Accessibility for Ontarians with Disabilities Act Alliance Update
United for a Barrier-Free Society for All People with Disabilities
Web: www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: www.facebook.com/aodaalliance/
New Captioned Video Tells the Whole Disability Discrimination Story in Ontario’s Critical Care Triage Plan – and – More Media Reports Reveal More Cause for Worry
May 6, 2021
Here are six more important developments in our campaign to protect people with disabilities from disability discrimination in Ontario’s critical care triage protocol.
1. New Captioned Video — Learn About the Disability Issues in Ontario’s Critical Care Triage Protocol
Day after day, you are getting so much information from us and others about the critical care triage issue for people with disabilities. That includes all the new information we report in this AODA Alliance Update.
Are you eager for a video that will explain what this is all about, from beginning to end? Check out the new captioned video by AODA Alliance Chair David Lepofsky where the whole story is explained. The video brings you up to date as of now. It explains the disability objections to the Ontario critical care triage, the troubling way the Ontario Government his dealing with this issue, and the bogus defences that the Government’s defenders have been giving the media, in their attempt to justify what the Government is doing.
We invite you to watch the video and share it with others. If you are teaching a course where this might be helpful, feel free to use this video. It is available at https://youtu.be/Ju8cyH7TbQo
Let us know what you think. Email your feedback to us at [email protected]
2. Where is the Public Accountability for Critical Care Triage Now Being Conducted by Ambulance Crews?
We have been warning for months about the danger of “trickle down triage”. For example, an ambulance crew, called to a medical emergency at your home, could decide whether or not to give a patient life-saving care, before they even get to hospital. We expect ambulance crews to do all they can to save lives, and not to decide whether or not to even try to save a life.
The Ford Government has refused to answer questions about this, whether from the AODA Alliance in writing or from the opposition in Question Period in the Legislature. In a very upsetting article in the April 28, 2021 Toronto Sun, set out below, it is evident that this triage is already going on.
This is a life and death issue. The public should daily be told how many lives are lost due to any form of triage, including this roadside triage. The Ford Government should now make public any directions to ambulance and emergency crews on this kind of triage. Protections need to be put in place to avert the danger of disability discrimination. We know that there is clear disability discrimination in the directions already sent to Ontario doctors, should they have to triage critical care services. There is no reason to be confident that there is no such danger if triage is done by ambulance crews before even reaching a hospital.
3. Who Exactly Will Live and Who Will Die if There is Critical care Triage in Hospitals? Behind Closed Doors, Practice Drills Have Been Going on For Months with No Public Accountability
The April 27, 2021 report by Global News, set out below, confirms that hospitals have been training for months on how to conduct critical care triage, in case it becomes necessary. This is all happening behind closed doors. We have no idea who ends up living and who ends up dying, according to these practice drills or simulations. We have no idea how differently the same case is decided from one hospital to the next, or from one doctor to the next. We have no word that anyone with human rights expertise is part of this, to alert doctors when they are running afoul of the Charter of Rights and the Ontario Human Rights Code. We have no idea if the Ford Government is monitoring any of this, to find out where its disability discriminatory Ontario critical care triage protocol needs to be fixed.
4. Pulling Back the Curtain on A Troubling and Misleading Media Strategy Now In Place, Seemingly Led by Those Behind Ontario’s Disability-Discriminatory Critical Care Triage Protocol
Those who are behind the creation and implementation of Ontario’s disability-discriminatory critical care triage protocol appear now to be conducting some sort of media public relations strategy to get out their version of this controversial issue. This appears to be underway to manage public expectations about critical care triage and to respond to some bad press that The Government has gotten on this issue. In the January 23, 2021 online webinar for doctors on the critical care triage protocol, those evidently at the centre of this indicated that they were planning such a communications strategy, to be later rolled out close to the time that critical care triage may become necessary.
Among the key people quoted in these stories include Dr. James Downar, co-author of the disability-discriminatory Ontario critical care triage protocol, and Dr. David Neilipovitz, a lead at the Ford Government’s secretive Critical Care COVID-19 Command Centre. We have asked the Ford Government who are the members of that command centre, and what its mandate includes. As with all our other inquiries, the Ford Government has refused to answer.
Part of this communication strategy seems to be the repetition of bogus arguments to defend the critical care triage protocols disability discrimination. In the April 20, 2021 AODA Alliance Update, we listed some of those bogus arguments.
