance for who should be prioritized for lifesaving care.

document leaked by physicians, dated Jan. 13, 2021, outlines a triage strategy for hospitals if there aren’t enough ventilators for everyone who needs one. The AODA Alliance, an advocacy group for people with disabilities, said parts of the guidance will prioritize lifesaving equipment for able-bodied people. But the government said it’s only a draft, and hasn’t been approved or endorsed by the Ministry of Health.

Doctors have spoken to the media about the overwhelming stress of planning to ration acute care — a situation that was practically unthinkable over the summer, but as cases have skyrocketed in the second wave, has become increasingly plausible.

The AODA Alliance said it’s concerned about the inclusion of the “clinical frailty scale,” which outlines how dependent people are on others to live their lives; and a patient’s 12-month likely survival as triage criteria.

AODA Alliance Chair David Lepofsky said the protocol also isn’t clear on whether doctors should withdraw critical care to make room for someone else. The Ministry of Health said the guidance does not involve withdrawal of care, but didn’t say whether care could be withdrawn based on other guidelines.

“Under the protocol, each triage doctor can end up being a law unto themselves. The protocol’s references to respecting human rights do not eliminate serious concerns about its authorizing disability discrimination,” Lepofsky said.

People with disabilities have been raising similar concerns since the beginning of the pandemic.

The Alliance also called for triage protocols to be enshrined in law, not a memo to hospitals, and slammed the Tories for keeping it from the public.

“The Ford government’s handling of the critical care triage issue from the start has been plagued with harmful secrecy, evasiveness and a lack of candor,” Lepofsky said. “The Ford government must now rescind and fix this discriminatory new triage protocol, and directly consult the public on this issue.”

Lepofsky wrote to Health Minister Christine Elliott on Monday asking her to fix the issues raised by the AODA Alliance.

“The Ontario government needs to announce and implement a clear and effective strategy to prevent the need for life-saving critical care services to ever have to be rationed or triaged,” he wrote.

Joel Harden, the NDP critic for seniors, accessibility and persons with disabilities, said he agrees with the AODA’s concerns.

“This shows that Ford knows how dire the situation is. And it leaves us all to ask why time and again, he keeps choosing half-measures,” said Harden. “There are people now forced to live in fear, believing that they may not get the care they deserve if they end up in the ICU.”

A source in Elliott’s office said the document “was not issued by the province and is guidance for the sector by the sector.”

The Ministry of Health said the province’s Bioethics Table has created separate guidelines that were “developed through rigorous review of existing and emerging academic literature and published policy statements on critical care triage in the COVID-19 pandemic, consultation with clinical, legal, and other experts, as well as community stakeholders, including disability rights organizations. Recent revisions include a more robust human rights and equity framing of the central issues,” ministry spoksperson David Jensen said in an email.

The document in question “has not been activated and has been released only for planning purposes to prepare for the possibility of a major surge in care, as an option of last resort, to be invoked only when all existing local and regional critical care resources have been used, all reasonable attempts have been made to move patients to or resources from areas with greater critical care resource availability, and only for as long as the major surge lasts,” Jensen said.

He said the ministry expects the Bioethics Table to keep consulting with stakeholders on the triage guidance.

Elliott’s office directed further questions to Dr. Andrew Baker, the critical care chief at St. Michael’s Hospital and incident commander of the Ontario Critical Care COVID-19 Command Centre. Baker did not respond to a request for comment.

NDP Leader Andrea Horwath said the guidance illustrates the “heart-wrenching choices” on the horizon if the government doesn’t add stronger lockdown measures like paid sick days, more aid for long-term care and more testing in workplaces and schools.

“People that are loved dearly — people that need medical help the most — could be left to die if we do not make the choice to throw everything we’ve got at this virus,” she said in a statement.

Horwath agreed with Lepofsky that the document should have been made public by the government.

This article has corrected a Ministry of Health error that stated the document dated Jan. 13 was created by the province’s Bioethics Table. It is in fact based on guidance from the Critical Care Command Centre.

