National Post (National Edition)
A plan of last resort: Choosing who lives and dies if ICUs are overrun
It's not quite drawing names from a hat.
But if COVID-19 pushes hospitals to crisis levels, Ontario hospitals have been instructed that, when faced with tiebreaking situations — one empty bed in the ICU, and two, four or more critically sick people with more or less equal chances of surviving competing for it — random selection should be applied.
Each person would be assigned a number. The administrator on call would enter the numbers in a random number generator like random.org, and then click the “generate” button.
“Randomization is efficient when decisions need to be made rapidly,” reads a critical care rationing plan prepared for Ontario hospitals designed to help doctors decide who should get access to beds, intensive care or ventilators in the event of a catastrophic COVID-19 surge. Randomization avoids power struggles between doctors, the document continues. It eliminates explicit or unconscious bias and, critically, reduces the moral and psychological burden of deciding whom, ultimately, wins the bed. Who gets a chance at living.
It may sound dystopian and dehumanized. But far worse than a random number generator would be a human being having to choose, said Dr. Judy Illes, a professor of neurology at the University of British Columbia. “Because the people who have to administer those decisions are hugely at risk for moral distress and trauma.”
Doctors in Canada have never faced critical care rationing. There is no historical precedent. If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.
And while thousands of people aren't getting the timely care they need — knee surgeries, hip replacements, the start of new experimental drug regimes, because of backlogs when hospitals shut down to all but urgent care — most people in Canada have never had to worry about getting rationed for life-saving care.
Critical care triage protocols, like those now being distributed to Ontario and Quebec hospitals, are formed from lessons learned in battle fields and natural disasters. “But it will be no less heart-wrenching in this situation, and maybe even more so,” because the decisions will be taken in urban hospitals, Illes said, not in fields with grenades going off.
“It's not a question of will the public cooperate? The public will have no choice,” said Illes, who warns that our autonomy will be eroded if we don't take better control of the situation.
Nothing is fair about COVID-19, Illes and UBC political science professor Max Cameron wrote in April, and now, nine months out, aggressive mutations are spreading. Hospitalizations and deaths are increasing. An average of 878 people were being treated in ICUs each day during the past seven days. Healthcare workers are frightened, anxious, exhausted. Social distancing is slipping, Peter
Loewen reported this week in Public Policy Forum; and most Canadians won't be vaccinated until the end of September. Ten months into the pandemic, “and there are 10 months to go,” wrote Loewen, a political science professor at the University of Toronto. “This is halftime.”
Meanwhile, Ontario surpassed 250,000 confirmed infections, Quebec a breath away from the same grim mark, and while Quebec's health ministry told the National Post Friday the province is still a long way from triggering its ICU prioritization protocol, doctors are nervously looking at the U.K, where a new variant is turning some hospitals into “war zones.”
“We want to avoid being patients,” Illes said. “We want to exercise our autonomy to help everyone get through this viral war that we're in and that we're not winning right now.”
If people don't double down on distancing and masking and other precautions, choice will no longer be relevant, she said. “Procedures will take over; protocols will supersede choice. And the focus will be on this public-centred approach, maximizing the most good for the most number of people.”
The Ontario ICU triage protocol, used as a model for triage protocols adopted in Quebec, prioritizes those with the greatest likelihood of survival. (It applies to adults only, not children). People who have a high likelihood of dying within 12 months of the onset of their critical illness would be assigned lower priority for critical care. Doctors would score each person on a “short-term mortality risk assessment,” and across a whole range of different conditions — cancer, heart failure, organ failure, trauma, stroke or severe COVID-19 — ideally before they are intubated, connected to a ventilator. It aims to reduce “preventable deaths to the degree possible” under major surge conditions, with the “least infringement of human rights.” Consultant doctors would be available 24/7 to provide a timely (within the hour) estimate of a person's survival, “recognizing that such estimates may not be perfect,” but likely more accurate than non-expert judgment. In the final “summary and care plan,” one of two boxes would be checked: the patient will, or will not be offered critical care. Those who don't meet “prioritization criteria” won't be
abandoned. They'll receive appropriate medical therapy and/or comfort care.
Most controversially is what is not included in the current plan — a recommendation before the Ontario government that life-support be withdrawn from people already in the ICU whose chances of survival are low, if someone with better prospects is waiting behind them.
The Post reported this week that Ontario Premier Doug Ford's government is being asked by its external advisory COVID-19 Bioethics Table to pass an “executive order” that would permit doctors, without the consent of patients or families, to remove breathing tubes, switch off ventilators and withdraw other life-saving care from people who are deteriorating, and where further treatment seems futile, so that someone who otherwise might live can take their place.
Withdrawing treatment from someone who hasn't consented to it could be argued to be culpable homicide, said disability rights advocate David Lepofsky. “There are huge legal questions here, and they need to be discussed in the open, because we're talking about possibly taking an active action that could accelerate someone's death,” he said.
“The government can't decide on who lives and who dies by a memo, written in secret, with no debate in the legislature.”
Under normal conditions, withdrawing treatment without consent would be an “illegitimate choice,” Annette Dufner, of the University of Bonn, wrote in the journal Bioethics. Even in a pandemic, doctors might risk legal charges.
“At the same time, it is by no mean obvious that patients already under treatment in a setting of scarcity have the same moral claim on the respective medical resources they would normally have,” Dufner wrote. When scarce, “the use of resources can, after all, come at the cost of other patients' lives.”
Any suspension of the consent act would be temporary, said Dr. James Downar, a member of Ontario's Bioethics Table “And, to be super clear: if there are enough resources for everybody, this never happens.”
Outside the horror of having to choose, even the practicalities of deciding who gets an ICU bed and who should be “discharged” — the dispassionate euphemism for stopping intensive
care — “these kinds of equitable, distributive justice kinds of decisions are very, very complicated,” said Dr. Peter Goldberg, head of critical care at Montreal's McGill University Health Centre.
And how will patients, and families, be told that, “by virtue of this decree” you will, or will not, receive life-saving care? “I don't know how it's going to be done,” Goldberg said. “No one has ever done this.”
“Families will presumably have heard about this, from the press. But they may not. They may think this is science fiction. They may go to the courts, and I don't know what the courts are even going to say in this case.”
Goldberg has never had to take community needs, values or resources into consideration when caring for the critically ill. “Never. Zero. When I have discussions with patients and families, my perspective is always deontological,” what's best for the person lying in that hospital bed. That “duty to the patient” is now being supplanted by a utilitarian view that says we need to rescue the most lives, he said.
“I understand it, intellectually. But from a physician point of view that I was taught all these years, and from my own personal perspective, it's just anathema.”
He takes comfort that admissions to his hospitals are coming down. He's hoping it's a trend. “The kids went back to school in Quebec yesterday, the high schoolers. The epidemiologists are telling us we may see a blip in 10 days or two weeks if schools really are a reservoir.”
“We're waiting. We're not putting our cards away. But we can't get far enough away from this.”
Triage protocols, medically-guided protocols that are blind to disability, socio-economic status, cultural origin, are the only way to manage and mitigate the moral distress facing the people who will have to enact them, Illes said. “At the end of the day, it is physicians on the front line in the ICU with blood flowing on the floor who will bear the burden of decision-making.”
“How do we protect families from moral distress? I don't know. No protocol is going to help anyone to understand that the people who cared for their loved person weren't able to take the last-mile possible saving procedure,” she said.
“Let's try to avoid ever going there.”