In the April 26, 2021 Metroland report set out below, yet another bogus defence is offered, as follows, quoting Dr. Downar:
“Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.
“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. “It’s not applied to everybody who has a disability.””
As in other contexts which we document in the April 20, 2021 AODA Alliance Update, this absurd argument presupposes that disability discrimination only exists if you discriminate against all people with disabilities at the same time. By that bankrupt approach, Nazi Germany’s viciously anti-Semitic Nuremberg laws did not discriminate because of religion. That is because they only applied to Jews and equally applied to all Jews. It would similarly justify separate schools for black children, as was the case in the US for decades, under the widely denounced 1896 U.S. Supreme Court ruling in Plessy v. Ferguson.
The Supreme Court of Canada wisely rejected such an impoverished approach to equality decades ago, in Andrews v. Law Society of BC, where the Court stated:
“The test as stated, however, is seriously deficient in that it excludes any consideration of the nature of the law. If it were to be applied literally, it could be used to justify the Nuremberg laws of Adolf Hitler. Similar treatment was contemplated for all Jews. The similarly situated test would have justified the formalistic separate but equal doctrine of Plessy v. Ferguson, 163 U.S. 637 (1896), …”
We encourage the Ford Government to get their human rights legal advice from the Ontario Human Rights Commission and human rights experts, and not from physicians.
Another bogus and misleading part of this communication strategy is to try to misleadingly water down what critical care triage is. If a patient is refused critical care triage, they are bound to die. Yet part of the communication strategy on which we pull back the curtain is to claim that no one will be refused care. The April 26, 2021 Metroland article, set out below, includes this:
“What would triaging look like in Ontario?
“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.”
Let’s decode this. If you are refused critical care you need, you won’t be kicked right out of the hospital. You will be offered some lesser form of care, like palliative care. However, that is not the care you need to have any hope o of surviving.
This would be like someone who gets a gunshot wound who is told that they can’t have surgery they need to survive, and then being told: “But we are not refusing you care. Here’s an aspirin.”
Later in this Update, a May 5, 2021 article from CBC news online includes some of the same dubious defences. It gives no attention to voices from the disability community. This appears to be another story that could well be part of the communication strategy being conducted on behalf of the Ford Government’s Critical Care COVID Command Centre, to manage public expectations.
5. Due to Protracted and Harmful Government Secrecy, Media Must Continue to Rely on Leaks to Report on Ontario’s Critical Care Triage situation
In a May 4, 2021 news report set out below, The Globe and Mail reported that Ontario’s ICU overload may be levelling off. This could avoid the need for The Government to green light rationing or triage of critical care, even though, as noted above, this appears to be going on already in our health care system in one form or another.
It is worrisome that the Globe and Mail report is based on a leaked internal memo. Those making these decisions are still cloistered behind closed doors.
That leak could have come from an aggrieved doctor working in the system. On the other hand, it could well have come from an official at the Ministry of Health, the Premier’s office or Ontario Health. They are taking heat for the critical care triage issue. Such a leak would help deflect some of that pressure. It could lead some reporters to think (wrongly, if so) that there is no longer a story here to cover, when it comes to disability discrimination in critical care triage. However, Ontario is certainly not out of the woods by any means.
6. Disability Accessibility, the Ford Government and the Big Picture
The Ford Government’s delays on disability accessibility just carry on. There have now been 826 days, or over 2 and a quarter years, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no effective plan of new action to implement that report. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis. The Ontario Government only has 1,336 days left until 2025, the deadline by which the Government must have led Ontario to become fully accessible to people with disabilities.
Toronto Sun April 28, 2021
Originally posted at https://torontosun.com/news/local-news/to-live-or-die-waves-of-covid-reality-hit-torontos-paramedics
TO LIVE OR DIE: Waves of COVID reality hit Toronto’s paramedics
Struggling to keep up with Toronto’s third wave, city paramedics say they’re having to ‘triage’ cardiac arrest patients
Author of the article: Bryan Passifiume
Paramedics wheel a patient into the emergency department at Mount Sinai Hospital in Toronto, Wednesday, Jan. 13, 2021. PHOTO BY COLE BURSTON /The Canadian Press
As soon as the call clears, another one’s loaded and ready.