St. Catharines Standard January 18, 2021

Originally posted at https://www.stcatharinesstandard.ca/ts/news/canada/2021/01/18/ontario-patients-to-be-ranked-for-life-saving-care-should-icus-become-full.html

Ontario patients to be ranked for life-saving care should ICUs become full

By Liam Casey The Canadian Press

Mon., Jan. 18, 2021

Hospitals in Ontario have received a much-anticipated document that lays out the criteria to be used if intensive care units fill up and medical resources are scarce.

According to the document, titled “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” and prepared by the province’s critical care COVID-19 command centre – patients will be scored by doctors on a “short-term mortality risk assessment.”

“Aim to prioritize those patients who are most likely to survive their critical illness,” the document notes.

“Patients who have a high likelihood of dying within twelve months from the onset of their episode of critical illness (based on an evaluation of their clinical presentation at the point of triage) would have a lower priority for critical care resources,” the document reads.

It lists three levels of critical care triage:

“Level 1 triage deprioritizes critical care resources for patients with a predicted mortality greater than 80 per cent,” the document notes.

“Level 2 triage deprioritizes critical care resources for patients with a predicted mortality (greater than) 50 per cent.”

At Level 3 triage, patients with predicted mortality of 30 per cent – or a 70 per cent chance of surviving beyond a year – will not receive critical care. At this stage, patients who have suffered a cardiac arrest will be deprioritized for critical care, as their predicted mortality is greater than 30 per cent.

At this level, clinicians may abandon the short-term mortality predictions in favour of randomization, which the document notes is to be used “as a last resort” and should be conducted by an administrator, not by bedside clinicians.

The protocol, dated Jan. 13, says there are three steps on the road to critical care triage:

Step 1 says hospitals should build surge capacity.

In Step 2, “if demand still exceeds capacity, the hospital will adjust the type of care being provided to focus on key critical care interventions,” which include basic modes of ventilation.

Step 3 is the initiation of critical care triage. Once that process kicks in, “all requests for ICU admission are managed by an administrator on call who supports the bedside clinicians.”

At the moment, there are 416 patients with COVID-19 in ICUs in Ontario, which has a total of 1,800 total ICU beds.

Modelling released by the province last week show that about 700 ICU beds will be used by COVID-19 patients by the first week February.

Dr. Andrew Baker, the head of the critical care COVID-19 command centre and director of critical care at St. Michael’s Hospital, said the triage protocol contains information and tools that are a standard way for physicians to conduct an assessment for a patient upon arrival at an emergency department.

“They were shared with the critical care community as background only and to ensure a common approach across the sector, so physicians and other health professional staff can learn how to quickly operationalize an emergency standard of care for admission to critical care, if ever needed,” he said.

Baker said an emergency standard of care is not in place, but will be enacted if needed.

He said there is an “extensive, sophisticated, provincewide effort” to transfer patients out of hospitals that are at capacity.

Dr. Michael Warner, the medical director of critical care at Michael Garron Hospital in Toronto, said the hospital is running at 105 per cent capacity, but has cancelled surgeries in order to keep some spots open in the ICU.

“I sincerely hope we never need to use this because it is terrible for patients, terrible for their families, causes moral distress for health-care workers, and it’s something that we should do everything possible to avoid having to implement,” Warner said. David Lepofsky, the chairman of Accessibility for Ontarians with Disabilities Act Alliance, said the triage guidelines are discriminatory.

He pointed to the clinical frailty scale, a prognostic tool doctors use in cases of progressive illnesses to assess a patient’s general deterioration over time.

“This is disability-based discrimination and that’s against the law in the Constitution,” Lepofsky said.

January 18, 2021 CBC News Online

Originally posted at https://www.cbc.ca/news/canada/toronto/covid-19-ontario-january-18-2021-vaughan-1.5877320Province to open new hospital to ease pressure as Ontario reports 2,578 new COVID-19 cases

The provincial government is opening a new hospital in Vaughan to help relieve pressure on other facilities in the Greater Toronto Area.

The Cortellucci Vaughan Hospital was originally scheduled to open in early February as the first brand new hospital — not a replacement of an older facility or a merger with an existing facility — in Ontario in almost three decades. Premier Doug Ford made the announcement at a Monday afternoon news conference, saying it would open in “a few short weeks.”

