AODA Alliance Endorses ARCH Disability Law Centre’s Brief that Shows in Even More Detail How the Ford Government’s Revised Draft Medical Triage Protocol, Now Undergoing Consultation, Would Discriminate Against COVID-19 Patients with Disabilities If There Were Not Enough Ventilators for All Patients Needing Them


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/

 AODA Alliance Endorses ARCH Disability Law Centre’s Brief that Shows in Even More Detail How the Ford Government’s Revised Draft Medical Triage Protocol, Now Undergoing Consultation, Would Discriminate Against COVID-19 Patients with Disabilities If There Were Not Enough Ventilators for All Patients Needing Them

July 24, 2020

          SUMMARY

The ARCH Disability Law Centre has made public a superb new brief to the Ford Government on the serious disability human rights problems with the revised draft medical triage protocol on which the Ford Government is now holding a consultation. The AODA Alliance strongly endorses ARCH’s brief and congratulates ARCH on excellent work. ARCH’s brief is set out below.

The Ford Government has still not rooted out the danger to people with disabilities that was created by the deeply flawed March 28, 2020 “medical triage protocol” that Ontario Health sent to all hospitals last spring. That protocol lets hospitals violate basic human rights of COVID-19 patients with disabilities if a surge in COVID-19 cases means there are not enough ventilators for all critical patients needing them. A number of disability organizations including the AODA Alliance have been pressing the Ford Government for over three months to fix the mess it thereby created.

The July 16, 2020 AODA Alliance Update made public a revised draft of the Government’s medical triage protocol, on which a consultation is now being held. We announced at that time that this revised draft medical triage protocol still has serious human rights problems from the disability perspective. We submitted that Update to the Ford Government’s advisory committee that is consulting on possible changes to that medical triage protocol.

Since then, on July 20, 2020, the ARCH Disability Law Centre submitted its new brief, set out below, to the Government’s advisory committee. The ARCH Disability Law Centre had a committee of human rights experts giving it input as it formulated this brief, including the AODA Alliance. The ARCH brief echoes and builds upon concerns that we have raised, and adds additional concerns, with which we entirely agree.

More Background

Check out:

* The July 16, 2020 AODA Alliance Update, that sets out serious disability human rights problems with the revised draft medical triage protocol.

* The text of the revised draft medical triage protocol.

* The April 7, 2020 virtual public forum on the impact of COVID-19 on people with disabilities, jointly organized by the AODA Alliance and the Ontario Autism Coalition. During this event, ARCH Disability Law Centre executive director Robert Lattanzio first made public the existence of the original March 28, 2020 medical triage protocol, and the disability human rights problems that it creates.

* The April 8, 2020 open letter, spearheaded by ARCH, identifying the serious disability human rights violations in the original March 28, 2020 medical triage protocol.

* The AODA Alliance’s April 14, 2020 Discussion Paper on what the medical triage protocol should include. In the three months since this was made public, no negative feedback was received about its recommendations.

* The Ford Government’s April 21, 2020 announcement that it would consult community and human rights experts on the medical triage protocol. It claimed that the March 28, 2020 protocol was only a “draft” even though it was never marked “draft”.

* The ARCH Disability Law Centre’s detailed May 13, 2020 analysis of the serious disability human rights violations created by the medical triage protocol, which the AODA Alliance endorses.

* To learn more about the many barriers that impede patients with disabilities in Ontario’s health care system, read the AODA Alliance’s February 25, 2020 Framework on what the promised Health Care Accessibility Standard should include, to be enacted under the Accessibility for Ontarians with Disabilities Act.

* The AODA Alliance’s health care web page, to learn more about the advocacy efforts to tear down the barriers facing people with disabilities in Ontario’s health care system.

* The AODA Alliance’s COVID-19 web page details the coalition’s efforts to advocate for the needs of people with disabilities during the COVID-19 pandemic.

          MORE DETAILS

Text of the ARCH Disability Law Centre’s July 20, 2020 Brief on the Ford Government’s Revised Draft Medical Triage Protocol

Originally posted at http://archdisabilitylaw.ca/resource/submissions-and-recommendations-regarding-ontarios-triage-protocol-draft/

55 University Avenue, 15th Floor

Toronto, Ontario M5J 2H7

www.archdisabilitylaw.ca

(416) 482-8255 (Main) 1 (866) 482-ARCH (2724) (Toll Free)

(416) 482-1254 (TTY) 1 (866) 482-ARCT (2728) (Toll Free)

(416) 482-2981 (FAX) 1 (866) 881-ARCF (2723) (Toll Free)

 

Sent via email to [email protected]

July 20, 2020

Joint Centre for Bioethics
University of Toronto
155 College Street, Suite 754
Toronto, ON M5T 1P8
Canada

Dear Ms. Gibson and Mr. Smith:

Re: ARCH Disability Law Centre Submissions and Recommendations Regarding Ontario’s Triage Protocol Draft dated July 7, 2020

The within document is the written submission of ARCH Disability Law Centre (ARCH) in response to a review of the draft Triage Protocol dated and delivered July 7, 2020[1] and from the discussion held at the July 15, 2020 Roundtable, co-convened by the Bioethics Table and the Ontario Human Rights Commission.[2] We provide these submissions in addition to our previous submissions dated May 13, 2020,[3] and not in substitute of them.

Background

While Triage Protocol 2 demonstrates some improvement over the first version,[4] there continues to be alarming issues that must be rectified to ensure that any response to a surge in COVID-19 cases does not adversely and disproportionately impact persons from marginalized communities including but not limited to persons with disabilities, elderly persons, Indigenous persons, Black persons and persons from other racialized communities. Representatives from various disability communities and organizations have made clear their concerns with both iterations of the Triage Protocol.

For ease of reference, the submissions that follow are divided into three sections. First, these submissions address the framework of Triage Protocol 2 – this captures the issues related to the overall structure and guiding principles of the document. The second section addresses procedural issues – this includes issues with the process of the development of the Triage Protocol and the lack of transparency. The third section addresses substantive issues, which includes the use of Clinical Frailty Scale as a metric to assess patients, the suggestion to use random selection as a method of fairness, and the importance of ensuring that a dispute resolution mechanism is in place.

ARCH submits the following recommendations to ensure that Triage Protocol 2 does not have an adverse impact on persons with disabilities:

  1. Non-discrimination must be a guiding principle in its own right to ensure appropriate weight is given to human rights in triage decisions.
  2. The Triage Protocol must not rely on medical utility as its primary guiding principle, as it leads to adverse consequences for persons with disabilities, and fails to consider systemic health discrepancies.
  3. The framework must shift from a focus on the intention not to discriminate to whether adverse impact (discrimination) flows from the approaches embodied in Triage Protocol 2.
  4. Ontario Health must communicate to every hospital and medical association/organization that the Triage Protocol dated March 28, 2020 is not be relied upon or implemented.
  5. Clear language and plain language versions of all drafts and the final version of the Triage Protocol are to be produced and distributed widely so that all relevant stakeholders are able to understand the information and provide feedback.
  6. Wider consultations are to be undertaken by the Bioethics Tables to ensure that the perspectives of persons with lived experience from marginalized and disproportionately impacted communities are heard and inform the drafting of the Triage Protocol.
  7. The Triage Protocol must not rely on the Clinical Frailty Scale in any capacity.
  8. The Triage Protocol must eliminate eligibility criteria that considers survivability beyond the acute COVID-related event.
  9. The Triage Protocol must provide clear and specific guidance and direction as to how random selection should be carried
  10. The Triage Protocol must include an individual dispute resolution process to ensure fairness, accountability, and due process.
  11. The Triage Protocol must include a section dedicated to providing guidance and direction on the duty to accommodate.

ARCH’s Recommendations are reproduced below following a discussion and rationale for each at the conclusion of each section.

Concerns with the overall Framework and Structure of the Triage Protocol

As noted at the July 15 Roundtable by members of the Bioethics Table, while it is not necessarily contemplated or envisioned that this Triage Protocol will be used beyond the COVID-19 pandemic, it will most likely inform responses to future pandemics.[5] It is beyond a doubt the Triage Protocol is an important document that will have long and consequential effects, some of which may be devastating and detrimental. Accordingly, it is imperative that such a document, despite its primary purpose being to provide direction to medical professionals, must not be framed solely within the medical model,[6] but also within a human rights framework. This is to ensure that the benefits of any emergency response are also afforded to marginalized communities, rather than at their expense.

In its current version, the Triage Protocol lists a number of ethical principles to guide and inform allocation of scarce critical care resources. These principles are to be considered the starting point, the foundation of any decisions made about critical care in the context of a major surge of COVID-19. These guiding principles, accordingly, seep into and colour all aspects of decisions about scarce resources, which are admittedly difficult decisions with grave significance and great public importance. As such, it is imperative that the principles that guide these decisions are strong, principled, and align with a human rights framework.

In short, the framework within which this Triage Protocol is being drafted must be reformed and reshaped. Without this necessary reformation, discrimination will continue to plague the Triage Protocol. As such, it is recommended that in drafting the Triage Protocol, the authors view the issues from a human rights lens, and in particular from a disability rights and intersectionality lens.

The Right to be Free from Discrimination

The Triage Protocol must be guided by non-discrimination in its own right. The right to be free from discrimination is a quasi-constitutional right afforded to every Ontarian and Canadian,[7] including when receiving health care services and medical attention.[8] It is a right that is elevated above other legal rights and restrictions.[9]

A patient’s right to be free from discrimination is not given its due weight in Triage Protocol 2. Guiding Principle 4, “Equity and Respect for Human Rights”, where a mention of a patient’s human rights is briefly made, is problematic for two reasons. First, it places the right to be free from discrimination on the same pedestal as other guiding principles, including beneficence and accountability. This is inappropriate, namely for the aforementioned reason that the right to be free from discrimination is a quasi-constitutional right, whereas beneficence, for example, is not. Second, Guiding Principle 4 is problematic because it collapses Equity and Human Rights and treats them as the same, or interchangeable, concepts which they are not.

Reframing the Triage Protocol 2 to reflect that the right to be free from discrimination is separate from, and superior to, the guiding principles will more accurately signal how fundamental and integral human rights law must be to the decision-making process. Moreover, this reframing will also account for, and acknowledge, intersectionality and how individuals who identify with multiple protected grounds by human rights law are impacted by the Triage Protocol.

Intersectionality[10] is a term used to refer to instances where persons may experience discrimination on more than one human rights protected ground simultaneously. The importance of an intersectional lens has been emphasized by the Human Rights Tribunal of Ontario which has stated that an awareness of compound discrimination is necessary in order to avoid a narrow and one-dimensional perspective.[11]

In the context of the Triage Protocol, it must be recognized that in treating patients who contract COVID-19 and require critical care within a surge, doctors must be cognizant of the compound discrimination that for example, a Black woman with a disability may experience. Accordingly, this section in the Triage Protocol should include a concrete explanation of what non-discrimination means and how it should be applied in a triage setting, such as “disability, age, race, or any other protected ground cannot factor, even 1%, into triage decisions.” [12]

In sum, the Triage Protocol must be framed within a human rights approach and place the principle of non-discrimination at the forefront, in order to set the proper foundation for triage decisions regarding the allocation of scarce resources and to give effect to the quasi-constitutional status of these rights.

Medical Utility is not a Proper Guiding Principle

 

Medical utility as a guiding ethical principle in the Triage Protocol is problematic. As set out in Triage Protocol 2, medical utility strives to create the maximum good for the maximum number of people.[13] While appearing facially neutral, utilitarianism actually often leads to adverse impacts for persons with disabilities.[14] By virtue of this principle, those that are not able-bodied are less likely to be part of the group that receives the “good” in question.

Utilitarian frameworks do not consider existing systemic health disparities.[15] Many persons with disabilities do not have equitable access to health care or health care outcomes. Many require additional resources to achieve equal health outcomes due to the need for disability-related accommodations, or due to systemic social inequities and/or intersectionality. But where a person’s health outcomes may be influenced by these factors, utility has the unintended consequence of disregarding individual needs.[16] A purely medical utility model has been criticized as “ruthless”[17] and at odds with societal values of defending and advancing the rights of marginalized communities.[18]

The problems with medical utility being a guiding factor are compounded when one considers that Triage Protocol 2 has attempted to distance itself from the pre-existing health and social inequities experienced by persons with disabilities and other marginalized groups in Ontario. At page 4 of Triage Protocol 2, it states that the pre-existing health and social inequities that have been revealed by the COVID pandemic will not be resolved by a triage approach.

Instead Triage Protocol 2 suggests that proactive measures must be taken in other sectors in order to prevent vulnerable groups from disproportionately contracting COVID. In effect, Triage Protocol 2 is offloading responsibility for these disproportionate impacts and distances itself from the systemic and pervasive barriers to health care in our society. This distancing is troubling, given that the very guiding principles that the triage approach is based on are likely to perpetuate and compound adverse health outcomes.

While the Triage Protocol cannot be expected to right all the systemic barriers experienced by marginalized communities, it cannot be permitted to perpetuate and compound these same inequities. Recognition of those pre-existing inequities is an important contextual factor that must be incorporated into and compensated for in the triage approach. This is an objective that is difficult to reconcile with pure medical utility being a primary guiding principle.

Focus on Impact

The Triage Protocol as a whole is written from a lens of intention without any focus on the impact that decisions made will have on patients from marginalized communities. It is well-established in human rights law that the intention to, or not to, discriminate is inconsequential and not a governing factor in determining whether or not a person has experienced discrimination.[19] Rather, it is the effect or impact experienced by the person alleging discrimination that is the focus of any human rights analysis.[20]

It is clear that neither the first version of the Triage Protocol nor Triage Protocol 2 contemplate the adverse impact that will be experienced by persons from marginalized communities, including persons with disabilities, flowing from decisions made pursuant to said Protocol. The inclusion of guiding ethical principles like medical utility[21] and (formalistic) fairness[22] demonstrate that the Triage Protocol inappropriately emphasizes the doctor’s intention, without turning its mind to the adverse impact that will be experienced by the person with a disability.[23] The result is a Triage Protocol with an approach that is problematic and discriminatory in nature.