And these days, it’ll most likely be another COVID patient.
That’s the reality for Toronto’s paramedics, who say nobody among their ranks thought COVID-19’s third wave would be this bad.
“You just don’t believe the news, the news says hospitals are overwhelmed, but are they?” said a veteran Toronto advanced-care paramedic, whom the Toronto Sun agreed not to identify.
“From the horse’s mouth: we’re seeing it — that’s something we’re all now realizing.”
While Toronto’s professional lifesavers have indeed been busy this past year, he told the Sun things really started to get bad earlier this month.
In fact, he remembers the exact call.
“Honestly, it was three weeks ago,” he said, describing the short-of-breath 30-something male he and his partner were dispatched to assist.
“This guy had a fever and couldn’t get up, and we’re like, ‘Oh, damn,’” he recalled.
“He had a room-air sat of 50%.”
Patients with blood-oxygen levels that low are almost always unconscious. In fact, anything below 90% is cause for concern.
Called “silent hypoxia,” it’s one of this pandemic’s biggest medical mysteries: how patients with such dangerously low oxygen levels show little outward evidence of their dire condition.
“They don’t even look tired,” he said.
“Then you check them and realize … ‘Dude, really?! You don’t feel this?! We need to go to the hospital.’”
It’s this deceptive pathology that makes COVID such a challenge.
“It causes moments where the patient looks OK, but they’re actually really, really bad,” he said, adding those patients often crash quickly and catastrophically.
What sticks out the most are the ages — and a lack of comorbidities — of those going into the back of his ambulance.
“Waves one and two were elderly people,” he said.
“Now we’re averaging late 40s.”
What irks him and his co-workers most are those who dismiss COVID as a bad flu.
“Influenza doesn’t make your O2 (oxygen) saturation drop below your age,” he said.
“We’re seeing patients with oxygen levels not seen without opioids in play, and neither Narcan nor oxygen are going to fix it.”
Emergency rooms and ICUs are full, he said — with many receiving care in the ER normally seen in intensive care.
“That’s what overcapacity means,” he said.
“It means that there’s people in emerge receiving ICU treatment — and that’s not the place for it.”
A paramedic transports a patient to Mount Sinai Hospital in Toronto, April 17, 2020.
City Council orders check-up on Toronto paramedics
Erik Sande is the president of Medavie Health Services.
SANDE: Paramedics answer the call — across Ontario’s health system
A Region of Durham Paramedic Services ambulance.
Gravely-ill patients more likely to be pronounced dead at scene
As city hospitals steel themselves for worst-case triage protocols, paramedics say it’s a reality they’re already experiencing.
Overrun emergency rooms and intensive-care units put paramedics in the position — as well as the base physic
ians overseeing them — of having to pronounce gravely ill patients, particularly in cases of cardiac arrest, deceased on scene rather than going through the usually hopeless motions of seeking hospital treatment.
“I haven’t actively run a cardiac arrest in the past five I’ve done,” said the Toronto advanced-care paramedic.
“We just said to the family, ‘Do you want anything done?’”
Cardiac arrest, particularly in older patients, is a dire medical emergency with less than 10% survival rates, according to the Heart and Stroke Foundation.
The COVID emergency, the paramedic said, means they’re more likely to pronounce such patients dead over pursuing lifesaving efforts that only serve to prolong the inevitable.
Except in cases of obvious and catastrophic trauma, paramedics seek guidance on pronouncing death from physicians over the phone.
“I got a pronouncement in 20 seconds the other day,” the paramedic said.
The alternative, he said, is often worse.
“If you get them back, where are they going to go, into the ICU to live for a day on a vent and die?” he said.
“The family’s able to see them now, be with them — there’s no closure bringing (the patient) to the hospital where, oh by the way, they can’t come.”
This leads to paramedics forced into end-of-life discussions with grieving family members.
“You know who does those? Doctors. Doctors have those conversations,” he said.
“Now, it’s us.”
Experts, including outspoken critical care physician Dr. Michael Warner, are warning Toronto’s hospitals are just days away from ICU triage, where decisions are made on who is and isn’t entitled to lifesaving care.
“The way Dr. Warner’s talking about how we don’t want to have to triage ICU patients, we are now triaging cardiac arrest patients,” the paramedic said. “If bringing this person back or giving them hope means only living for one more day on a ventilator … man, no. Let them go.”
