Grim moral choices ahead?
Decide now who gets ventilators, doctors urge
Within four to five weeks, doctors in Canada could be grappling with the kind of grim moral choices facing doctors in Italy, where it is being proposed that only COVID-19 patients who have the greatest chance of survival and those with the most years of potential life left get access to precious ICU beds and ventilators.
Some of the nation’s leading infectious diseases and critical care doctors say that Canada needs to prepare now for a possible total saturation of intensive care resources, and begin discussing the once unthinkable: Which patients should get routed to the ICU and, of those who could hypothetically benefit, who should be left behind?
“I think we should be having these conversations calmly and rationally now as opposed to waiting until it happens, and I want to emphasize if it happens,” said Dr. Anand Kumar, a critical-care doctor at Winnipeg Health Sciences Centre who is also trained in infectious diseases.
Modelling suggests that ICUS may collapse under the strain of a dramatic spike in COVID-19 cases if the measures being implemented now — Ontario Premier Doug Ford’s declaration Tuesday of a state of emergency that has forced the shutdown of bars, restaurants, theatres, cinemas, schools and daycares until at least March 31, the sweeping travel restrictions announced by Prime Minister Justin Trudeau Monday, the urging of Ottawa’s medical officer of health to “stay home” — don’t buy the time needed to slow the virus’ spread.
The country isn’t overrun with known infections but no one has a firm grasp on just how much community spread is occurring because we aren’t testing every person in the country with a fever or cough.
As the country braces for a potential crush of the virus-infected, hospitals are restricting visitors, ramping down non-urgent procedures and surgeries to free up hospital beds, especially ventilated ones, ordering more ventilators, clearing operating rooms for virus patients and refitting mothballed ICU’S. In Toronto, lung and living kidney donor transplants have been put on hold for 14 days to free up ICU beds.
Even then, “the system is likely to be overwhelmed and that’s why I think we need to get more aggressive with this now while we have time,” Kumar said, adding that the kind of aggressive social distancing measures announced by Ontario and Quebec should be implemented nationwide.
In China and Italy, five per cent or more of those known infected with COVID-19 require intensive care. Among all infected people, the death rate is hovering at around one to three per cent, but among the critically ill, it climbs as high as 62 per cent. Most deaths are due to hypoxia, an insufficient supply of oxygen to the body’s tissues, or multi-organ collapse.
There are currently about 3,200 ICU beds in the country. “So maybe you double that by throwing everything you’ve got at it,” Kumar said. “You increase your bed capacity by an additional 3,000 beds or maybe 4,000 beds.”
In the U.S., 20 per cent of the population was infected with H1N1 in the first year of the outbreak. Onethird of the world’s population became infected with the 1918 pandemic virus. If one-quarter of the Canadian population is infected with COVID-19 in the first year, “that’s roughly 10 million people,” he said.
If five per cent require ICU support that could mean 500,000 people requiring intensive care.
If mitigation strategies can stretch the outbreak over a substantial period of time — “and I’m talking a year, two years, assuming a vaccine doesn’t become available,” Kumar said — then we might not exceed the threshold of what the system can handle.
More unnerving would be the scenes unfolding in Italy, where hospital staff have been forced to practice “catastrophe medicine,” where even the young and healthy with no underlying medical problems have ended up “vented” — tethered to a mechanical ventilator — or dead, and where Italy’s Association of Anesthesia, Analgesia, Resuscitation and Intensive Care has published new guidance on which patients should be intubated or considered “deserving of intensive care” should their situation deteriorate and provided the resources are even available, according to an unofficial English translation after the criteria were first published in The Atlantic.
Kumar and other experts worry Canada could be following the same trajectory as Italy, only two or three weeks behind.
In addition to a shortage of ventilators, other choke points in Canada include staffing — will there be enough experienced ICU nurses and respiratory technicians to manage a deluge of patients with viral pneumonia? Will there be a shortage of oxygen tanks? Infected Italians are being sent home from emergency departments with prescriptions for home oxygen, but only two out of every 10 orders for oxygen are being filled. Without oxygen, people inevitably get worse and show up in the ER again struggling to breathe.
After the 2009-2010 H1N1 pandemic, researchers surveyed all acute care hospitals in Canada to assess ICU capacity. They counted 3,170 ICU beds and 4,982 ventilators. There were 10 ICU beds capable of providing mechanical ventilation per 100,000 population, and 15 invasive mechanical ventilators, placing Canada above the U.K. but well below the U.S., Germany and Belgium. There are also huge regional differences. According to the Canadian Institute for Health Information, in 2013-14, Newfoundland and Labrador had 22 ICU beds per 100,000, compared to Alberta’s 10 beds per 100,000.
No matter how the numbers are plugged in, doctors fear it won’t be enough if we don’t substantially squash down the epidemic curve. Overcrowded emergency departments are frankly dysfunctional on a good day, said Dr. Alan Drummond of the Canadian Association of Emergency Physicians.
“We have told the government for 25 years now, and critically for the last 20 years, that hospital crowding has to be a priority and increasing bed capacity to allow surge capacity, and they have been wilfully blind and studiously ignorant to the issue and now the chickens may well come home to roost,” Drummond said.
“We may dodge a big bullet here. This may be all about not very much, and that would be fantastic. But we may well end up in a situation where we have to make some very tough ethical decisions about who gets the ventilator.”
Different jurisdictions in Europe are trying to come up with rationing criteria. Some take age into account, others underlying medical illnesses. Some simply take the first-come, first-served approach when it comes to a ventilator, Kumar said. “But at this stage, to the best of my knowledge, there is no consensus or even substantial discussion of (ventilator access criteria) in Canada.”
Critical care doctors make those kinds of decisions not infrequently, he said. “Not in the context of, ‘do I put this patient or that patient on the ventilator.’ We’ve never really had to be in that kind of situation,” Kumar said. However in situations that are virtually 100 per cent fatal, “we do make decisions that we shouldn’t offer ventilation.”
“But this kind of triage, where you have to pick somebody who might have a better chance of benefiting from the treatment, those aren’t scenarios that anybody has experience with and frankly that anybody wants to have any experience with.”
The ICU admission criteria in Italy would apply to all critically ill people, its creators said, not only those infected with COVID-19. The reason for underlying risk to life wouldn’t matter, whether COVID-19 or a car crash. Everyone would fall into the same basket.
Kumar is hopeful Canada won’t see an overwhelming crush of very sick COVID-19 patients. “But in the case that we do end up with an Italian-type scenario, I think we would be well served to consider these issues in advance and engage members of the public to the extent possible.
“It’s awfully difficult, if it comes to that, for the public to have faith in criteria that are developed if the public has had no input into their development.”
Dr. Andrew Morris agrees that “absolutely now is the time to be having those discussions,” and not waiting until “we have a bunch of exhausted and overworked intensivists.”
“What Italy is forced to do is something they thought was unimaginable in a high-income country,” said Morris, an infectious diseases specialist at Sinai Health System and University Health Network in Toronto.
“I’m hoping we don’t have to, but we should at least be prepared for that and start to ask those very, very difficult questions,” Morris said. Is it right and ethical to offer everything to all is no longer just an academic exercise, he said.