“It’s like reinforcements coming over the hill,” Ford said, adding that the province is also adding 500 additional surge capacity hospital beds in Toronto, Durham, Kingston and Ottawa.

Health Minister Christine Elliott also said Monday that once the situation with COVID-19 has stabilized in the province, the hospital will open as originally planned.

“The idea is this hospital is going to be used … in order to take the load off of some other hospitals that are experiencing capacity challenges.” Elliott said.

The hospital will accept both COVID-19 and non-COVID-19 patients “based on the system needs during this surge,” a spokesperson for Mackenzie Health said in a statement to CBC Toronto.

The news comes as Ontario reported 2,578 additional cases of COVID-19 on Monday, as the number of patients with the illness who required a ventilator to breathe climbed above 300 for the first time since the pandemic began.

The new cases in today’s update are the fewest logged on a single day in about two and a half weeks. They include 815 in Toronto, 507 in Peel Region, 151 in both York and Niagara regions, and 121 in Hamilton.

New COVID-19 variant cases expected, Yaffe says

“Our health-care system continues to be strained with elevated numbers of people in hospital,” Dr. Barbara Yaffe, Ontario’s associate chief medical officer of health, said on Monday.

Thirty-one new outbreaks were reported as of Monday, Yaffe said, which was slightly lower than Monday of the previous week.

Yaffe said Ontario is reporting 15 new cases of the COVID-19 variant first identified in the United Kingdom, with the most recent case detected in London, Ont. in a patient with no known travel history.

“We do expect more cases to be identified in the weeks to follow as there is evidence of community transmission,” Yaffe added.

She said the data indicated that the new strain is 56 per cent more easily transmissible in comparison to other variants.

Other public health units that saw double-digit increases were:

Windsor-Essex: 97

Ottawa: 92

Waterloo region: 85

Halton Region: 79

Durham Region: 76

Middlesex-London: 67

Simcoe Muskoka: 65

Lambton: 52

Wellington-Dufferin-Guelph: 51

Eastern Ontario: 36

Southwestern: 31

Chatham-Kent: 29

Huron Perth: 15

Haldimand-Norfolk: 13

Brant County: 12

(Note: All of the figures used in this story are found on the Ministry of Health’s COVID-19 dashboard or in its Daily Epidemiologic Summary. The number of cases for any region may differ from what is reported by the local public health unit, because local units report figures at different times.)

The additional infections come as the province’s labs processed just 40,301 test samples for the novel coronavirus — tens of thousands fewer than there is capacity for in the system — and reported a test positivity rate of 6.6 per cent.

The seven-day average of new daily cases fell to 3,035. It reached a high of 3,555 on January 11.

Yaffe said Monday’s figures may have been low due to the number of tests processed Sunday, which was the lowest since Jan. 5.

Ontario’s Chief Medical Officer of Health Dr. David Williams said the current test positivity rate shows improvement from previous weeks when it would spike following weekends.

“The numbers are dropping, I take that as a sign that Ontarians are doing what we’re supposed to be doing,” Williams said on Monday.

But Williams said the province must cut its daily COVID-19 case counts to below 1,000 before lockdown measures can be lifted.

He called the goal “achievable” and said the last time the province saw similar daily case counts was late October.

Williams said he would also like to see the number of COVID-19 patients in intensive care units drop to 150 before lifting any restrictions.

Another 2,826 cases were marked resolved in today’s report. There are now 28,621 confirmed, active infections provincewide. The number of resolved cases have outpaced new cases on six of the last seven days in Ontario.

There were 1,571 total patients with COVID-19 in Ontario’s hospitals. Of those, 394 were being treated in intensive care units and 303 were on ventilators.

Revised projections released last week by the province suggested that hospitals, especially those throughout southern Ontario, risk being overwhelmed by COVID-19 patients in the coming weeks. The influx could result in doctors having to triage emergency patients, running the risk that some will not get a hospital bed when needed.

Ontario seniors ‘living in fear’ of COVID-19 feel forgotten in vaccine rollout plan

This morning, the Ontario NDP released a document they say is the province’s triage protocol. However, a spokesperson for the Minister of Health later said in an email to CBC News Monday that it is not a triage protocol but rather “guidance that originated from experts in the sector, for use by the sector.”