Accordingly, a shift in the drafting framework must occur. The important question is not, whether the triage approach appears to be neutral and well-intentioned, but rather, whether marginalized communities could be adversely impacted. This shift in focus should lead to a shift in perspective when contemplating the guiding ethical principles; for example, when the focus is impact and not intention then substantive fairness, rather than formalistic fairness, becomes the objective.

Framework and Structural Recommendations:

 

  1. Non-discrimination must be a guiding principle in its own right to ensure appropriate weight is given to human rights in triage decisions.
  2. The Triage Protocol must not rely on medical utility as its primary guiding principle, as it leads to adverse consequences for persons with disabilities, and fails to consider systemic health discrepancies.
  3. The framework must shift from a focus on the intention not to discriminate to whether adverse impact (discrimination) flows from the approaches embodied in Triage Protocol 2.

 

Concerns regarding the process of Triage Protocol development

 

Follow-Up Communication to March Triage Protocol

It is imperative that Ontario Health notify the recipients of the first draft that it is not to be operationalized or applied.

In the cover letter to Triage Protocol 2, the Bioethics Table states that the March 28, 2020 Triage Protocol was sent out to hospitals by Ontario Health. In particular, it states that “[t]he draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions.”[24]

We are deeply concerned that, at the time it was delivered and distributed to hospitals and medical associations at least, it was not made clear to the recipients that these recommendations and the Triage Protocol in which they are housed were a draft.[25] The potential harm of this oversight cannot be overstated. Given the highly problematic and discriminatory nature of the first draft, the concern is that should hospitals hit surge prior to the approval or authorization of an improved version, then doctors will rely on the previous version, which may lead to devastating and disproportionate impacts on persons from marginalized communities.

Case in point: in or around May 2020 it was brought to ARCH’s attention that at least three different medical organizations had published the draft Triage Protocol on their websites as a resource for its members – including doctors, nurses and other health professionals – as if this was a finalized document.

Around the middle of May 2020, ARCH reached out to these three organizations, namely the Nurse Practitioners’ Association of Ontario (NPAO), CorHealth Ontario, and Canadian Association of Emergency Physicians (CAEP), and requested that they immediately remove the draft Triage Protocol from their websites in light of the Provincial Government’s statement that this was a draft and not a finalized document. Each organization complied.

It is beyond ARCH’s reach, however, to contact every single hospital and medical association to which the Triage Protocol was delivered on March 28, 2020 or soon thereafter. Frankly, it is also beyond ARCH’s responsibility to do same. Rather, it is incumbent upon Ontario Health to discharge this responsibility.

Accordingly, it is imperative that Ontario Health immediately contact every recipient of the original Triage Protocol to (a) ensure that the hospital/medical association is aware that the March 28, 2020 version is a draft that is not to be relied upon nor implemented, and (b) to ensure that no hospital staff or medical organization members are referring to or relying on that version of the Triage Protocol.

Clear and Plain Language Versions of the Triage Protocol

It is understood that the primary purpose of the Triage Protocol is to provide guidance to medical professionals and healthcare workers in the event that Ontario hits surge conditions. Simultaneously, however, it must be recognized that it is members of the public who will be subject to and impacted by decisions made pursuant to this Triage Protocol. Consequently, the public is entitled to know how doctors are expected to make these decisions and the basis upon which these decisions are made.

For clarification, clear language and plain language are two distinct concepts and are not to be used interchangeably. Clear language refers to the use of straightforward, direct language to convey ideas in a simple manner making the document accessible to everyone. Plain language is the use of techniques, like providing concrete examples and using clear language, to ensure that people with intellectual and/or developmental disabilities are able to access the information.

Accordingly, it is recommended that both clear language and plain language versions of the Triage Protocol be developed and made available to the public to disseminate this information in an accessible manner to as wide an audience as possible. It is imperative that any and all versions of the Triage Protocol be made accessible. This means that not only should the final version of the Triage Protocol also be produced in clear and plain language versions, but any drafts developed along the way as well.[26]

Wider Consultations Needed

Wider consultations on a document such as Triage Protocol 2, which will have wide and varying effects, including consequences that may be detrimental in nature, is imperative. These consultations, however, cannot be formalistic nor performative.

Consultations are imperative in order to ensure that the perspectives of persons who are being disproportionately impacted by COVID-19 and who are, in turn, disproportionately impacted by the Triage Protocol are considered and incorporated. This, of course, includes the perspective of persons with disabilities, Indigenous persons and persons from racialized communities including Black persons and persons from other racialized communities. Moreover, wider consultations ensure that a multi-dimensional lens, including one that emphasizes intersectionality, is applied when drafting any Triage Protocol.

It is important to note, however, that in order to have these consultations be truly accessible and receive feedback from relevant stakeholders, including persons with disabilities, a clear language and plain language versions of the Triage Protocol must be made available to said stakeholders (as stated above). The absence of an accessible version dilutes the purpose of these consultations, namely, to receive feedback from persons from disability communities.

 

Process-related Recommendations:

  1. Ontario Health must communicate to every hospital and medical association/organization that the Triage Protocol dated March 28, 2020 is not be relied upon or implemented.
  2. Clear language and plain language versions of all drafts and the final version of the Triage Protocol are to be produced and distributed widely so that all relevant stakeholders are able to understand the information and provide feedback.
  3. Wider consultations are to be undertaken by the Bioethics Tables to ensure that the perspectives of persons with lived experience from marginalized and disproportionately impacted communities are heard and inform the drafting of the Triage Protocol.

 

Substantive Concerns regarding the Triage Protocol

 

The Continued Inclusion of the Clinical Frailty Scale

The Clinical Frailty Scale (CFS) must be entirely removed from Triage Protocol 2.[27] While Triage Protocol 2 removes the visual chart of the CFS, it is still referred to in the exclusion criteria chart[28], albeit more infrequently than in the previous draft, and is included in Appendix C as a Triage Criteria Tool.[29]

As already submitted in ARCH’s Brief dated May 13 2020, the CFS is included in the Triage Protocol to serve a purpose for which it was neither designed nor developed. The application of the CFS to persons with disabilities without the context of a pandemic is inappropriate. The application of the CFS to persons with disabilities within the context of a pandemic is catastrophic and devastating.

It is understood that the goal and intention of the CFS is to create a situation where all patients are treated fairly by applying the same metric across the board in a non-discriminatory manner,[30] this belief, however, is not only misguided, but a deductive and logical fallacy. In applying the CFS as it is, to all patients, the able-bodied will always score lower (for example, a 1 on the CFS) and persons with disabilities will always score higher deeming them frail.[31] In a pandemic setting this means that the able-bodied person will always be prioritized for care over persons with disabilities. This is not fairness nor is it treatment on an equitable basis.

Several jurisdictions have already recognized the error in initially including the CFS in their Triage Protocols and have remedied their error by removing the CFS from any COVID-19 protocols and committing to an individualized assessment of each patient. For example, in the United Kingdom,[32] the use of the CFS was challenged and the government conceded the problematic nature of the CFS for the purposes of allocating critical care resources.[33] Despite this, reliance on this problematic scale persists in Triage Protocol 2.

Recalling that intention is of no consequence – it is irrelevant whether, with the application of the CFS, a doctor, healthcare worker, hospital, medical organization or government department intended to discriminate against a specific demographic of patients or not. Rather, of importance is the adverse impact experienced by a person with a disability by being subject to a seemingly neutral metric that will disproportionately place them at a disadvantage

The inclusion of the CFS in the Triage Protocol may not have been accompanied by an intention to discriminate, and yet the adverse impact experienced by persons with disabilities is real and tangible. In short, the adverse impact that flows from the inclusion and application of the Triage Protocol renders it discriminatory, regardless of the initial intention.

Survivability Beyond COVID-19

It is inappropriate to rely on ineligibility criteria that extends beyond the recovery of the acute COVID-related event.[34] It is arbitrary and invites a higher risk of ableist value assumptions about the quality of a person’s life, which will inevitably cause a disproportionate adverse impact on persons with disabilities.[35]

Triage Protocol 2 states that a person would be ineligible for critical care where they have a low probability of surviving “more than a few months” beyond recovering from COVID. Triage Protocol 2 further explains that a person would be ineligible if they were “very likely to die in the near future if they recovered from their critical illness.”[36]

First, “more than a few months” is a speculative and subjective assessment, which could mean a number of different things to different doctors making these decisions. Second, this criteria goes beyond an assessment of the person’s chance of survival of the acute COVID-19-related event, and invites ableist presumptions about chances of survival or quality of life after Intensive Care Unit (ICU) treatment to seep into clinical evaluations.[37] These types of assessments tend to disproportionately affect people with disabilities.[38]

As stated by Profs. Trudo Lemmens and Roxanne Mykitiuk:

While the protocol does not clarify the time frame used to determine the risk of ‘mortality’ (i.e. mortality by when?), it goes beyond survival in the ICU, and includes the likelihood of survival months after ICU treatment. As mentioned above, the further one moves beyond ICU discharge, the more a policy will disproportionately impact on the elderly and people with disabilities.[39]

It is clear that survivability beyond the acute COVID-related incident is subjective, arbitrary, and risks discriminating against persons with disabilities. As such, it must not be relied on as a criteria of ineligibility.

 

Random Selection

Safeguards must be put into place to ensure that random selection is not polluted by unconscious biases and prejudices. In an effort to uphold the principle of fairness, Triage Protocol 2 suggests applying the method of random selection in situations where it is not possible to rely on medical utility to make clinical decisions.[40] The aim, according to Triage Protocol 2, is to mitigate against the potential of explicit or unconscious bias in decision-making.[41]

The concern is how random selection will be carried out in practice as any decision-making is always subject to human and inherent bias. Triage Protocol 2 is vague as to how random selection will translate into practice, only noting that “a record of the outcome of the process of randomization should be documented.”[42]

In order to remedy against the influence of inherent bias, safeguards must be put in place to ensure a truly random selection process. It is also important to ensure that accountability and transparency are pillars in any random selection process implemented pursuant to the Triage Protocol. It is of utmost importance that the Triage Protocol be specific and thorough in how the random selection process is to be applied. As it stands at the moment, there is very little guidance and direction on this point which will lead to different practices of random selection across hospitals.[43]

Dispute Resolution Mechanisms

It is imperative that Triage Protocol 2 includes a dispute resolution mechanism. An appeals procedure is an essential procedural aspect of due process, which cannot be set aside in pandemic conditions.

In addressing the possibility of a dispute resolution process for patients/families who disagree with the outcome of a triage decision, Triage Protocol 2 suggests that a formal appeal process “may not be feasible or appropriate.”[44] Instead, it offers to patients who have been subject to triage decisions that the hospital “[c]ommunicat[e] the rationale” to the patient/family and “respond […] compassionately to patient or family concerns.”[45] It also suggests that it will conduct a retrospective, global review by monitoring triage data, and reviewing and revising the approach to ensure it is not leading to adverse consequences.[46] With respect, while these elements are important parts of a triage approach, this is not an acceptable substitute for individual due process.

To the contrary, it is possible and necessary to include an individual dispute resolution mechanism in Triage Protocol 2. A real-time review of individual complaints is vital for ensuring that no individual has been treated unjustly by the decision-makers and so that a new decision can be implemented before irreparable harm is done. This would allow the patient or family member to seek a remedy before a potentially discriminatory and irreversible decision is carried out.

Other jurisdictions recognize the importance of an appeal framework within a triage approach.[47] The University of Virginia Health System Ethics Committee, for example, recommends that triage decisions be supported by an appeal process in order “[t]o promote the ethical principles of trustworthiness, equity, fairness, and justice.”[48]

It has been noted that while global review of the triage approach is important for accountability and on-going improvement of the triage process, it “does not protect vulnerable patients, because it does not allow for timely intervention in individual triage decisions.”[49] As the Indiana State Department of Health noted in its Crisis Standards of Patient Care Guidance, “while meticulous record keeping is desirable, in such cases, it is ethically important to prioritize energies spent in the direct saving of lives over those spent keeping records and in post‐hoc analyses.”[50]

 

Duty to Accommodate

It is imperative that Triage Protocol 2 includes a section that focuses on providing specific guidance and directions about the duty to accommodate. Triage Protocol 2 makes only brief references to the provision of accommodations for persons with disabilities accessing the Triage Protocol and decisions about critical care resources. These references are not specific nor directive.[51]

Disability-related accommodations for the purposes of accessing health care services are a basic tenet of human rights law.[52] Disability-related accommodations ensure that persons with disabilities have equal opportunity to receive, understand, and benefit from critical care.

Other jurisdictions have acknowledged the importance of providing disability-related accommodations to persons to ensure they have equal access to health care during the COVID-19 pandemic. The British Medical Association’s guidance for COVID-19 reiterates that hospitals have a positive obligation to ensure that persons with disabilities are able to access and take advantage of public services in a manner as closely as reasonably possible to someone without disabilities.[53] Similar directives can be found in other ICU decision-making guidance in jurisdictions like Tennessee.[54]

Accommodations may include interpretation, alternative and augmentative communication, support persons, or other supports that allow a person to gain equal access to medical services.[55] These must be provided to the patient during the application of the Triage Protocol and the duration of the patient’s time at the hospital.

Triage Protocol 2 should include detailed directives regarding how accommodations are provided in the context of a pandemic. Disability-related needs vary depending on the person with a disability and may fluctuate throughout a period of time. Accordingly, and as discussed in the preceding paragraph, it is highly recommended that best practices be included such as asking each patient in the emergency room and/or upon admission to the hospital if they require disability-related accommodation and, if they do, what those accommodations are. These patient-specific accommodations should be recorded in the chart and applied by every healthcare worker that comes into contact with the patient. Practices such as these that are in line with human rights obligations will also assist in ensuring that all appropriate accommodations are in place when any assessments are made pursuant to the Triage Protocol.

Substantive Recommendations:

 

  1. The Triage Protocol must not rely on the Clinical Frailty Scale in any capacity.
  2. The Triage Protocol must eliminate eligibility criteria that considers survivability beyond the acute COVID related event.
  3. Triage Protocol 2 should provide clear and specific guidance and direction as to how random selection should be carried out.
  4. The Triage Protocol must include an individual dispute resolution process to ensure fairness, accountability, and due process.
  5. The Triage Protocol must include a section dedicated to providing guidance and direction on the duty to accommodate.