Families forced to make this decision, he said, are almost always grateful.
“They say ‘Thank you for not working on them, thank you for letting them pass as peacefully as possible,” he said.
“Then you walk out, do your paperwork, grab a coffee, then go on to the next one.”
On Twitter: @bryanpassifiume
Global News April 27, 2021
Originally posted at https://fm96.com/news/7812658/covid-ontario-icu-emergency-triage/
Pushing Ontario’s ICUs to the brink: How some hospitals are preparing for the worst FM96 London
Rachael D’Amore GlobalNews.ca
More than a year into the COVID-19 pandemic, Ontario doctors and nurses may have more experience treating the disease but are increasingly staring life-or-death decisions in the face.
The spike in cases has strained intensive care capacity across the province. There are about 875 COVID-19 patients in Ontario hospital ICUs as of Tuesday — an all-time high — and 589 people in intensive care units (ICUs) on a ventilator. With staffing shortages — particularly the lack of ICU-trained nurses — and beds rapidly filling up, discussions about the possible need to triage life-saving care are mounting.
A “critical care triage protocol,” something that was not done during earlier waves of the virus, could be enacted, meaning health-care providers may have to decide who gets potentially life-saving care and who doesn’t.
“If you’ve ever participated in a fire drill, you understand what we’re talking about here,” said Dr. James Downar, a palliative and critical care physician in Ottawa who co-wrote Ontario’s ICU protocol.
“The purpose of training is to be prepared because if a crisis arrives and you run out of your resources and you don’t have a plan and you’re not prepared to institute your plan, things will get very, very bad.”
Ontario hospitals received a document in January laying out guidelines on how to deal with critical care triage. In other words, what to do if there aren’t enough ICU beds.
Under those guidelines, patients are essentially ranked on their likelihood to survive one year after the onset of a critical illness. The process came under criticism from human rights advocates, saying it is discriminatory, particularly toward people with disabilities and seniors.
At this point, the province has not finalized the protocol nor has it officially been published, but a widely circulating draft titled “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” – said patients could be scored by doctors on a “short-term mortality risk assessment.”
The aim would be to “prioritize those patients who are most likely to survive their critical illness,” the document reads.
“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,” it said.
The 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.
- 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 level, clinicians may abandon the short-term mortality predictions in favour of randomization, which the document noted is to be used “as a last resort” and should be conducted by an administrator, not by bedside clinicians.
The leaked document was prepared by the province’s critical care COVID-19 command centre, which would ultimately declare when to use it.
Hundreds of COVID-19 ICU patient transfers planned as Ontario braces for ‘horrific’ 2 weeks
The College of Physicians and Surgeons of Ontario told doctors on April 8 that the province was considering “enacting the critical care triage protocol,” and that it would support such a tool once it is “initiated by the command tables of the province” and “even when doing so requires departing from our policy expectations.”
Downar emphasized that the protocol has not been instituted, echoing Ontario Health Minister Christine Elliott who on April 7 said “there are some emergency protocols out there” but they “have not finalized any of that yet.”
“None of us want to be in this position, none of us want to be doing this,” said Downar. “We are prepared for it if it comes to that, but we are focused on not letting it come to that.”
While a standard provincial protocol has not been formally established, some Ontario hospitals have been preparing anyway.
The University Health Network (UHN), which includes Toronto General, Toronto Western and Princess Margaret hospitals, have started virtual training sessions for staff on what to do if the virus’ growth gets the better of all other efforts to expand and accommodate the ICU system.
Dr. Niall Ferguson, the head of critical care at UHN, said while preparations for worst-case scenarios are happening, it doesn’t necessarily mean they’ll be enacted.
“We’re not expecting to be implementing them anytime in the near future… I think the likelihood is probably low,” he told Global News.
“COVID is more like a controlled train crash as opposed to an actual train crash where you’ve got a thousand critically ill people all on the same day — then triage is inevitable. When you’re getting a thousand critical care patients over the course of weeks, which we are here, then there is an opportunity to adapt the system and grow capacity and do things differently.”
Ontario’s latest modelling predictions cast doubt on short-term improvements. Even as cases slow or plateau, hospitalizations and ICU numbers are so-called “lagging indicators” of the severity of the virus in a certain jurisdiction. The provincial data predicts a peak of at least 1,500 virus cases in ICUs by the first week of May — that’s next week — and it could be higher, pushing Ontario’s total 2,000-ICU-bed capacity over the edge.