Dated Jan. 13, the 32-page document outlines the details and critical elements of the triage process should there be a major surge in COVID-19 patients requiring hospital care.

The documents say this should be considered only “as an option of last resort,” prioritizes care for those “with the greatest likelihood of survival.” It emphasizes the need for protection of individual human rights, non-discriminatory decision making and accountability.

The spokesperson said as of Monday, nothing has been issued or approved by the Ministry of Health.

“The expectation of the Ministry of Health is for the Bioethics Table to continue its engagement in consultations and discussions with various stakeholder groups,” the statement from the ministry reads.

In a news release, the NDP said the document “shows that the crisis in hospitals is out of control” while accusing Premier Doug Ford and his government of trying to keep it out of public view.

“Had physicians not reached out to the Official Opposition and others, the directive that was written in secret, without consultation, would remain a secret,” the NDP said.

Public health units also reported another 24 deaths of people with the illness, pushing the official toll to 5,433.

Vaccine clinic opens at Metro Toronto Convention Centre

A clinic dedicated to administering COVID-19 vaccines opened in a Toronto convention centre on Monday.

The same day, city officials announced the clinic will have to be paused as of Friday, due to a lack of access to vaccines.

The clinic at the Metro Toronto Convention Centre, which is in the downtown core, aims to vaccinate 250 people per day, but the city noted that is entirely dependent upon vaccine supply.

City officials said the “proof-of-concept” clinic will help Ontario’s Ministry of Health test and adjust the setup of immunization clinics in non-hospital settings.

The clinic at the Metro Toronto Convention Centre, which is in the downtown core, aims to vaccinate 250 people per day, but the city noted that it will have to pause the clinic on Friday due to a lack of vaccines. (Evan Mitsui/CBC)

The Ministry of Health said this morning that another 9,691 doses of COVID-19 vaccines were administered in Ontario yesterday. A total of 209,788 shots of vaccine have been given out so far, while 21,752 people have received both doses and are considered fully immunized to the illness.

Pfizer-BioNTech, which manufactures one of the two Health Canada-approved vaccines, announced last week that it’s temporarily delaying international shipments of the shots while it upgrades production facilities in Europe.

Ontario wants everyone vaccinated by early August, general says

The Ontario government has said that will affect the province’s vaccine distribution plan, and some people will see their booster shots delayed by several weeks.

Officials in Hamilton, meanwhile, said the province has directed it to temporarily cease administering the first dose of both the Pfizer-BioNTech and Moderna vaccines to everyone except residents, staff and essential caregivers at long-term care homes and retirement facilities.

A spokeswoman for Health Minister Christine Elliott did not say how many regions of the province had received that directive.

With files from Lucas Powers, Adam Carter and The Canadian Press

TVO Online January 15, 2021

Originally posted at https://www.tvo.org/article/what-happens-to-disabled-ontarians-if-we-run-out-of-icu-beds

What happens to disabled Ontarians if we run out of ICU beds?

The government has not publicly shared a triage protocol — but what we know about its thinking has experts and advocates worried that Ontarians with disabilities will be denied care

By Sarah Trick – Published on Jan 15, 2021

medical workers gather around a hospital bed

Health-care workers with a COVID-19 patient in the ICU at Toronto’s Humber River Hospital on December 9, 2020. (Nathan Denette/CP)

OTTAWA — With Ontario’s ICUs closer to being overwhelmed than they’ve ever been and COVID-19 case counts still worrisomely high, one question is becoming ever more urgent: What happens when the province runs out of capacity for critical care?

It is becoming more and more likely that doctors will have to make decisions about who does and does not get critical care in the event of a surge — Anthony Dale, the president of the Ontario Hospital Association, recently told TVO.org that, based on Ontario Health projections, by February 24, “we will absolutely have exceeded our health system’s capability of caring for COVID patients and all the other people needing other forms of life-saving care.”

But there are serious concerns with both the content and the transparency of Ontario’s draft triage protocol, and advocates for people with disabilities say that even with changes incorporated at the behest of the disability community, they are at risk of human-rights violations and being denied care unjustly.