 

Conclusion:

In sum, there continue to be concerns with Triage Protocol 2 that must be rectified to ensure that any response to a surge in COVID-19 cases does not adversely and disproportionately impact persons from marginalized communities including but not limited to persons from disability communities, elderly persons, Indigenous persons, Black persons and persons from other racialized communities.

The above submissions address a number of those concerns and provide Recommendations for reform. The Recommendations herein aim to align the Triage Protocol with human rights law and ensure that marginalized communities are not disproportionately impacted. The Recommendations impact the overall structure and guiding principles of the document, those related to the process within which the Triage Protocol has been developed, and those related to the substantive concerns, such as the use of the Clinical Frailty Scale or survivability beyond the acute event as metrics to assess patients, the use of random selection, the lack of a dispute resolution mechanism, and the importance of upholding the duty to accommodate.

Please do not hesitate to contact us should you wish to discuss any of these Recommendations in further and greater detail.

Sincerely,

 

ARCH DISABILITY LAW CENTRE

 

Robert Lattanzio

Executive Director

Mariam Shanouda

Staff Lawyer

Jessica De Marinis

Staff Lawyer

[1] Critical Care Triage for Major Surge in the COVID-19 Pandemic: Updated Recommendations, delivered and dated July 7, 2020 [“Triage Protocol 2”].

[2] ARCH would like to especially and sincerely thank members of its Advisory Committee for engaging in extensive discussion and providing thoughtful guidance and expertise on the important issues raised by the Triage Protocol. ARCH’s Advisory Committee, in alphabetical order, includes: Chris Beesley, Executive Director at Community Living Ontario, Laura LaChance, Interim Executive Director at Canadian Down Syndrome Society, Trudo Lemmens Professor, Scholl Chair in Health Law and Policy at University of Toronto Law School, David Lepofsky, Chair of the AODA Alliance, Leanne Mielczarek, Executive Director of Lupus Canada, Elizabeth Mohler, Board Member at Citizens With Disabilities – Ontario, Roxanne Mykitiuk, Disability Law, Health Law, Bioethics and Family Law Professor at Osgoode Hall Law School, Tracy Odell, Executive Director of Citizens with Disabilities – Ontario, Dr. Homira Osman, Director of Knowledge Translation & External Engagement at Muscular Dystrophy Canada, and Wendy Porch, Executive Director at the Centre for Independent Living Toronto.

[3] ARCH submissions, dated May 13, 2020 [“ARCH May Submissions”] available online here: https://archdisabilitylaw.ca/wp-content/uploads/2020/05/ARCH-Lttr-re-Clinical-Triage-Protocol-May-13-2020-PDF.pdf

[4] Critical Care Triage for Major Surge in the COVID-19 Pandemic dated March 28, 2020.

[5] This point was succinctly made by Ms. Jennifer Gibson in her introduction providing background and context on the drafting of the Triage Protocol.

[6] Law Commission of Ontario, The Law As It Affects Persons With Disabilities. Preliminary Consultation Paper: Approaches to Defining Disability [2009], online: Law Commission of Ontario www.lco-cdo.org

[7] Ont Human Rights Comm v Simpson-Sears, [1985] 2 SCR 536 [“Simpson-Sears”].

[8] Eldridge v British Columbia (Attorney General), [1997] 3 SCR 624 [“Eldridge”].

[9] Simpson-Sears, supra note 7.

[10] Professor Kimberlé Crenshaw introduced the term intersectionality in 1989 to address the marginalization of Black women within not only antidiscrimination law but also in feminist and antiracist theory and politics. The term was elaborated upon by Professor Crenshaw in 1991 and has been adopted by human rights law.

[11] Baylis-Flannery v. DeWilde (No. 2), (2003) 48 CHRR D/197 (Ont HRT) at para 144.

[12] AODA Alliance, A Discussion Paper on Ensuring that Medical Triage or Rationing of Health Care Services During the COVID-19 Crisis does not Discriminate Against Patients with Disabilities, April 14 2020, online: https://www.aodaalliance.org/whats-new/a-discussion-paper-on-ensuring-that-medical-triage-or-rationing-of-health-care-services-during-the-covid-19-crisis-does-not-discriminate-against-patients-with-disabilities/ [“AODA Alliance April Discussion Paper”]. See also, AODA Alliance, In a Second COVID-19 Wave, if there aren’t enough Ventilators for all Patients Needing them, a new Draft Ontario Protocol Would Continue to Discriminate Against COVID-19 Patients with Disabilities, July 16 2020, online: https://www.aodaalliance.org/whats-new/in-a-second-covid-19-wave-if-there-arent-enough-ventilators-for-all-patients-needing-them-a-new-draft-ontario-medical-triage-protocol-would-continue-to-discriminate-against-covid-19patients-with-d/

[13] Triage Protocol 2, supra note 1 at 2.

[14] Şerife Tekin, Health Disparities in COVID-19 Triage Protocols, April 8, 2020, Impact Ethics, online: https://impactethics.ca/2020/04/08/health-disparities-in-covid-19-triage-protocols/

[15] Tekin, ibid.

[16] Tekin, ibid.

[17] See HHS Office for Civil Rights in Action, Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19), march 28, 2020, online: https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf . See also Peterson, Andrew, Emily A Largent, Emanuel Hart & Jason Karlawish, “Ethics of reallocating ventilators in the covid-19 pandemic” BMJ 2020;369:m1828, online: https://www.bmj.com/content/369/bmj.m1828

[18] New York State Task Force on Life and the Law, New York State Department of Health, Ventilator Allocation Guidelines, November 2015 at 41, online: https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

[19] Simpson-Sears, supra note 7 at paras 12-13.

[20] Ibid.

[21] Triage Protocol 2, supra note 1 at 2.

[22] Ibid at 3.

[23] An apt example of this, of course, is the inclusion of the Clinical Frailty Scale in the Triage Protocol 2. This is further explored below.

[24] Correspondence from Ontario COVID-19 Bioethics Table to Roundtable Participants dated July 7, 2020 at 1.

[25] This is the second time ARCH raises this concern. It was first raised in ARCH’s May 13, 2020 submissions where we stated: A further concern is that, despite stating that the current version of the Triage Protocol is a draft, the Government has taken no action to clearly withdraw the draft to ensure that it is not implemented should the medical system become overburdened whilst Ontario Health conducts consultations. See ARCH May Submission, supra note 3.

[26] At the July 15, 2020 Round-table discussion co-convened by the Bioethics Table and the Ontario Human Rights Commission, Ms. Jennifer Gibson clarified that she had been advised that there is currently a clear language version of the Triage Protocol being developed.

[27] These submissions are made in addition to ARCH’s previous objections to the inclusion of the Clinical Frailty Scale. See ARCH May Submissions, supra note 3.

[28] Triage Protocol 2, supra note 1 at 7.

[29] Ibid at 20.

[30] Lastly, the July Triage Protocol provides an explanatory note following the exclusion criteria chart noting the purpose for which the CFS is to be used. This qualifier does provide some clarification; however, in saying that, the Bioethics Table still has not demonstrated why the inclusion of the CFS is of necessity in the first place. Secondly, the explanatory note focuses on the intention of the CFS rather than the impact.

[31] A salient point here, of course, is that frailty and disability are two distinct issues – a distinction that the CFS and the Triage Protocol both fail to acknowledge.

[32] Hodge, Jones & Allen, News Release, NICE Amends COVID-19 Critical Care Guideline After Judicial Review Challenge, March 31, 2020 available: https://www.hja.net/press-releases/nice-amends-covid-19-critical-care-guideline-after-judicial-review-challenge/

[33] The Bioethics Table’s attention is also directed to the states of Alabama, Tennessee and Washington in the United States for similar legal challenges to the identification of specific disabilities to be excluded or deprioritized from receiving critical care. Available: https://adap.ua.edu/uploads/5/7/8/9/57892141/al-ocr-complaint_3.24.20.pdf and http://thearc.org/wp-content/uploads/2020/03/2020-03-27-TN-OCR-Complaint-re-Healthcare-Rationing-Guidelines.pdf

[34] A helpful and concrete example of this can be found in the AODA Alliance April Discussion Paper, supra note 12. The example is as follows:

A patient with a history of cancer contracts serious COVID-19 symptoms and goes to hospital for emergency treatment. They need a ventilator. The hospital has too few ventilators to meet the needs of all its COVID-19 patients who need ventilators.

A physician is considering which patients will get a ventilator. The physician decides that the cancer patient’s long-term future lifespan may be shorter due to their cancer than other patients who have no disability. That physician thinks that this should be a factor weighing against that cancer patient getting the use of a ventilator.

Such decisions should not be based on the physician’s predictions, whether accurate or stereotype-based, about the eventual long-term lifespan of that patient unrelated to the COVID-19 diagnosis. The hospital or physician deciding who will get the ventilator must not weigh or hold against that patient with a disability the fact of their disability or its perceived impact on their long-term lifespan.

[35] Trudo Lemmens, Quebec’s clinical triage protocol opens door to discrimination, June 15, 2020, online: https://policyoptions.irpp.org/magazines/june-2020/quebecs-clinical-triage-protocol-opens-door-to-discrimination/

[36] Triage Protocol 2, supra note 1 at 5.

[37] Roxanne Mykitiuk & Trudo Lemmens, Assessing the value of a life : COVID-19 triage orders mustn’t work against those with disabilities, April 9, 2020, CBC online: https://www.cbc.ca/news/opinion/opinion-disabled-covid-19-triage-orders-1.5532137;

[38] Trudo Lemmens & Roxanne Mykitiuk, “Disability Rights Concerns and Clinical Triage Protocol Development During the COVID-19 Pandemic” 2020 HLCJ 40:4 at 107.

[39] Lemmens & Mykitiuk, ibid.

[40] Triage Protocol 2, supra note 1 at 8.

[41] Ibid.

[42] Ibid.

[43] It was noted at the July 15 Round-table by Ms. Jennifer Gibson that the aim of the Triage Protocol is to ensure that the same treatment and approach are taken across all hospitals. With respect, random selection as it is currently set out in Triage Protocol 2 fails to satisfy this objective as it is too vague and lacks direction to hospitals and healthcare workers.

[44] Triage Protocol 2, supra note 1 at 12.

[45] Triage Protocol 2, ibid.

[46] Triage Protocol 2, ibid.

[47] University of Virginia Health System Ethics Committee, “Ethical Framework and Recommendations for COVID-19 Resources Allocation When Scarcity is Anticipated” March 26, 2020 online: https://med.virginia.edu/biomedical-ethics/wp-content/uploads/sites/129/2020/03/Ethical-Framework-for-Co-vid-19-Resources-Allocation-3.26.20.pdf

[48] Ibid at 7

[49] Ibid at 233.

[50] Indiana State Dep’t of Health, Crisis Standards of Care Community Advisory Group, Crisis Standards of Patient Care Guidance with an Emphasis on Pandemic Influenza: Triage and Ventilator Allocation Guidelines, 13 (2014) http://www.phe.gov/coi/Documents/Indiana%20Crisis%20Standards%20of%20Care%202014.pdf

[51] Triage Protocol 2, supra note 1 at 3, 4 and 11.

[52] Eldridge, supra note 8.

[53] British Medical Association, “COVID-19 – ethical issues. A guidance note” (2020) at 7, online (pdf): BMA https://www.bma.org.uk/media/2360/bma-covid-19-ethics-guidance-april-2020.pdf .

[54] Tennessee, Tennessee Altered Standards of Care Workgroup, Guidance for the Ethical Allocation of Scarce Resources during a Community-Wide Public Health Emergency as Declared by the Governor of Tennessee (Version 1.6) (2020) online: Tennessee State Government

https://www.tn.gov/content/dam/tn/health/documents/cedep/ep/Guidance_for_the_Ethical_Allocation_of_Scarce_Resources.pdf .

[55] See AODA Alliance April Discussion Paper, supra note 12:

More than one hospital patient needs a ventilator. There are not enough ventilators for all the patients who need one at that hospital. At least one of the patients who needs a ventilator has disabilities. Some of the patients who need a ventilator have no apparent disabilities.

One of the patients with disabilities who needs the ventilator will need disability-related accommodations in hospital in order to receive health care services, such as a deaf patient who needs Sign Language interpreters to effectively communicate with hospital staff. The emergency room doctor, deciding who will get the ventilator, is concerned that the patient with disabilities who needs such accommodations in the hospital setting will pose a greater demand on the hospital’s services and resources, if they survive, than would other patients who need the ventilator.

The hospital or physician who is deciding who will get to use the ventilator must never use a patient’s need for disability-related accommodations as a factor or reason for refusing them the ventilator.



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AODA Alliance Endorses ARCH Disability Law Centre’s Brief that Shows in Even More Detail How the Ford Government’s Revised Draft Medical Triage Protocol, Now Undergoing Consultation, Would Discriminate Against COVID-19 Patients with Disabilities If There Were Not Enough Ventilators for All Patients Needing Them


Accessibility for Ontarians with Disabilities Act Alliance Update United for a Barrier-Free Society for All People with Disabilities
Web: http://www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: http://www.facebook.com/aodaalliance/

July 24, 2020

SUMMARY

The ARCH Disability Law Centre has made public a superb new brief to the Ford Government on the serious disability human rights problems with the revised draft medical triage protocol on which the Ford Government is now holding a consultation. The AODA Alliance strongly endorses ARCH’s brief and congratulates ARCH on excellent work. ARCH’s brief is set out below.

The Ford Government has still not rooted out the danger to people with disabilities that was created by the deeply flawed March 28, 2020 medical triage protocol that Ontario Health sent to all hospitals last spring. That protocol lets hospitals violate basic human rights of COVID-19 patients with disabilities if a surge in COVID-19 cases means there are not enough ventilators for all critical patients needing them. A number of disability organizations including the AODA Alliance have been pressing the Ford Government for over three months to fix the mess it thereby created.

The July 16, 2020 AODA Alliance Update made public a revised draft of the Government’s medical triage protocol, on which a consultation is now being held. We announced at that time that this revised draft medical triage protocol still has serious human rights problems from the disability perspective. We submitted that Update to the Ford Government’s advisory committee that is consulting on possible changes to that medical triage protocol.