Downar said some training around emergency care standards has been “going on for months.”
He said avoiding the worst-case scenario depends on a lot of things and is not as simple as “staring at the number of COVID cases.”
“It’s tough. Everybody wants to know a number and everybody wants to know where that line is, but it’s just not something that is easily put into numbers at the moment.”
What’s unfolded over the past few weeks exemplifies just how bad it’s gotten — but also how the system has been forced to adapt, as Ferguson said. Hundreds of patients from already over-capacity hospitals in the Greater Toronto Area are being transferred to other hospitals hours away. The province has directed hospitals to “ramp down” all elective and non-emergency surgeries to help alleviate pressure on the health-care system.
“Transfers are not completely benign. There is a risk when we transfer people from one place to another,” Downar said. “It’s important for everybody to recognize that there already consequences to what we’ve been doing.”
Metroland DurhamRegion.com April 26, 2021
Originally posted at https://www.durhamregion.com/news-story/10381003-what-would-triaging-patients-look-like-in-ontario-s-hospitals-if-invoked-/
What would triaging patients look like in Ontario’s hospitals if invoked?
Protocol created to ‘counteract implicit biases and subjectivity’
Monday, April 26, 2021
This story is Part Two of a two-part explainer about the current surge of patients in Ontario’s intensive care units amid the third wave of COVID-19, and the possibility of the province invoking the Emergency Standard of Care protocol. Read Part One here.
Amid a rise in ICU admissions across the province, medical experts have been discussing the possibility of invoking the Emergency Standard of Care protocol, released by the Ontario Critical Care COVID-19 Command Centre earlier this year, which includes three triaging scenarios.
Dr. David Neilipovitz, the department head of critical care at the Ottawa Hospital and a lead at the Ontario Critical Care COVID-19 Command Centre, said it’s important to note that the Emergency Standard of Care protocol has different aspects to it and “not everything is triage.”
“Triage has a different connotation,” he said, adding that this would typically mean withdrawing care from patients without their family’s consent.
Neilipovitz said that while the Emergency Standard of Care protocol has similar aspects, there is no withdrawal of care.
What would triaging look like in Ontario?
“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.
Rather, he said, it would be a matter of determining other appropriate ways to support the patients that would not have access to critical care.
“The whole principle of triage is to try to maximize the number of lives saved with the resources that you have and so, in general, the concept is we want to be able to identify patients who are most likely to benefit from receiving IC services,” Wax noted.
Dr. James Downar, a palliative and critical care specialist who was responsible for creating the protocol, added that the decision as to who would have access, under the protocol, would solely be determined by mortality risk.
Is triaging patients a likely reality for Ontario’s hospitals?
“Everybody who would be considered for critical care would have two separate assessments performed by qualified physicians to assess what would be felt to be their short-term mortality risk and they would use their clinical judgment, aided by the guidance provided,” he said, adding that in cases where there is insufficient data or disagreement between physicians, the hospital would take the most optimistic approach.
What are the human rights implications?
The concept of triaging has been cause for concern for human rights advocates and disability groups.
In an April 22 statement to Metroland, Ena Chadha, chief commissioner of the Ontario Human Rights Commission (OHRC), said the Emergency Standard of Care protocol “includes potentially discriminatory triage criteria, should doctors be forced to decide who gets access to critical care and who does not.”
She stated that since December 2020, human rights groups and vulnerable populations have not been consulted on the protocol.
On April 9, the OHRC issued a public statement asking the government to provide the status of the Emergency Standard of Care protocol, confirm that the Health Care Consent Act prevails to protect the rights of patients and families, consult human rights stakeholders and require hospitals to collect data about the populations most affected by COVID-19.
In response to these concerns, Downar said that the reason the protocol was created in the first place was to ensure there wouldn’t be any human rights concerns in these scenarios.
“When human beings are overwhelmed and confronted by difficult decisions in emotional situations, that’s where implicit biases and subjectivity become major factors and undermine decision-making,” he said.
“You counteract that with explicit guidance and consistent rules.”
Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.
“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. “It’s not applied to to everybody who has a disability.”