Since the beginning of the COVID-19 pandemic, health-care systems around the world have been concerned about what might happen if the number of patients needing critical care resources, such as ventilators, exceeded the capacity of those resources. In some jurisdictions, such as Los Angeles, this has already happened: first responders have been told to reserve oxygen and not to transport patients to the hospital whom they see as having little chance of survival. Making decisions about how to ration care — sometimes referred to as triage — is an option of last resort.

We already experience a form of triage whenever we go to the emergency room. In normal times, you’ll see a doctor sooner for chest pain than you would for a sprained ankle. In a mass-casualty event, such as a natural disaster, where there are limited resources in the field, triage is a way to make sure those resources get used effectively. The people most in need get them first.

A pandemic is similar to a mass-casualty event in that there are many people who need treatment and limited treatment resources. But triage in this context, where there are limits on equipment and available staff, involves excluding people from care. “You can buy ventilators,” James Downar, critical-care physician at the Ottawa Hospital and a member of the province’s bioethics table, told The Agenda this week. “You can buy beds, and you can find space in a hospital. It’s a lot harder to get trained and expert staff to manage critically ill patients in a short period of time, and I think that’s more than likely going to be the limitation we hit.”

The bioethics table completed a draft version of a triage protocol in March. Although the first version of it was never made public or formally adopted, it was circulated to hospitals and community organizations for their feedback. Immediately, advocates began to sound the alarm, due to clauses in the protocol they saw as discriminatory toward people with disabilities.

One of those advocates was Brian Dunne, executive director at Participation House Support Services in London, whose clients he describes as “the people that long-term care won’t take.” The clients living there are often medically fragile, and many use ventilators in their daily lives already. Under the original triage protocol, Dunne says, his clients would have been “triaged to palliative care” despite the fact that their disabilities are stable and they live in the community.

In order to treat its patients, PHSS set up a hospital space right in the building, where it can provide everything a hospital would, short of actual critical care, Dunne says, adding that the space is also used as the facility’s isolation ward for COVID-19 patients, which helps with infection control. “We would do everything we can to save them,” he says. While he notes that he has not been told his patients can’t come to the hospital, he says there’s generally a reluctance to treat them and an understanding that the hospital is a last resort: “There’s kind of a general rule: do not send people here unless they absolutely need to go.”

Dunne isn’t the only one concerned. David Lepofsky, chair of the AODA Alliance, a disability consumer advocacy group, says that the first version of the protocol is grounded in a discriminatory approach to people with disabilities. “The fact that experts that the government hand-picked in medicine and bioethics could write a protocol ridden with disability discrimination and bias is horribly disturbing,” he says. The draft relies on a tool called the Clinical Frailty Scale, which assesses whether a patient can perform certain activities of daily living, such as getting dressed, going to the bathroom, and managing finances. Higher scores indicate greater frailty.

Because people with disabilities often have difficulty performing these tasks without assistance, he says, the use of this scale can result in discrimination against them or in a presumption of frailty — when, in fact, the patient is stable. The CFS has not been validated as a triaging tool for younger people, and its was originally used to figure out which kinds of care should be provided to frail elderly patients, not which kinds of care they should be excluded from.

A statement from ARCH Disability Law Centre, an organization that provides legal assistance to people with disabilities, said that this constitutes discrimination against disabled people because it means that a disabled person will always be at a relative disadvantage to those without disabilities.

“In effect, the Triage Protocol adopts the absence of a pre-existing disability as a qualification for prioritization in accessing critical care,” the briefing note reads. “The way in which the Triage Protocol currently operates, a person with a disability is much less likely, if ever, to be prioritized above a person without a disability. This concern is further exacerbated by the fact that a broad categorization of disabilities — progressive disabilities — is a criteria upon which a patient will be denied access to critical care.” (ARCH did not respond to interview requests from TVO.org.)

The Bioethics Table did respond to feedback about this issue — Lepofsky describes it as having been “very responsive.” In later versions of the draft protocol, the most recent of which was completed in December, the application of the CFS is more limited. Downar told The Agenda that it should be applied only to “frail patients” but did not provide additional explanation. The new version of the protocol, he said, triages based on expected survival time. Although this is an improvement in the eyes of disability advocates — since progressive disabilities, such as Alzheimer’s disease, muscular dystrophy, or Parkinson’s disease, are not singled out — Lepofsky noted on The Agenda that there is a lot of room for interpretation when it comes to expected survival time.