Since then, on July 20, 2020, the ARCH Disability Law Centre submitted its new brief, set out below, to the Government’s advisory committee. The ARCH Disability Law Centre had a committee of human rights experts giving it input as it formulated this brief, including the AODA Alliance. The ARCH brief echoes and builds upon concerns that we have raised, and adds additional concerns, with which we entirely agree.

More Background

Check out:

* The July 16, 2020 AODA Alliance Update, that sets out serious disability human rights problems with the revised draft medical triage protocol.

* The text of the revised draft medical triage protocol.

* The April 7, 2020 virtual public forum on the impact of COVID-19 on people with disabilities, jointly organized by the AODA Alliance and the Ontario Autism Coalition. During this event, ARCH Disability Law Centre executive director Robert Lattanzio first made public the existence of the original March 28, 2020 medical triage protocol, and the disability human rights problems that it creates.

* The April 8, 2020 open letter, spearheaded by ARCH, identifying the serious disability human rights violations in the original March 28, 2020 medical triage protocol.

* The AODA Alliance’s April 14, 2020 Discussion Paper on what the medical triage protocol should include. In the three months since this was made public, no negative feedback was received about its recommendations.

* The Ford Government’s April 21, 2020 announcement that it would consult community and human rights experts on the medical triage protocol. It claimed that the March 28, 2020 protocol was only a draft even though it was never marked draft.

* The ARCH Disability Law Centre’s detailed May 13, 2020 analysis of the serious disability human rights violations created by the medical triage protocol, which the AODA Alliance endorses.

* To learn more about the many barriers that impede patients with disabilities in Ontario’s health care system, read the AODA Alliance’s February 25, 2020 Framework on what the promised Health Care Accessibility Standard should include, to be enacted under the Accessibility for Ontarians with Disabilities Act.

* The AODA Alliance’s health care web page, to learn more about the advocacy efforts to tear down the barriers facing people with disabilities in Ontario’s health care system.

* The AODA Alliance’s COVID-19 web page details the coalition’s efforts to advocate for the needs of people with disabilities during the COVID-19 pandemic.

MORE DETAILS

Text of the ARCH Disability Law Centre’s July 20, 2020 Brief on the Ford Government’s Revised Draft Medical Triage Protocol

Originally posted at http://archdisabilitylaw.ca/resource/submissions-and-recommendations-regarding-ontarios-triage-protocol-draft/ 55 University Avenue, 15th Floor Toronto, Ontario M5J 2H7
www.archdisabilitylaw.ca
(416) 482-8255 (Main) 1 (866) 482-ARCH (2724) (Toll Free)
(416) 482-1254 (TTY) 1 (866) 482-ARCT (2728) (Toll Free)
(416) 482-2981 (FAX) 1 (866) 881-ARCF (2723) (Toll Free)

Sent via email to [email protected]
July 20, 2020
Joint Centre for Bioethics
University of Toronto
155 College Street, Suite 754
Toronto, ON M5T 1P8
Canada

Dear Ms. Gibson and Mr. Smith:

Re: ARCH Disability Law Centre Submissions and Recommendations Regarding Ontario’s Triage Protocol Draft dated July 7, 2020

The within document is the written submission of ARCH Disability Law Centre (ARCH) in response to a review of the draft Triage Protocol dated and delivered July 7, 20201 and from the discussion held at the July 15, 2020 Roundtable, co-convened by the Bioethics Table and the Ontario Human Rights Commission.2 We provide these submissions in addition to our previous submissions dated May 13, 2020,3 and not in substitute of them.

Background

While Triage Protocol 2 demonstrates some improvement over the first version,4 there continues to be alarming issues that must be rectified to ensure that any response to a surge in COVID-19 cases does not adversely and disproportionately impact persons from marginalized communities including but not limited to persons with disabilities, elderly persons, Indigenous persons, Black persons and persons from other racialized communities. Representatives from various disability communities and organizations have made clear their concerns with both iterations of the Triage Protocol.

For ease of reference, the submissions that follow are divided into three sections. First, these submissions address the framework of Triage Protocol 2 this captures the issues related to the overall structure and guiding principles of the document. The second section addresses procedural issues this includes issues with the process of the development of the Triage Protocol and the lack of transparency. The third section addresses substantive issues, which includes the use of Clinical Frailty Scale as a metric to assess patients, the suggestion to use random selection as a method of fairness, and the importance of ensuring that a dispute resolution mechanism is in place.

ARCH submits the following recommendations to ensure that Triage Protocol 2 does not have an adverse impact on persons with disabilities:

1. Non-discrimination must be a guiding principle in its own right to ensure appropriate weight is given to human rights in triage decisions.
2. The Triage Protocol must not rely on medical utility as its primary guiding principle, as it leads to adverse consequences for persons with disabilities, and fails to consider systemic health discrepancies.
3. The framework must shift from a focus on the intention not to discriminate to whether adverse impact (discrimination) flows from the approaches embodied in Triage Protocol 2.
4. Ontario Health must communicate to every hospital and medical association/organization that the Triage Protocol dated March 28, 2020 is not be relied upon or implemented.
5. Clear language and plain language versions of all drafts and the final version of the Triage Protocol are to be produced and distributed widely so that all relevant stakeholders are able to understand the information and provide feedback.
6. Wider consultations are to be undertaken by the Bioethics Tables to ensure that the perspectives of persons with lived experience from marginalized and disproportionately impacted communities are heard and inform the drafting of the Triage Protocol.
7. The Triage Protocol must not rely on the Clinical Frailty Scale in any capacity.
8. The Triage Protocol must eliminate eligibility criteria that considers survivability beyond the acute COVID-related event.
9. The Triage Protocol must provide clear and specific guidance and direction as to how random selection should be carried out.
10. The Triage Protocol must include an individual dispute resolution process to ensure fairness, accountability, and due process.
11. The Triage Protocol must include a section dedicated to providing guidance and direction on the duty to accommodate.

ARCH’s Recommendations are reproduced below following a discussion and rationale for each at the conclusion of each section.

Concerns with the overall Framework and Structure of the Triage Protocol

As noted at the July 15 Roundtable by members of the Bioethics Table, while it is not necessarily contemplated or envisioned that this Triage Protocol will be used beyond the COVID-19 pandemic, it will most likely inform responses to future pandemics.5 It is beyond a doubt the Triage Protocol is an important document that will have long and consequential effects, some of which may be devastating and detrimental. Accordingly, it is imperative that such a document, despite its primary purpose being to provide direction to medical professionals, must not be framed solely within the medical model,6 but also within a human rights framework. This is to ensure that the benefits of any emergency response are also afforded to marginalized communities, rather than at their expense.

In its current version, the Triage Protocol lists a number of ethical principles to guide and inform allocation of scarce critical care resources. These principles are to be considered the starting point, the foundation of any decisions made about critical care in the context of a major surge of COVID-19. These guiding principles, accordingly, seep into and colour all aspects of decisions about scarce resources, which are admittedly difficult decisions with grave significance and great public importance. As such, it is imperative that the principles that guide these decisions are strong, principled, and align with a human rights framework.

In short, the framework within which this Triage Protocol is being drafted must be reformed and reshaped. Without this necessary reformation, discrimination will continue to plague the Triage Protocol. As such, it is recommended that in drafting the Triage Protocol, the authors view the issues from a human rights lens, and in particular from a disability rights and intersectionality lens.

The Right to be Free from Discrimination

The Triage Protocol must be guided by non-discrimination in its own right. The right to be free from discrimination is a quasi-constitutional right afforded to every Ontarian and Canadian,7 including when receiving health care services and medical attention.8 It is a right that is elevated above other legal rights and restrictions.9

A patient’s right to be free from discrimination is not given its due weight in Triage Protocol 2. Guiding Principle 4, Equity and Respect for Human Rights, where a mention of a patient’s human rights is briefly made, is problematic for two reasons. First, it places the right to be free from discrimination on the same pedestal as other guiding principles, including beneficence and accountability. This is inappropriate, namely for the aforementioned reason that the right to be free from discrimination is a quasi-constitutional right, whereas beneficence, for example, is not. Second, Guiding Principle 4 is problematic because it collapses Equity and Human Rights and treats them as the same, or interchangeable, concepts which they are not.

Reframing the Triage Protocol 2 to reflect that the right to be free from discrimination is separate from, and superior to, the guiding principles will more accurately signal how fundamental and integral human rights law must be to the decision-making process. Moreover, this reframing will also account for, and acknowledge, intersectionality and how individuals who identify with multiple protected grounds by human rights law are impacted by the Triage Protocol.

Intersectionality10 is a term used to refer to instances where persons may experience discrimination on more than one human rights protected ground simultaneously. The importance of an intersectional lens has been emphasized by the Human Rights Tribunal of Ontario which has stated that an awareness of compound discrimination is necessary in order to avoid a narrow and one-dimensional perspective.11

In the context of the Triage Protocol, it must be recognized that in treating patients who contract COVID-19 and require critical care within a surge, doctors must be cognizant of the compound discrimination that for example, a Black woman with a disability may experience. Accordingly, this section in the Triage Protocol should include a concrete explanation of what non-discrimination means and how it should be applied in a triage setting, such as disability, age, race, or any other protected ground cannot factor, even 1%, into triage decisions. 12
In sum, the Triage Protocol must be framed within a human rights approach and place the principle of non-discrimination at the forefront, in order to set the proper foundation for triage decisions regarding the allocation of scarce resources and to give effect to the quasi-constitutional status of these rights.

Medical Utility is not a Proper Guiding Principle

Medical utility as a guiding ethical principle in the Triage Protocol is problematic. As set out in Triage Protocol 2, medical utility strives to create the maximum good for the maximum number of people.13 While appearing facially neutral, utilitarianism actually often leads to adverse impacts for persons with disabilities.14 By virtue of this principle, those that are not able-bodied are less likely to be part of the group that receives the good in question.

Utilitarian frameworks do not consider existing systemic health disparities.15 Many persons with disabilities do not have equitable access to health care or health care outcomes. Many require additional resources to achieve equal health outcomes due to the need for disability-related accommodations, or due to systemic social inequities and/or intersectionality. But where a person’s health outcomes may be influenced by these factors, utility has the unintended consequence of disregarding individual needs.16 A purely medical utility model has been criticized as ruthless17 and at odds with societal values of defending and advancing the rights of marginalized communities.18

The problems with medical utility being a guiding factor are compounded when one considers that Triage Protocol 2 has attempted to distance itself from the pre-existing health and social inequities experienced by persons with disabilities and other marginalized groups in Ontario. At page 4 of Triage Protocol 2, it states that the pre-existing health and social inequities that have been revealed by the COVID pandemic will not be resolved by a triage approach.

Instead Triage Protocol 2 suggests that proactive measures must be taken in other sectors in order to prevent vulnerable groups from disproportionately contracting COVID. In effect, Triage Protocol 2 is offloading responsibility for these disproportionate impacts and distances itself from the systemic and pervasive barriers to health care in our society. This distancing is troubling, given that the very guiding principles that the triage approach is based on are likely to perpetuate and compound adverse health outcomes.

While the Triage Protocol cannot be expected to right all the systemic barriers experienced by marginalized communities, it cannot be permitted to perpetuate and compound these same inequities. Recognition of those pre-existing inequities is an important contextual factor that must be incorporated into and compensated for in the triage approach. This is an objective that is difficult to reconcile with pure medical utility being a primary guiding principle.

Focus on Impact

The Triage Protocol as a whole is written from a lens of intention without any focus on the impact that decisions made will have on patients from marginalized communities. It is well-established in human rights law that the intention to, or not to, discriminate is inconsequential and not a governing factor in determining whether or not a person has experienced discrimination.19 Rather, it is the effect or impact experienced by the person alleging discrimination that is the focus of any human rights analysis.20

It is clear that neither the first version of the Triage Protocol nor Triage Protocol 2 contemplate the adverse impact that will be experienced by persons from marginalized communities, including persons with disabilities, flowing from decisions made pursuant to said Protocol. The inclusion of guiding ethical principles like medical utility21 and (formalistic) fairness22 demonstrate that the Triage Protocol inappropriately emphasizes the doctor’s intention, without turning its mind to the adverse impact that will be experienced by the person with a disability.23 The result is a Triage Protocol with an approach that is problematic and discriminatory in nature.

Accordingly, a shift in the drafting framework must occur. The important question is not, whether the triage approach appears to be neutral and well-intentioned, but rather, whether marginalized communities could be adversely impacted. This shift in focus should lead to a shift in perspective when contemplating the guiding ethical principles; for example, when the focus is impact and not intention then substantive fairness, rather than formalistic fairness, becomes the objective.

Framework and Structural Recommendations:

1. Non-discrimination must be a guiding principle in its own right to ensure appropriate weight is given to human rights in triage decisions.
2. The Triage Protocol must not rely on medical utility as its primary guiding principle, as it leads to adverse consequences for persons with disabilities, and fails to consider systemic health discrepancies.
3. The framework must shift from a focus on the intention not to discriminate to whether adverse impact (discrimination) flows from the approaches embodied in Triage Protocol 2.

Concerns regarding the process of Triage Protocol development

Follow-Up Communication to March Triage Protocol

It is imperative that Ontario Health notify the recipients of the first draft that it is not to be operationalized or applied.

In the cover letter to Triage Protocol 2, the Bioethics Table states that the March 28, 2020 Triage Protocol was sent out to hospitals by Ontario Health. In particular, it states that [t]he draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions.24

We are deeply concerned that, at the time it was delivered and distributed to hospitals and medical associations at least, it was not made clear to the recipients that these recommendations and the Triage Protocol in which they are housed were a draft.25 The potential harm of this oversight cannot be overstated. Given the highly problematic and discriminatory nature of the first draft, the concern is that should hospitals hit surge prior to the approval or authorization of an improved version, then doctors will rely on the previous version, which may lead to devastating and disproportionate impacts on persons from marginalized communities.

Case in point: in or around May 2020 it was brought to ARCH’s attention that at least three different medical organizations had published the draft Triage Protocol on their websites as a resource for its members including doctors, nurses and other health professionals as if this was a finalized document.

Around the middle of May 2020, ARCH reached out to these three organizations, namely the Nurse Practitioners’ Association of Ontario (NPAO), CorHealth Ontario, and Canadian Association of Emergency Physicians (CAEP), and requested that they immediately remove the draft Triage Protocol from their websites in light of the Provincial Government’s statement that this was a draft and not a finalized document. Each organization complied.