Veronica Appia is a reporter with Torstar Corporation Community Brands, covering COVID-19 news across Ontario.
The Globe and Mail May 4, 2021
Memo says Ontario hospitals may avoid triage protocol
By JEFF GRAY
Ontario’s hospitals, despite facing an unprecedented strain from COVID-19, will likely escape the pandemic’s third wave without resorting to a triage protocol that would have forced doctors to decide who lives and who dies, according to a memo obtained by The Globe and Mail.
Doctors and hospital officials warn that weeks of tough public-health restrictions are still needed to keep slowing the virus’s spread. Hospitals will also need to keep increasing their already ballooned intensive-care capacity, postponing non-emergency operations and helicoptering patients from jammed facilities in hot spots to other beds across the province.
As of Monday, Ontario had 881 COVID-19 patients in its ICUs, more than double the total from just a month ago.
But the rate of increase appeared to be slowing. (In all, there were just over 2,000 patients of all kinds in the province’s ICUs.)
In a message to hospital chief executives dated May 2, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says recent provincial modelling is still “concerning,” even as it shows a lower estimated number of COVID-19 ICU admissions than it did two weeks ago.
The memo asks hospitals to put 284 more ICU beds, already identified as ready to go at short notice, into operation and to prepare to receive more transferred patients. And it says the command centre will monitor staffing levels, and the effects of recent moves to transfer more elderly patients into long-term care homes, to determine whether hospitals should try to create even more critical-care capacity.
But the memo adds that it now looks as though the worst can be avoided: “I also wanted to share with you and your teams that we are increasingly confident that we will not need to activate the Emergency Standard of Care or recommend the use of the triage protocol.”
Requests for comment from Dr. Baker, who is chair of the critical-care department at St. Michael’s Hospital in Toronto, were referred to Ontario Health, the government agency that oversees health care in the province.
Ontario Health executive vice-president Chris Simpson, also a Kingston cardiologist, said the worst-case scenario from the most recent modelling by the province’s external COVID-19 Science Table – which projected the potential for more than 1,400 COVID-19 patients in the province’s ICUs by month’s end – would mean triage could be necessary.
But the province appears to be tracking the modelling’s mid-range scenario, in which ICU admissions crest around 1,000 before descending gradually.
“I think that scenario, if that were to unfold, does keep us out of triage-tool territory,” Dr. Simpson said. “But only because of the extra capacity that we have been able to bring online.”
He cautioned that the stresses on the system were already having effects on the quality of care for patients. He also raised concerns there could be “tremendous pressure” to reopen the province too quickly if cases continue to plateau or fall.
Doing so, he warned, could plunge the province into a fourth wave.
Kevin Smith, president and CEO of University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said even as numbers appear to be levelling off, hospitals and their staff are stretched past their normal limits. To avoid the worst, he said Ontarians need to keep following strict public-health rules, get vaccinated as quickly as possible and not let their guard down over the May long weekend.
“I would certainly hate for anyone to think that this is a time to relax,” he said.
“Absolutely that is not the case.”
Anthony Dale, president and CEO of the Ontario Hospital Association, said the science table predictions are cause for hope, noting that daily new infection numbers have been moderating. (Ontario recorded 3,436 new cases on Monday, down from a peak of more than 4,800 in mid-April.)
But he said nothing about COVID-19 can be taken for granted. Even if these encouraging trends continue, he said, the health care system will still be in a state of massive disruption for months, noting that more than 250,000 operations have been postponed in the pandemic.
“There’s nothing natural or normal about any of this,” Mr. Dale said.
Ontario’s triage protocol has been clouded by secrecy. A draft was only made public after a leaked copy was obtained by a disability rights group. Under the plans, incoming patients would be assessed for their likelihood of survival after 12 months. Those with the best chances would be prioritized for ICU beds.
CBC Online News May 5, 2021
Originally posted at: https://www.cbc.ca/news/canada/toronto/doctors-describe-critical-care-triage-training-as-surreal-emotional-1.6013411
Doctors express relief, cautious optimism at news Ontario will likely avoid triage protocol
Province says no triage model has been activated in Ontario at this time
Talia Ricci CBC News
Dr. Shajan Ahmed says most of his colleagues had never done any kind of triage training before. He was part of a group of physicians at UHN who participated in mock scenarios during the second wave. (Submitted/Shajan Ahmed)
Dr. Shajan Ahmed says he always thought of triage training as something needed in other countries or in war zones, where doctors must decide who gets potentially life-saving care and who doesn’t.