Perhaps more concerning is the fact that the government has not made the triage protocol public, advocates say. The latest version of the protocol does incorporate feedback from advocates, but, contrary to the table’s recommendations, it has not been widely distributed. (As with many COVID-19 policies, it’s the provincial government that decides whether it will be adopted — the bioethics table does not have final say.) But Lepofsky says that the very fact that the first draft protocol circulated for so long could lead to medical professionals inadvertently applying old, discriminatory rules, possibly without even realizing: “You can’t hit the clear button on their brains.”

When the protocol was being revised, a spokesperson for the Ministry of Health told TVO.org via email that “the Ministry of Health has asked the Bioethics Table to ensure that concerns and perspectives of those representing Indigenous people, black and racialized communities, persons with disabilities, and others who may be disproportionately affected by critical care triage due to systemic discrimination, are meaningfully considered and reflected in a revised protocol.” (TVO.org has asked for an updated comment but did not hear back by publication time.)

In a series of letters written during the fall of 2020, Ena Chadha, the chair of the Ontario Human Rights Commission, called on the government to release the protocol not only to stakeholders but also to the wider public. The government, she wrote, should “ensure that human rights is the primary guiding principle” of any protocol and that any protocol should ensure that there is a legislative basis for whatever decisions are being made and have built-in accountability measures.

Chadha says that she recognizes that any protocol will necessarily result in decisions that exclude some people from treatment. “I don’t know if we can create a protocol that completely eliminates all differential treatment, but what we could do is develop one that has differential treatment that doesn’t discriminate, so it isn’t based on stereotypes about people with disabilities and the quality of their lives,” she says. “The discrimination comes in when you’re relying on biases that just assume someone with a disability will not have a good quality of life.”

Lepofsky says that is a major concern for those in the disability community, because of the stigma they already face: “If a patient is nearing the end of their life, imagine the family being told, ‘Well, what’s their quality of life?’” Studies have shown that disabled people tend to rate their own quality of life higher than medical professionals do.

Lepofsky says he doesn’t blame doctors for the situation. “I’m totally sympathetic with them — they go into medicine to save lives, not to decide ‘you should not live.’”

According to the CBC, hospitals in Ontario began sending out memos Wednesday about training critical-care physicians on triage. As of Friday morning, the protocol had not yet been officially released to the general public.

Time is of the essence, Lepofsky says: “If you want to train [health-care staff], you need to train them now. In the States, they’re already doing some rationing. It’s not a hypothetical.”

 Ontario New Democratic Party January 18, 2021 Media Statement

PRESS RELEASE

January 18, 2021

Ford’s secret triage protocols troubling: NDP

HAMILTON AND OTTAWA — As hospitals continue to fill beyond capacity, the Ford government has issued a triage protocol to decide who will get life saving ventilator support, and who will not. NDP Leader Andrea Horwath said the protocol shows that the crisis in hospitals is out of control, and that Ford’s attempt to keep it secret is wrong.

“This document shows us all that we are on the path to heart-wrenching choices and devastating loss if we don’t make this lockdown count with stronger measures — paid sick days, more help in long-term care, and in-workplace and in-school testing,” said Horwath. “People that are loved dearly — people that need medical help the most — could be left to die if we do not make the choice to throw everything we’ve got at this virus.”

The protocol, obtained by the NDP, is dated Jan. 13. It was wrong to keep it under wraps, said Horwath. Had physicians not reached out to the Official Opposition and others, the directive that was written in secret, without consultation, would remain a secret.

Joel Harden, NDP critic for Seniors as well as Accessibility and Persons with Disabilities, said he agrees with the Accessibility for Ontarians with Disabilities Act Alliance (AODA), which has also read the protocols, and is raising concerns that some people, including those living with disabilities, could be denied care.

“This shows that Ford knows how dire the situation is. And it leaves us all to ask why time and again, he keeps choosing half-measures,” said Harden. “There are people now forced to live in fear, believing that they may not get the care they deserve if they end up in the ICU.