It is beyond ARCH’s reach, however, to contact every single hospital and medical association to which the Triage Protocol was delivered on March 28, 2020 or soon thereafter. Frankly, it is also beyond ARCH’s responsibility to do same. Rather, it is incumbent upon Ontario Health to discharge this responsibility.

Accordingly, it is imperative that Ontario Health immediately contact every recipient of the original Triage Protocol to (a) ensure that the hospital/medical association is aware that the March 28, 2020 version is a draft that is not to be relied upon nor implemented, and (b) to ensure that no hospital staff or medical organization members are referring to or relying on that version of the Triage Protocol.

Clear and Plain Language Versions of the Triage Protocol

It is understood that the primary purpose of the Triage Protocol is to provide guidance to medical professionals and healthcare workers in the event that Ontario hits surge conditions. Simultaneously, however, it must be recognized that it is members of the public who will be subject to and impacted by decisions made pursuant to this Triage Protocol. Consequently, the public is entitled to know how doctors are expected to make these decisions and the basis upon which these decisions are made.

For clarification, clear language and plain language are two distinct concepts and are not to be used interchangeably. Clear language refers to the use of straightforward, direct language to convey ideas in a simple manner making the document accessible to everyone. Plain language is the use of techniques, like providing concrete examples and using clear language, to ensure that people with intellectual and/or developmental disabilities are able to access the information.

Accordingly, it is recommended that both clear language and plain language versions of the Triage Protocol be developed and made available to the public to disseminate this information in an accessible manner to as wide an audience as possible. It is imperative that any and all versions of the Triage Protocol be made accessible. This means that not only should the final version of the Triage Protocol also be produced in clear and plain language versions, but any drafts developed along the way as well.26

Wider Consultations Needed

Wider consultations on a document such as Triage Protocol 2, which will have wide and varying effects, including consequences that may be detrimental in nature, is imperative. These consultations, however, cannot be formalistic nor performative.

Consultations are imperative in order to ensure that the perspectives of persons who are being disproportionately impacted by COVID-19 and who are, in turn, disproportionately impacted by the Triage Protocol are considered and incorporated. This, of course, includes the perspective of persons with disabilities, Indigenous persons and persons from racialized communities including Black persons and persons from other racialized communities. Moreover, wider consultations ensure that a multi-dimensional lens, including one that emphasizes intersectionality, is applied when drafting any Triage Protocol.

It is important to note, however, that in order to have these consultations be truly accessible and receive feedback from relevant stakeholders, including persons with disabilities, a clear language and plain language versions of the Triage Protocol must be made available to said stakeholders (as stated above). The absence of an accessible version dilutes the purpose of these consultations, namely, to receive feedback from persons from disability communities.

Process-related Recommendations:
4. Ontario Health must communicate to every hospital and medical association/organization that the Triage Protocol dated March 28, 2020 is not be relied upon or implemented.
5. Clear language and plain language versions of all drafts and the final version of the Triage Protocol are to be produced and distributed widely so that all relevant stakeholders are able to understand the information and provide feedback.
6. Wider consultations are to be undertaken by the Bioethics Tables to ensure that the perspectives of persons with lived experience from marginalized and disproportionately impacted communities are heard and inform the drafting of the Triage Protocol.

Substantive Concerns regarding the Triage Protocol

The Continued Inclusion of the Clinical Frailty Scale

The Clinical Frailty Scale (CFS) must be entirely removed from Triage Protocol 2.27 While Triage Protocol 2 removes the visual chart of the CFS, it is still referred to in the exclusion criteria chart28, albeit more infrequently than in the previous draft, and is included in Appendix C as a Triage Criteria Tool.29

As already submitted in ARCH’s Brief dated May 13 2020, the CFS is included in the Triage Protocol to serve a purpose for which it was neither designed nor developed. The application of the CFS to persons with disabilities without the context of a pandemic is inappropriate. The application of the CFS to persons with disabilities within the context of a pandemic is catastrophic and devastating.

It is understood that the goal and intention of the CFS is to create a situation where all patients are treated fairly by applying the same metric across the board in a non-discriminatory manner,30 this belief, however, is not only misguided, but a deductive and logical fallacy. In applying the CFS as it is, to all patients, the able-bodied will always score lower (for example, a 1 on the CFS) and persons with disabilities will always score higher deeming them frail.31 In a pandemic setting this means that the able-bodied person will always be prioritized for care over persons with disabilities. This is not fairness nor is it treatment on an equitable basis.

Several jurisdictions have already recognized the error in initially including the CFS in their Triage Protocols and have remedied their error by removing the CFS from any COVID-19 protocols and committing to an individualized assessment of each patient. For example, in the United Kingdom,32 the use of the CFS was challenged and the government conceded the problematic nature of the CFS for the purposes of allocating critical care resources.33 Despite this, reliance on this problematic scale persists in Triage Protocol 2.

Recalling that intention is of no consequence it is irrelevant whether, with the application of the CFS, a doctor, healthcare worker, hospital, medical organization or government department intended to discriminate against a specific demographic of patients or not. Rather, of importance is the adverse impact experienced by a person with a disability by being subject to a seemingly neutral metric that will disproportionately place them at a disadvantage
The inclusion of the CFS in the Triage Protocol may not have been accompanied by an intention to discriminate, and yet the adverse impact experienced by persons with disabilities is real and tangible. In short, the adverse impact that flows from the inclusion and application of the Triage Protocol renders it discriminatory, regardless of the initial intention.

Survivability Beyond COVID-19

It is inappropriate to rely on ineligibility criteria that extends beyond the recovery of the acute COVID-related event.34 It is arbitrary and invites a higher risk of ableist value assumptions about the quality of a person’s life, which will inevitably cause a disproportionate adverse impact on persons with disabilities.35

Triage Protocol 2 states that a person would be ineligible for critical care where they have a low probability of surviving more than a few months beyond recovering from COVID. Triage Protocol 2 further explains that a person would be ineligible if they were very likely to die in the near future if they recovered from their critical illness.36

First, more than a few months is a speculative and subjective assessment, which could mean a number of different things to different doctors making these decisions. Second, this criteria goes beyond an assessment of the person’s chance of survival of the acute COVID-19-related event, and invites ableist presumptions about chances of survival or quality of life after Intensive Care Unit (ICU) treatment to seep into clinical evaluations.37 These types of assessments tend to disproportionately affect people with disabilities.38

As stated by Profs. Trudo Lemmens and Roxanne Mykitiuk:

While the protocol does not clarify the time frame used to determine the risk of mortality’ (i.e. mortality by when?), it goes beyond survival in the ICU, and includes the likelihood of survival months after ICU treatment. As mentioned above, the further one moves beyond ICU discharge, the more a policy will disproportionately impact on the elderly and people with disabilities.39

It is clear that survivability beyond the acute COVID-related incident is subjective, arbitrary, and risks discriminating against persons with disabilities. As such, it must not be relied on as a criteria of ineligibility.

Random Selection

Safeguards must be put into place to ensure that random selection is not polluted by unconscious biases and prejudices. In an effort to uphold the principle of fairness, Triage Protocol 2 suggests applying the method of random selection in situations where it is not possible to rely on medical utility to make clinical decisions.40 The aim, according to Triage Protocol 2, is to mitigate against the potential of explicit or unconscious bias in decision-making.41

The concern is how random selection will be carried out in practice as any decision-making is always subject to human and inherent bias. Triage Protocol 2 is vague as to how random selection will translate into practice, only noting that a record of the outcome of the process of randomization should be documented.42

In order to remedy against the influence of inherent bias, safeguards must be put in place to ensure a truly random selection process. It is also important to ensure that accountability and transparency are pillars in any random selection process implemented pursuant to the Triage Protocol. It is of utmost importance that the Triage Protocol be specific and thorough in how the random selection process is to be applied. As it stands at the moment, there is very little guidance and direction on this point which will lead to different practices of random selection across hospitals.43

Dispute Resolution Mechanisms

It is imperative that Triage Protocol 2 includes a dispute resolution mechanism. An appeals procedure is an essential procedural aspect of due process, which cannot be set aside in pandemic conditions.

In addressing the possibility of a dispute resolution process for patients/families who disagree with the outcome of a triage decision, Triage Protocol 2 suggests that a formal appeal process may not be feasible or appropriate.44 Instead, it offers to patients who have been subject to triage decisions that the hospital [c]ommunicat[e] the rationale to the patient/family and respond [?] compassionately to patient or family concerns.45 It also suggests that it will conduct a retrospective, global review by monitoring triage data, and reviewing and revising the approach to ensure it is not leading to adverse consequences.46 With respect, while these elements are important parts of a triage approach, this is not an acceptable substitute for individual due process.

To the contrary, it is possible and necessary to include an individual dispute resolution mechanism in Triage Protocol 2. A real-time review of individual complaints is vital for ensuring that no individual has been treated unjustly by the decision-makers and so that a new decision can be implemented before irreparable harm is done. This would allow the patient or family member to seek a remedy before a potentially discriminatory and irreversible decision is carried out.

Other jurisdictions recognize the importance of an appeal framework within a triage approach.47 The University of Virginia Health System Ethics Committee, for example, recommends that triage decisions be supported by an appeal process in order [t]o promote the ethical principles of trustworthiness, equity, fairness, and justice.48

It has been noted that while global review of the triage approach is important for accountability and on-going improvement of the triage process, it does not protect vulnerable patients, because it does not allow for timely intervention in individual triage decisions.49 As the Indiana State Department of Health noted in its Crisis Standards of Patient Care Guidance, while meticulous record keeping is desirable, in such cases, it is ethically important to prioritize energies spent in the direct saving of lives over those spent keeping records and in post?hoc analyses.50

Duty to Accommodate

It is imperative that Triage Protocol 2 includes a section that focuses on providing specific guidance and directions about the duty to accommodate. Triage Protocol 2 makes only brief references to the provision of accommodations for persons with disabilities accessing the Triage Protocol and decisions about critical care resources. These references are not specific nor directive.51

Disability-related accommodations for the purposes of accessing health care services are a basic tenet of human rights law.52 Disability-related accommodations ensure that persons with disabilities have equal opportunity to receive, understand, and benefit from critical care.

Other jurisdictions have acknowledged the importance of providing disability-related accommodations to persons to ensure they have equal access to health care during the COVID-19 pandemic. The British Medical Association’s guidance for COVID-19 reiterates that hospitals have a positive obligation to ensure that persons with disabilities are able to access and take advantage of public services in a manner as closely as reasonably possible to someone without disabilities.53 Similar directives can be found in other ICU decision-making guidance in jurisdictions like Tennessee.54

Accommodations may include interpretation, alternative and augmentative communication, support persons, or other supports that allow a person to gain equal access to medical services.55 These must be provided to the patient during the application of the Triage Protocol and the duration of the patient’s time at the hospital.

Triage Protocol 2 should include detailed directives regarding how accommodations are provided in the context of a pandemic. Disability-related needs vary depending on the person with a disability and may fluctuate throughout a period of time. Accordingly, and as discussed in the preceding paragraph, it is highly recommended that best practices be included such as asking each patient in the emergency room and/or upon admission to the hospital if they require disability-related accommodation and, if they do, what those accommodations are. These patient-specific accommodations should be recorded in the chart and applied by every healthcare worker that comes into contact with the patient. Practices such as these that are in line with human rights obligations will also assist in ensuring that all appropriate accommodations are in place when any assessments are made pursuant to the Triage Protocol.

Substantive Recommendations:

7. The Triage Protocol must not rely on the Clinical Frailty Scale in any capacity.
8. The Triage Protocol must eliminate eligibility criteria that considers survivability beyond the acute COVID related event.
9. Triage Protocol 2 should provide clear and specific guidance and direction as to how random selection should be carried out.
10. The Triage Protocol must include an individual dispute resolution process to ensure fairness, accountability, and due process.
11. The Triage Protocol must include a section dedicated to providing guidance and direction on the duty to accommodate.

Conclusion:

In sum, there continue to be concerns with Triage Protocol 2 that must be rectified to ensure that any response to a surge in COVID-19 cases does not adversely and disproportionately impact persons from marginalized communities including but not limited to persons from disability communities, elderly persons, Indigenous persons, Black persons and persons from other racialized communities.

The above submissions address a number of those concerns and provide Recommendations for reform. The Recommendations herein aim to align the Triage Protocol with human rights law and ensure that marginalized communities are not disproportionately impacted. The Recommendations impact the overall structure and guiding principles of the document, those related to the process within which the Triage Protocol has been developed, and those related to the substantive concerns, such as the use of the Clinical Frailty Scale or survivability beyond the acute event as metrics to assess patients, the use of random selection, the lack of a dispute resolution mechanism, and the importance of upholding the duty to accommodate.

Please do not hesitate to contact us should you wish to discuss any of these Recommendations in further and greater detail.