So when the emergency room physician with Toronto’s University Health Network found himself watching a webinar about it to help prepare doctors for the third wave of COVID-19, he says he was in a bit of shock.
“To come to grips with this being right at our [doorsteps] here in Toronto, a place where we have all kinds of resources, it was really bizarre, it was surreal,” he told CBC Toronto.
“None of us had trained for it before and none of us really signed up for this, to be honest with you.”
Ahmed was among a group of around 60 physicians who received the training earlier this year. It included running through mock cases, reading material and referencing online resources. The virtual sessions were conducted over Zoom with experts in simulation, ethics and palliative care.
The province says no triage model has been activated in Ontario at this time, and although the overall number of ICU admissions climbed to 900 for the first time last Saturday, the rate of increase appears to have started to slow down. In a memo obtained by CBC News directed to hospital CEOs, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says projections remained “very concerning.” But the memo also adds they are “increasingly confident” that they will not need to recommend the use of the triage protocol.
But the prospect still weighs on the minds of some doctors, and for Ahmed, the training made the situation feel “very real.”
Hospitals in Ontario may not have to use triage protocol, memo says
“You read about it and you think it may come, but until you are actually doing the training it doesn’t feel real until that point,” he said, adding the sessions were more challenging than he anticipated.
“We would debrief after the sessions to talk about how it felt, and what was going through our minds and collectively everyone had to take a deep breath and, I guess, also a bit of a sigh of relief because we aren’t actually in this situation.”
Despite describing the current situation in GTA hospitals as “bursting at the seams,” Ahmed wants people to know if the triage model is activated, patients will still be cared for. The decision is not whether someone lives or dies but whether the person would be offered ICU level care.
“It’s very complex and there’s a lot of logistics involved but I don’t want the public to think we’re making decisions as to booting people to the street without providing care,” he said.
“We absolutely will provide care.”
Compassionate conversations part of the training
Dr. Erin O’ Connor, the deputy medical director of the University Health Network’s emergency departments, was part of the team that led the training.
“There’s a lot of emotion around this and this isn’t something any physician or any health-care provider wants to do, but when we were getting ever closer to it we realized we needed to prepare ourselves,” she said.
She adds that conversations with patients and their families were a big part of it.
“It helped people find the right way to say this kindly and empathetically and to also recognize and process their own emotions around it.”
Dr. Erin O’Connor is the deputy medical director of emergency departments at Toronto’s University
Health Network. O’Connor describes the process as an application of tools to help determine how likely someone is to survive and their likelihood of survival after a year of any acute illness, not just COVID-19. She says the team looked at five cases that represented typical situations in the emergency department and had participants evaluate the patients’ chances of survival.
“It was a little bit of how you would apply the tools to different cases, so it wasn’t so abstract,” she explained. She says the whole point of developing the short term mortality risk tools was to remove any bias from the system.
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“It was very clearly laid out that decisions cannot be made based on race, gender, economic status, disability, or age. This is really looking at as much as possible the medical factors that contribute to whether someone has a high chance of survival at a year,” she said.
Resources have been expanded through bringing health-care workers from other parts of the country, redeploying and retraining health-care workers, cancelling surgeries, bringing in more ventilators and transferring patients from hot-spot areas, among other measures. The Ministry of Health says the province continues to create additional hospital beds in the province, including the creation of two mobile health units.
“The logistics have been massive. But all of these things are being done to prevent us from getting into a position where we have to triage resources,” O’Connor said.
She says she’s feeling cautiously optimistic given the recent trends.
“We’re not out of the woods yet because we know patients stay in the ICU for a long time but we are slightly backing away from the need to use this.”
But Ahmed still thinks about it, and is still concerned about the current state of ICUs. He’s encouraging people to have conversations with loved ones about their goals of care.
“A lot of us lose sleep over it.”
ABOUT THE AUTHOR
Talia Ricci is a CBC reporter based in Toronto. She has travelled around the globe with her camera documenting people and places as well as volunteering. Talia enjoys covering offbeat human interest stories and exposing social justice issues. When she’s not reporting, you can find her reading or strolling the city with a film camera.