Sincerely,

ARCH DISABILITY LAW CENTRE

Robert Lattanzio
Executive Director

Mariam Shanouda
Staff Lawyer

Jessica De Marinis
Staff Lawyer

1 Critical Care Triage for Major Surge in the COVID-19 Pandemic: Updated Recommendations, delivered and dated July 7, 2020 [?Triage Protocol 2?].
2 ARCH would like to especially and sincerely thank members of its Advisory Committee for engaging in extensive discussion and providing thoughtful guidance and expertise on the important issues raised by the Triage Protocol. ARCH’s Advisory Committee, in alphabetical order, includes: Chris Beesley, Executive Director at Community Living Ontario, Laura LaChance, Interim Executive Director at Canadian Down Syndrome Society, Trudo Lemmens Professor, Scholl Chair in Health Law and Policy at University of Toronto Law School, David Lepofsky, Chair of the AODA Alliance, Leanne Mielczarek, Executive Director of Lupus Canada, Elizabeth Mohler, Board Member at Citizens With Disabilities Ontario, Roxanne Mykitiuk, Disability Law, Health Law, Bioethics and Family Law Professor at Osgoode Hall Law School, Tracy Odell, Executive Director of Citizens with Disabilities Ontario, Dr. Homira Osman, Director of Knowledge Translation & External Engagement at Muscular Dystrophy Canada, and Wendy Porch, Executive Director at the Centre for Independent Living Toronto.
3 ARCH submissions, dated May 13, 2020 [?ARCH May Submissions?] available online here: https://archdisabilitylaw.ca/wp-content/uploads/2020/05/ARCH-Lttr-re-Clinical-Triage-Protocol-May-13-2020-PDF.pdf 4 Critical Care Triage for Major Surge in the COVID-19 Pandemic dated March 28, 2020.
5 This point was succinctly made by Ms. Jennifer Gibson in her introduction providing background and context on the drafting of the Triage Protocol.
6 Law Commission of Ontario, The Law As It Affects Persons With Disabilities. Preliminary Consultation Paper: Approaches to Defining Disability [2009], online: Law Commission of Ontario www.lco-cdo.org 7 Ont Human Rights Comm v Simpson-Sears, [1985] 2 SCR 536 [?Simpson-Sears?]. 8 Eldridge v British Columbia (Attorney General), [1997] 3 SCR 624 [?Eldridge?]. 9 Simpson-Sears, supra note 7.
10 Professor Kimberlé Crenshaw introduced the term intersectionality in 1989 to address the marginalization of Black women within not only antidiscrimination law but also in feminist and antiracist theory and politics. The term was elaborated upon by Professor Crenshaw in 1991 and has been adopted by human rights law.
11 Baylis-Flannery v. DeWilde (No. 2),(2003) 48 CHRR D/197 (Ont HRT) at para 144.
12 AODA Alliance, A Discussion Paper on Ensuring that Medical Triage or Rationing of Health Care Services During the COVID-19 Crisis does not Discriminate Against Patients with Disabilities, April 14 2020, online: https://www.aodaalliance.org/whats-new/a-discussion-paper-on-ensuring-that-medical-triage-or-rationing-of-health-care-services-during-the-covid-19-crisis-does-not-discriminate-against-patients-with-disabilities/ [?AODA Alliance April Discussion Paper?]. See also, AODA Alliance, In a Second COVID-19 Wave, if there aren’t enough Ventilators for all Patients Needing them, a new Draft Ontario Protocol Would Continue to Discriminate Against COVID-19 Patients with Disabilities, July 16 2020, online: https://www.aodaalliance.org/whats-new/in-a-second-covid-19-wave-if-there-arent-enough-ventilators-for-all-patients-needing-them-a-new-draft-ontario-medical-triage-protocol-would-continue-to-discriminate-against-covid-19patients-with-d/ 13 Triage Protocol 2, supra note 1 at 2.
14 ?erife Tekin, Health Disparities in COVID-19 Triage Protocols, April 8, 2020, Impact Ethics, online: https://impactethics.ca/2020/04/08/health-disparities-in-covid-19-triage-protocols/ 15 Tekin, ibid. 16 Tekin, ibid.
17 See HHS Office for Civil Rights in Action, Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19), march 28, 2020, online: https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf . See also Peterson, Andrew, Emily A Largent, Emanuel Hart & Jason Karlawish, Ethics of reallocating ventilators in the covid-19 pandemic BMJ 2020;369:m1828, online: https://www.bmj.com/content/369/bmj.m1828
18 New York State Task Force on Life and the Law, New York State Department of Health, Ventilator Allocation Guidelines, November 2015 at 41, online: https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf 19 Simpson-Sears, supra note 7 at paras 12-13. 20 Ibid.
21 Triage Protocol 2, supra note 1 at 2.
22 Ibid at 3.
23 An apt example of this, of course, is the inclusion of the Clinical Frailty Scale in the Triage Protocol 2. This is further explored below.
24 Correspondence from Ontario COVID-19 Bioethics Table to Roundtable Participants dated July 7, 2020 at 1.
25 This is the second time ARCH raises this concern. It was first raised in ARCH’s May 13, 2020 submissions where we stated: A further concern is that, despite stating that the current version of the Triage Protocol is a draft, the Government has taken no action to clearly withdraw the draft to ensure that it is not implemented should the medical system become overburdened whilst Ontario Health conducts consultations. See ARCH May Submission, supra note 3.

26 At the July 15, 2020 Round-table discussion co-convened by the Bioethics Table and the Ontario Human Rights Commission, Ms. Jennifer Gibson clarified that she had been advised that there is currently a clear language version of the Triage Protocol being developed.
27 These submissions are made in addition to ARCH’s previous objections to the inclusion of the Clinical Frailty Scale. See ARCH May Submissions, supra note 3. 28 Triage Protocol 2, supra note 1 at 7.
29 Ibid at 20.
30 Lastly, the July Triage Protocol provides an explanatory note following the exclusion criteria chart noting the purpose for which the CFS is to be used. This qualifier does provide some clarification; however, in saying that, the Bioethics Table still has not demonstrated why the inclusion of the CFS is of necessity in the first place. Secondly, the explanatory note focuses on the intention of the CFS rather than the impact.
31 A salient point here, of course, is that frailty and disability are two distinct issues a distinction that the CFS and the Triage Protocol both fail to acknowledge.
32 Hodge, Jones & Allen, News Release, NICE Amends COVID-19 Critical Care Guideline After Judicial Review Challenge, March 31, 2020 available: https://www.hja.net/press-releases/nice-amends-covid-19-critical-care-guideline-after-judicial-review-challenge/ 33 The Bioethics Table’s attention is also directed to the states of Alabama, Tennessee and Washington in the United States for similar legal challenges to the identification of specific disabilities to be excluded or deprioritized from receiving critical care. Available: https://adap.ua.edu/uploads/5/7/8/9/57892141/al-ocr-complaint_3.24.20.pdf and http://thearc.org/wp-content/uploads/2020/03/2020-03-27-TN-OCR-Complaint-re-Healthcare-Rationing-Guidelines.pdf
34 A helpful and concrete example of this can be found in the AODA Alliance April Discussion Paper, supra note 12. The example is as follows:
A patient with a history of cancer contracts serious COVID-19 symptoms and goes to hospital for emergency treatment. They need a ventilator. The hospital has too few ventilators to meet the needs of all its COVID-19 patients who need ventilators.
A physician is considering which patients will get a ventilator. The physician decides that the cancer patient’s long-term future lifespan may be shorter due to their cancer than other patients who have no disability. That physician thinks that this should be a factor weighing against that cancer patient getting the use of a ventilator.
Such decisions should not be based on the physician’s predictions, whether accurate or stereotype-based, about the eventual long-term lifespan of that patient unrelated to the COVID-19 diagnosis. The hospital or physician deciding who will get the ventilator must not weigh or hold against that patient with a disability the fact of their disability or its perceived impact on their long-term lifespan.
35 Trudo Lemmens, Quebec’s clinical triage protocol opens door to discrimination, June 15, 2020, online: https://policyoptions.irpp.org/magazines/june-2020/quebecs-clinical-triage-protocol-opens-door-to-discrimination/ 36 Triage Protocol 2, supra note 1 at 5.
37 Roxanne Mykitiuk & Trudo Lemmens, Assessing the value of a life: COVID-19 triage orders mustn’t work against those with disabilities, April 9, 2020, CBC online: https://www.cbc.ca/news/opinion/opinion-disabled-covid-19-triage-orders-1.5532137;
38 Trudo Lemmens & Roxanne Mykitiuk, Disability Rights Concerns and Clinical Triage Protocol Development During the COVID-19 Pandemic 2020 HLCJ 40:4 at 107. 39 Lemmens & Mykitiuk, ibid.
40 Triage Protocol 2, supra note 1 at 8.
41 Ibid.
42 Ibid.
43 It was noted at the July 15 Round-table by Ms. Jennifer Gibson that the aim of the Triage Protocol is to ensure that the same treatment and approach are taken across all hospitals. With respect, random selection as it is currently set out in Triage Protocol 2 fails to satisfy this objective as it is too vague and lacks direction to hospitals and healthcare workers. 44 Triage Protocol 2, supra note 1 at 12.
45 Triage Protocol 2, ibid.
46 Triage Protocol 2, ibid.
47 University of Virginia Health System Ethics Committee, Ethical Framework and Recommendations for COVID-19 Resources Allocation When Scarcity is Anticipated March 26, 2020 online: https://med.virginia.edu/biomedical-ethics/wp-content/uploads/sites/129/2020/03/Ethical-Framework-for-Co-vid-19-Resources-Allocation-3.26.20.pdf 48 Ibid at 7
49 Ibid at 233.
50 Indiana State Dep’t of Health, Crisis Standards of Care Community Advisory Group, Crisis Standards of Patient Care Guidance with an Emphasis on Pandemic Influenza: Triage and Ventilator Allocation Guidelines, 13 (2014) http://www.phe.gov/coi/Documents/Indiana%20Crisis%20Standards%20of%20Care%202014.pdf 51 Triage Protocol 2, supra note 1 at 3, 4 and 11. 52 Eldridge, supra note 8.
53 British Medical Association, COVID-19 ethical issues. A guidance note (2020) at 7, online (pdf): BMA https://www.bma.org.uk/media/2360/bma-covid-19-ethics-guidance-april-2020.pdf .
54 Tennessee, Tennessee Altered Standards of Care Workgroup, Guidance for the Ethical Allocation of Scarce Resources during a Community-Wide Public Health Emergency as Declared by the Governor of Tennessee (Version 1.6) (2020) online: Tennessee State Government
https://www.tn.gov/content/dam/tn/health/documents/cedep/ep/Guidance_for_the_Ethical_Allocation_of_Scarce_Resources.pdf . 55 See AODA Alliance April Discussion Paper, supra note 12:
More than one hospital patient needs a ventilator. There are not enough ventilators for all the patients who need one at that hospital. At least one of the patients who needs a ventilator has disabilities. Some of the patients who need a ventilator have no apparent disabilities.
One of the patients with disabilities who needs the ventilator will need disability-related accommodations in hospital in order to receive health care services, such as a deaf patient who needs Sign Language interpreters to effectively communicate with hospital staff. The emergency room doctor, deciding who will get the ventilator, is concerned that the patient with disabilities who needs such accommodations in the hospital setting will pose a greater demand on the hospital’s services and resources, if they survive, than would other patients who need the ventilator.
The hospital or physician who is deciding who will get to use the ventilator must never use a patient’s need for disability-related accommodations as a factor or reason for refusing them the ventilator.




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In A Second COVID-19 Wave If There Aren’t Enough Ventilators for All Patients Needing Them, A new Draft Ontario Medical Triage Protocol Would Continue to Discriminate Against COVID-19Patients with Disabilities


Accessibility for Ontarians with Disabilities Act Alliance Update United for a Barrier-Free Society for All People with Disabilities
Web: http://www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: http://www.facebook.com/aodaalliance/

July 16, 2020

SUMMARY

1. Whats the Serious Issue?

Despite having four months to fix this serious problem, in the COVID-19 crisis the Ford Government has still not rooted out the current danger to people with disabilities, induced by a protocol that Ontario Health sent to all hospitals last spring. That protocol lets hospitals violate basic human rights of COVID-19 patients with disabilities if a surge in COVID-19 cases meant theres not enough ventilators for all critical patients needing them. Despite months of efforts by disability advocates, a new draft medical triage protocol which the Government has under consideration, and which we reveal to the public here while it is open for input, leaves the danger of disability discrimination in place.

Thankfully, Ontario now has no ventilator shortage. However a second wave of COVID-19 cases later this year could create a surge in demand for ventilators. To date, the Ford Governments troubling handling of what to do if there are too few ventilators for COVID-19 patients has been improperly shrouded in secrecy.

Early in the COVID-19 crisis, Ontario Health, part of the Ontario Government, sent a very troubling March 28, 2020 medical triage protocol to Ontario hospitals. It spelled out what to do if there is more demand for life-saving ventilators than there are ventilators to go around. The Government did not make that protocol public. After it was leaked early last April to some within the disability community, disability advocates slammed it and called for it to be rescinded and replaced.

2. Whats New on This Issue?

Here is the late-breaking news on this issue, backed by Government documents that we are making public in this Update.

1. We now confirm that the Government sent the original March 28, 2020 medical triage protocol to Ontario hospitals. A July 7, 2020 letter from Ontario Healths team drafting the triage protocol, set out below, states:

The draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals to prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions.

2. It is now clear and beyond dispute that the Government has still not rescinded that original March 28, 2020 medical triage protocol. Disability advocates including the AODA Alliance, as well as the Ontario Human Rights Commission, have called on the Government to rescind that original medical triage protocol, because it violates the human rights of patients with disabilities. Ontario Healths June 15, 2020 letter to the Ontario Human Rights Commission, set out below, states the following regarding the medical triage protocol:

Our goal is to have a final document by the end of July, or to rescind it.

3. A Government-appointed committee of physicians and bioethicists that have been assigned to lead the work in this area have written a new revised draft of the medical triage protocol. We among others have received it. We are here making it public, setting it out below, along with related correspondence between the Ontario Human Rights Commission and Ontario Health.

4. On July 15, 2020, a number of members of Ontario Healths committee of physicians and bioethicists, assigned to lead this protocols development, held a two-hour virtual consultation with several disability community representatives, including the AODA Alliance. This is the first time the AODA Alliance had an opportunity to speak with those leading this issue for the Ford Government. We were not named on that Committees list of organizations it had consulted, or to be consulted. This virtual meeting came some three months after a senior official involved in the development of the initial protocol announced on province-wide television that it was a top priority for the Government to consult on this protocol.

As detailed further below, the disability advocates consulted at that meeting unanimously showed that the revised draft medical triage protocol still creates a real and serious danger of discrimination against patients with disabilities.

5. Ontario Healths team developing this new draft medical triage protocol aims to submit to the Ford Government its recommendation for a revised medical triage protocol by July 31, 2020. Written submissions can be sent to that team by writing [email protected] up to July 20, 2020.

6. The ARCH Disability Law Centre, which has played a tremendous leadership role on this issue, will be making a written submission by July 20, 2020 in which the AODA Alliance will contribute our input. We will make it public as quickly as we can.

3. Whats Wrong With the New Revised Draft Medical Triage Protocol?

Here is a summary of just some of the many serious problems with the revised draft medical triage protocol that is set out below.

1. This new revised draft medical triage protocol does not effectively undo the damage that the March 28, 2020 protocol caused for people with disabilities. The Government had spread that harmful earlier protocol across Ontarios health care system. Any revised protocol must fully and effectively undo that damage.

2. The draft revised protocol continues to discriminate against patients with disabilities. It includes some vague references to human rights. Those references are entirely insufficient to eliminate the discrimination that the original protocol and this revised draft protocol each cause. As but one example, the revised draft protocol, like the original one, continues to use the Clinical Frailty Scale, which itself presents real and serious disability human rights concerns. Its prominence in the protocol has been reduced but its use has not been eliminated. Whether or not there are any studies on that scale does not detract from the fact that that scale should not be used.

3. On April 14, 2020, the AODA Alliance made public a Discussion Paper on this issue. It set out clear illustrations of things that need to be spelled out in the medical triage protocol to address the risk of discrimination against patients with disabilities. The committee drafting the protocol has seen that Discussion Paper. However, the revised medical triage protocol does not include any of the Discussion Papers proposals, nor does it cure any of the harms to patients with disabilities that the Discussion Paper illustrates. The protocol should be amended to include all the specific directions and recommendations in the AODA Alliances Discussion Paper.

4. The revised draft medical triage protocol uses vague criteria that any two doctors might interpret very differently. It speaks of patients with a low probability of surviving more than a few months. One doctor might think that means 2 to 3 months. Another doctor might think that means 6 to 8 months. Its directions must be far clearer and less open to arbitrarily different applications from one doctor to the next.

5. The revised medical triage protocol uses lofty and vague language such as its references to ethics, equity, human rights, and fairness. However, those lofty terms will do nothing to stop a well-intentioned doctor or hospital from taking action that discriminates against patients with disabilities. Indeed, as is the case here, many if not most of the barriers facing people with disabilities are created without any intent to harm people with disabilities.

For example, the revised draft medical triage protocol states:

Triage decisions should treat similar cases similarly based on clinical criteria, i.e., those with similar prognoses should be treated similarly.

The medical triage protocol might thereby be meant to implement the authors notions of fairness and equality. However, this flies in the face of the Supreme Court of Canadas important ruling in its landmark decision on the meaning of equality rights, Andrews v. Law Society of British Columbia [1989] 1 SCR 143, where the Court proclaimed:

Thus, mere equality of application to similarly situated groups or individuals does not afford a realistic test for a violation of equality rights.

6. If there is a shortage of ventilators during a second wave of COVID-19, this revised draft medical triage protocol in effect creates a death panel of two doctors who will decide in an individual case in an individual hospital who gets the ventilators and who does not, among all the patients who need them. It requires no prior training on this issue for the doctors chosen to play that role. It provides no fair procedures or due process to the very patient whose life hangs in the balance. The patient and their family have no right to be heard by those deciding the patients fate. There is no assurance that the family can get their family doctor to chime in and add their voice to the discussion. There is no right of appeal to anyone else in the hospital.

There is no duty on the doctors or hospitals to give the patient or their family basic rights advice. This is so even though the revised draft medical triage protocol gives superficial and inadequate lip service to due process concerns, stating:

Due process considerations (e.g., transparency about reasons for triage decisions) are especially important in this context. Hospitals should plan for how they might proactively prepare patients and families for possible outcomes of the triage process as well as how they would respond transparently and compassionately to patient or family concerns should these arise.

Appendix E to the revised draft protocol sets out a sample of what a doctor might tell a patient and their family if it has been decided to refuse them a needed ventilator due to a ventilator shortage. That seriously deficient text gives the patient and family no rights advice or other basic information of what they can do if they wish to dispute the decision and to have it reconsidered.

The revised draft Medical triage protocol in substance wrongly and summarily rejects the idea of any appeal, stating:

critically ill patients must be assessed rapidly in a dynamic and over-taxed environment, a formal process for patients and families to appeal triage decisions may not be feasible or appropriate (e.g., if critical care is contrary to the patients wishes).

4. For More Background

* The April 7, 2020 virtual public forum on the impact of COVID-19on people with disabilities, jointly organized by the AODA Alliance and the Ontario Autism Coalition. During this event, ARCH Disability Law Centre executive director Robert Lattanzio first made public the existence of the original March 28, 2020 medical triage protocol, and the disability human rights problems that it creates.

* The April 8, 2020 open letter, spearheaded by ARCH, identifying the serious disability human rights violations in the original March 28, 2020 medical triage protocol.

* The AODA Alliances April 14, 2020 Discussion Paper on what the medical triage protocol should include. In the three months since this was made public, no negative feedback was received about its recommendations.

* The Ford Governments April 21, 2020 announcement that it would consult community and human rights experts on the medical triage protocol. It claimed that the March 28, 2020 protocol was only a draft even though it was never marked draft.

* The ARCH Disability Law Centres detailed May 13, 2020 analysis of the serious disability human rights violations, which the AODA Alliance endorses.

* To learn more about the many barriers that impede patients with disabilities in Ontarios health care system, read the AODA Alliances February 25, 2020 Framework on what the promised Health Care Accessibility Standard should include, to be enacted under the Accessibility for Ontarians with Disabilities Act.

* The AODA Alliances health care web page, to learn more about the advocacy efforts to tear down the barriers facing people with disabilities in Ontarios health care system.

* The AODA Alliances COVID-19 web page details the coalitions efforts to advocate for the needs of people with disabilities during the COVID-19 pandemic.

Below we set out:

* The second draft Critical Care Medical Triage Protocol.

* the July 7, 2020 letter from the Ontario COVID-19 Bioethics Table of Ontario Health to organizations taking part in the July 15, 2020 roundtable on the triage protocol and people with disabilities.

* the June 15, 2020 letter from Ontario Health to the Ontario Human Rights Commission

* the June 4, 2020 letter from the Ontario Human Rights Commission to Ontario Health

* the June 4, 2020 Ontario Human Rights Commission letter to the Ontario Minister of Health We always invite your feedback. Write us as [email protected]

MORE DETAILS

Text of the Revised Draft Ontario Medical Triage Protocol

Critical Care Triage for Major Surge in the COVID-19 Pandemic: Updated Recommendations

Note: This document offers recommendations developed by provincial experts in bioethics in consultation with clinical experts and informed by stakeholder feedback. It reflects best knowledge and advice at the time of writing and is subject to revision based on changing conditions and new evidence in the COVID pandemic.1

Overview:
During the COVID-19 pandemic, a major surge in demand for critical care may exceed available health system capacity. Difficult decisions would need to be made about how critical care resources should be allocated to meet patient needs. Although advanced health systems have experience with and are well-prepared to manage minor and moderate surges in demand for critical care, there is limited clinical and ethical guidance for how a major surge in demand for critical care should be managed. In Ontario, major surge is defined as: an unusually high increase in demand that overwhelms the health care resources of individual hospitals and regions for an extended period of time, where an organized response at the provincial or national level is required.2 The purpose of this document is to propose a critical care triage approach for major surge in the COVID-19 pandemic, to raise key ethical and clinical considerations for critical care triage in this context, and to offer suggestions for implementation of the critical care triage approach in the Ontario health system if needed.3

Critical care triage in the COVID-19 pandemic should aim to maximize the survival and recovery of as many critically ill patients4 as possible and as equitably as possible within available critical care resources. In a pandemic, critical care triage for major surge will inevitably involve an alternative standard of care. For this reason, critical care triage for major surge should be considered an option of last resort to be invoked only when all existing local or regional critical care resources have been used, all reasonable attempts have been made to move patients to or resources from areas with greater critical resource availability, and only for as long as the major surge lasts and would require an emergency order in order to be implemented in Ontario. When not all patient needs can be met within resource constraints, triage is the systematic and consistent process of determining priorities for treatment based on objective and explicit clinical criteria. This is especially important in the context of a major surge, when the number of patients with critical illness exceeds critical care capacity. In the absence of explicit triage criteria and a systematic and consistent process of triage, inconsistencies in clinical practice may result in increased mortality and morbidity.

Critical care triage for a major surge should be predictable and apply to an entire region rather than to individual hospitals alone. In the current COVID-19 pandemic context, the decision to initiate triage falls under the authority of, and would be made by, the Ontario Health Critical Care Command Centre with full situational awareness of the existing critical care resources and demand for critical care. In a major surge, a proportionate response to increasing and decreasing levels of demand on scarce critical care resources is essential. The degree of triage should be calibrated to the degree of demand in order to limit the possibility that a patient will be denied critical care resources unnecessarily. As critical care demand increases in a major surge, triage criteria should become proportionately more stringent; similarly, as critical care demand decreases in a major surge, triage criteria should become proportionately less stringent. Triage criteria and their application should be evaluated at regular intervals to ensure that the overarching goal of maximizing survival and recovery of critically ill patients within available critical care resources is met.

Critical care triage for major surge in the COVID-19 pandemic should be guided by ethical principles. Relevant ethical principles include medical utility, proportionality, fairness, equity, beneficence (including non-abandonment), respect for autonomy, and accountability. Respect for human rights and solidarity with all community members are key values of an ethical triage approach. In a major surge in demand for critical care resources, the necessity of critical care triage does not change the fact that the lives of all Ontarians are of equal moral worth and that all patients must be cared for and receive appropriate symptom management. Those who do not receive critical care resources due to triage should continue to receive other appropriate treatments and supports, including palliative care if needed. Importantly, critical care triage may have a differential impact on some patient populations who may be disadvantaged due to pre-existing health and social inequities or conscious or unconscious bias in clinical settings. Evidence of systemic bias against specific groups should be considered as reason to review and potentially revise these triage recommendations and their application.

Guiding Ethical Principles:
The overall purpose of a triage system in a pandemic is to minimize mortality and morbidity for a population overall as opposed to an individual mortality and morbidity risk. There are published frameworks outlining ethical principles to guide triage systems.1-4 Recent studies of Canadian perspectives on priority setting of critical care resources in a pandemic indicate a preference for maximizing the number of lives saved,5,5 followed by the application of a fair procedure for prioritization of people with similar likelihood of benefit.1,6 In addition, there is published guidance on how triage systems can minimize risk of discrimination based on factors unrelated to a patients clinical needs and mitigate discriminatory application of such frameworks in practice.6-8 This body of work informs the ethical underpinnings of the proposed triage approach.

In the context of a major surge in demand for critical care in a pandemic, the following ethical principles are foremost:

1. Medical Utility Aim to derive the maximum benefit from critical care resources by prioritizing those patients who are most likely to survive their critical illness. When resources are scarce in a pandemic, patients who are very likely to die from their critical illness or who are very likely to die in the near future7 even if they recovered from their critical illness would have a lower priority for critical care resources.
2. Proportionality Ensure that the number of individuals who are negatively affected by the use of critical care triage criteria in a pandemic does not exceed what would be required to accommodate the surge in demand. Given that critical care capacity and demand can be dynamic, access to critical care should be restricted only to the extent necessary to achieve maximum benefit within resource constraints and should become less restrictive as resources become available or the surge abates.
3. Fairness Ensure all patients have a fair chance to benefit from critical care by allocating critical care resources on the basis of clinical criteria relevant to predicting the patients likelihood of survival. Triage decisions should treat similar cases similarly based on clinical criteria, i.e., those with similar prognoses should be treated similarly. In the event that clinical criteria are not sufficient to prioritize one patient over another, a fair procedure should be used.
4. Equity and Respect for Human Rights Affirm and safeguard the equal moral worth of all people in Ontario by implementing measures to minimize the risk of perpetuating or exacerbating the effects of systemic discrimination or marginalization on access to health care8 and to uphold individual human rights to the extent possible in a pandemic emergency.9 This includes ensuring triage decisions: i) are based on objective clinical criteria grounded in best available evidence and not any particular demographic,10 disease, or disability independent of an individual patients prognosis,11 ii) involve an individual assessment of a patients clinical condition in relation to the triage criteria and not to a judgment of the individuals social value, quality of life or long-term survival, and iii) are supported by accommodations as appropriate for an individual patient to the extent possible in an infection control context (see Respect for Autonomy below).
5. Beneficence Act in a way that promotes patients well-being to the greatest extent possible given resource constraints by clarifying patient goals of care (i.e., patient wishes, beliefs, and values regarding their treatment) in relation to their critical care needs, providing continuity of care for all patients appropriate to their clinical circumstances, including those whose critical care needs cannot be met, and ensuring no patient is left without care. Although resource scarcity in a pandemic may limit the ability to meet all patient needs, maintaining a caring relationship with all patients is essential.
6. Respect for Autonomy Ensure all patients have a chance to make their goals and wishes known and to have treatment provided in alignment with these goals and wishes wherever possible. Patients (or their substitute decision-makers) may need support to make free and informed decisions about their care. To ensure effective communication and informed decision-making, individual patients may require accommodations (e.g., plain language, use of communication devices, interpretation services) and/or participation of attendant care worker or other support person to the extent possible in an infection control context.
7. Accountability Remain answerable for decisions made in the context of triage. This means communicating triage decisions, including the criteria used to make those decisions, in an open and honest manner to patients or their substitute decision-makers and to the broader community served. It also involves monitoring the implementation of the triage approach to ensure decisions are based in best clinical evidence and expertise supported by ethical reasoning. Triage decisions, criteria, and processes should be evaluated at regular intervals at local, regional and provincial levels to assess the extent to which they are clinically and ethically justified.

In a pandemic context, there is an intrinsic tension between some of the ethical principles outlined above. On the one hand, a criteria-based triage approach that focuses on an individual clinical assessment of predicted mortality and not on any other factors (demographic, quality of life, social standing, etc.) offers a defensible way to reconcile some of the tensions between the principle of medical utility (saving the most lives possible) and the principle of equity (mitigating systemic discrimination or implicit bias in health care). On the other hand, for patients who might wish but who are found ineligible for critical care in a major surge, the pandemic context creates a tension between the principles of medical utility and respect for autonomy, and underscores the importance of the principle of beneficence to ensure all patients receive care even if critical care treatment is not available. The evolving COVID pandemic context in Ontario reveals pre-existing health and social inequities in health care, which a triage approach by itself will be unable to resolve. However, the potential adverse consequences of a triage approach for vulnerable groups can be mitigated in a few ways, including: i) the systematic collection of data on triage outcomes to monitor the effect of the triage approach on vulnerable groups, and ii) proactive measures taken upstream in the community and across the health system to prevent members of vulnerable groups from exposure to COVID-19 in the first place. Some of these tensions may not be fully resolved in a pandemic. For this reason, the principles of proportionality and accountability are essential bulwarks for an ethical triage approach under difficult pandemic circumstances.

Clinical Triage Criteria for Critical Care in a Major Surge:
Explicit criteria-based triage decision-making has been recommended in other published guidance for critical care in a pandemic.12 Use of explicit criteria fosters consistency, advances medical utility and fairness, and supports accountability. It may also alleviate clinician burden at a time of high stress.13 Eligibility and ineligibility criteria are specified below based on the best available evidence and expert opinion regarding predicted mortality. A patient should meet one of the eligibility criteria and should not meet any of the ineligibility criteria for access to critical care. Where there is insufficient evidence to support a reasonable clinical judgement regarding whether a patient meets ineligibility criteria, a decision of ineligibility should be avoided. In all cases, an individualized review of each patients clinical condition should be performed, ensuring not to assume that any specific diagnosis is determinative of prognosis or near-term survival without an analysis of current and best available evidence and the individuals ability to respond to treatment. Please note: these criteria apply only to patients aged 18 years and should only be used in the context of a major surge in demand for critical care.

Eligibility criteria were outlined by Christian et al.9 and are repeated here:

Variable
Eligibility Criteria for Critical Care Admission
Requirement for invasive ventilator support
Refractory hypoxemia (SpO2 <90% on FiO2 0.85) OR
Respiratory acidosis with pH <7.2 OR
Clinical evidence of respiratory failure OR
Inability to protect or maintain airway
Hypotension
Low systolic BP (e.g., SBP <90 mm Hg for most adults) OR
relative hypotension with clinical evidence of shock (altered level of consciousness, decreased urine output, end-organ hypoperfusion), refractory to volume resuscitation requiring vasopressor/inotrope support that cannot be managed on a medical ward SpO2 = oxygen saturation as measured by pulse oximetry

Ineligibility criteria for critical care triage in a pandemic have typically fallen under two categories: (1) criteria that indicate a low probability of surviving an acute episode of critical illness, and (2) criteria that indicate a low probability of surviving more than a few months regardless of the acute episode of critical illness.9 These categories are not mutually exclusive, as life-limiting illnesses affect prognosis from acute illness, and acute illness affects the trajectory of chronic illness. The criteria outlined below would limit eligibility for critical care if someone is very likely to die from their critical illness or are very likely to die in the near future even if they recovered from their critical illness. Please note: these criteria are not exhaustive and are meant to reflect known evidence and/or clinical experience-based prognostic indicators for specific conditions. Some medical conditions not listed may also indicate a similarly poor prognosis, and such patients should be triaged accordingly. Conversely, some medical conditions listed may not indicate a poor prognosis in specific situations and such patients should not be found ineligible. Clinicians should use their best clinical judgment informed by these clinical triage criteria as appropriate to determine whether an individual patients clinical circumstances would indicate that they should receive critical care resources. The tools listed in the table below can be found in Appendix C.

Criterion
Level 1 Triage Scenario (Aiming to exclude people with >~80% predicted mortality)
Level 2 Triage Scenario (Aiming to exclude people with >~50% predicted mortality)
Level 3 Triage Scenario (Aiming to exclude people with ~>30% predicted mortality) A
Severe Trauma with predicted mortality >80% based on TRISS score Severe Trauma with predicted mortality >50% based on TRISS score Trauma with predicted mortality >30% based on TRISS score
B
Severe burns with any 2 of: Age >60, >40% total body surface area affected, inhalation injury Same as Level 1
Same as Level 1
C
Cardiac arrest
* Unwitnessed cardiac arrest
* Witnessed cardiac arrest with non-shockable rhythm
* Recurrent cardiac arrest
Same as Level 1
Cardiac arrest

D
Progressive, late or end-stage illness marked by severe cognitive impairment, clinically defined as an inability to independently perform basic activities of daily living at baseline (2-4 weeks before admission). This criterion does not refer to all conditions that cause cognitive impairment or all conditions clinically defined by an inability to independently perform basic activities of daily living – see explanatory note at end of table. Same as Level 1
Progressive, end-stage illness marked by moderate or severe cognitive impairment, clinically defined as an inability to independently perform multiple instrumental activities of daily living (IADLs – e.g., finances, medications, transportation) or any of the basic activities of daily living (BADLs – e.g., bathing, dressing, feeding) at baseline (2-4 weeks before admission). This criterion does not refer to all conditions that cause cognitive impairment or all conditions clinically defined by an inability to independently perform instrumental or basic activities of daily living – see explanatory note at end of table. E
Progressive, end-stage neurodegenerative disease
Same as Level 1
Progressive neurodegenerative disease
F
Metastatic malignant disease with any of the following:
* ECOG class >=2
* Disease progressing or stable on treatment
* Active treatment plan with >80% predicted mortality during or soon after critical illness * Unproven (experimental) treatment plan
* Treatment plan that would only be started if the patient recovers from critical illness Metastatic malignant disease with any of the following:
* ECOG class >=2
* Disease progressing or stable on treatment
* Active treatment plan with >50% predicted mortality during or soon after critical illness * Unproven (experimental) treatment plan
* Treatment plan that would only be started if the patient recovers from critical illness Metastatic malignant disease
G
Advanced and irreversible immunocompromised
Same as Level 1
Same as Level 1
H
Severe and irreversible neurologic event with >80% risk of death or poor outcome based on: * For Intracerebral Hemorrhage a modified ICH score of 4-7
* For Subarachnoid Hemorrhage, a WFNS grade 5 (GCS 3-6)
* For Traumatic Brain Injury, the IMPACT score
* Acute ischemic stroke alone would not be excluded at this level
Severe and irreversible neurologic event with >50% risk of death or poor outcome based on: * For Intracerebral Hemorrhage a modified ICH score of 3-7
* For Subarachnoid Hemorrhage, a WFNS grade 3-5
(GCS 3-12 OR GCS 13-14 AND focal neurological deficits)
* For Traumatic Brain Injury, the IMPACT score
* For acute ischemic stroke, an NIHSS of 22-42.
Irreversible neurologic event/condition with >30% risk of death or poor outcome based on: * For Intracerebral Hemorrhage a modified ICH score of 2-7
* For Subarachnoid Hemorrhage, a WFNS grade 2-5 (GCS <15)
* For Traumatic Brain Injury, the IMPACT score
* For acute ischemic stroke, an NIHSS of 14-42.
I
End-stage organ failure meeting the following criteria:
Heart
* Chronic End-stage Heart Failure with NYHA Class 4 symptoms, ineligible for advanced therapies (mechanical support, transplant) Lung
* COPD with chronic home O2 >12h per day or breathlessness at rest
* Cystic Fibrosis with FEV1 <20% predicted when measured at time of clinical stability
* Pulmonary fibrosis with VC or TLC <60% predicted, baseline PaO2 <55 mmHg, or secondary pulmonary hypertension * For pulmonary hypertension, anyone with ESC/ERS high risk criteria (see below) Liver
* Chronic Liver Disease with failure of 2 or more organ systems (ACLF Grades 2-3) * MELD score >=25

Note that patients who meet these criteria may be eligible for ICU admission if they are currently on an organ donation waiting list and would be given highest priority if admitted to ICU (e.g., status 4/4F for liver transplantation). This does not include people who have been referred to a transplant service but have not yet been listed for a transplantation. This also would not apply if organ donation processes are halted due to triage conditions precluding organ procurement. End-stage organ failure meeting the following criteria:
Heart
* Chronic End-stage Heart Failure with NYHA Class 3 or 4 symptoms, ineligible for advanced therapies (mechanical support, transplant) PLUS any of: o High/increasing BNP
o Cardiorenal syndrome
o Recent discharge (<30d) or multiple admissions for CHF in past 6 months Lung
* COPD with
o Chronic home O2 OR
o >=1 admission for COPD in past 12 months AND has to stop for shortness of breath when walking at own pace
* Cystic Fibrosis with FEV1 <20% predicted when measured at time of clinical stability
* Pulmonary fibrosis with VC or TLC <60% predicted, baseline PaO2 <55 mmHg, or secondary pulmonary hypertension * For pulmonary hypertension, anyone with ESC/ERS high risk criteria (see below) Liver
* Chronic Liver Disease with failure of 1 or more organ systems (ACLF Grades 1-3) * MELD score >=15

Note that patients who meet these criteria may be eligible for ICU admission if they are currently on an organ donation waiting list and would be given highest priority if admitted to ICU (e.g., status 4/4F for liver transplantation). This does not include people who have been referred to a transplant service but have not yet been listed for a transplantation. This also would not apply if organ donation processes are halted due to triage conditions precluding organ procurement.
End-stage organ failure with one-year mortality risk >30% as suggested by an unscheduled admission for an exacerbation or complication of their chronic illness in the past 12 months or previous organ transplant with evidence of chronic rejection or chronic organ dysfunction in the transplanted organ. Note that some admissions (e.g., catheter or access infections) may not suggest an elevated risk of mortality, and for some less common conditions (e.g., CF) unscheduled admissions may not suggest an elevated risk of mortality and specialist input should be sought. J
Anyone with a Clinical Frailty Score of >=7 (on the 9-point tool) at baseline (2-4 weeks before admission) due to a progressive illness or generalized deterioration of health status (see explanatory note at end of table)
Anyone with a Clinical Frailty Score of >=5 (on the 9-point tool) at baseline (2-4 weeks before admission) due to a progressive illness or generalized deterioration of health status (see explanatory note at end of table) Same as Level 2
K
Elective palliative surgery
Same as Level 1
Elective or emergency palliative surgery
L
Anyone receiving mechanical ventilation for >=14 days with a ProVent score of 4-5.
Anyone receiving mechanical ventilation for >=14 days with a ProVent score of 2-5. Anyone receiving mechanical ventilation for >=14 days who is not improving M
Any other clinical condition that is judged to have a >80% chance of mortality during or soon after critical illness
Any other clinical condition that is judged to have a >50% chance of mortality during or soon after critical illness
Any other clinical condition that is judged to have a >30% chance of mortality during or soon after critical illness Explanatory Note:
Criterion D (progressive, end-stage illness marked by severe cognitive impairment) and criterion J (clinical frailty due to a progressive illness or generalized deterioration of health status) would be relevant ineligibility criteria for progressive and life-limiting conditions, such as Alzheimers disease or high level of multi-morbidity, which are known to be associated with a higher risk of mortality during or soon after an episode of critical illness.10 By contrast, criterion D and criterion J would not be ineligibility criteria for non-progressive conditions with cognitive impairment, clinical frailty, or dependency, such as developmental disability, spinal cord injury, or traumatic brain injury, because these are not necessarily associated with a higher risk of death during or soon after an episode of critical illness. To be clear, the clinical focus of critical care triage decision in major surge should be on the prognosis (predicted mortality) of the individual in question and not any particular demography, disease or disability. The clinical criteria are not intended to exclude nor to deprioritize all people with clinical frailty, multimorbidity, and cognitive impairment or all individuals with a given diagnosis.

Additional Considerations at Level 3:
At Level 3, only patients with the lowest risk of death in the near future would be eligible for critical care. However, if demand for critical care continues to exceed available resources, there may come a point where there may be little clinical evidence to guide triage decisions on the basis of medical utility.14 As a result, triage decisions must appeal to fairness.

Fairness would suggest that those patients who are already receiving critical care and are benefiting from it should continue to receive it. In other words, demand for critical care from new patients does not justify withdrawing life-sustaining measures from admitted patients with a similar prospect of benefitting from them. Decisions to withdraw life-sustaining measures from someone already admitted to critical care should be driven by clinical considerations. In practice, this would involve a frequent reassessment of admitted patients by the clinical team for any indication that the patient is no longer responding to treatment, or where the patients clinical trajectory suggests that their chances of recovery have substantially worsened from when they were admitted. It is important to reiterate that a decision to withdraw critical care should be based solely on clinical considerations, integrating all relevant information, and not on any demography, disease, or disability, or other factors. As with all triage decisions, such patients should be referred for a second opinion to confirm the assessment (i.e., that the persons chance of survival is poor).

Fairness would also suggest that, when an opportunity emerges to admit a new patient into critical care and a triage decision must be made between multiple patients who cannot be distinguished on the basis of medical utility (i.e., all meet an eligibility criterion and do not meet any ineligibility criteria), then a system of random selection among eligible and not-yet-admitted patients should be implemented. Random selection upholds the principle of fairness in situations where it is not possible to rely on medical utility to make clinical decisions.15 It mitigates against the potential of explicit or unconscious bias in decision-making and demonstrates the value of humility when uncertainty is high. Random selection also has other advantages as a decision-making strategy in the context of an overwhelming surge of critically ill patients: it is already a well-established practice for making decisions in situations of uncertainty or equipoise in medicine (e.g., randomized controlled trials); it reduces the moral and psychological burden of deciding who receives life-saving treatment, which can lead to moral injury and burnout after repeated cases; it is efficient when decisions need to be made rapidly; and it allows for procedural transparency and accountability. When decisions are made through random selection, this should be done with one or more witnesses, and a record of the outcome of the process of randomization should be documented.

Critical Care Triage Approach:
Critical care triage for major surge in a pandemic should be well-coordinated, consistent, predictable, and responsive to an evolving pandemic context.16 A three-level triage approach is proposed. A proportionate response to increasing levels of demand on scarce resources is essential. As system pressures increase, triage criteria become proportionately more stringent. The degree of triage should be calibrated to the degree of demand in order to limit the possibility that a patient will be denied critical care resources unnecessarily.

In the current COVID-19 pandemic context, the decision to initiate critical care triage for major surge would fall under the authority of, and would be made by, the provincial Critical Care Command Centre with full situational awareness of existing critical care resources and demands. Each hospital should be aware of the precise number of critically ill and mechanically-ventilated patients they can accommodate with their resources (including consumables), staff, and space. The timing and degree of the surge in demand is likely to be variable in different institutions and regions, so as one hospital or region approaches their maximum capacity, significant efforts should be taken to transfer patients to, or resources from, hospitals with lower occupancy to ensure that all resources are maximally used prior to the initiation of critical care triage for major surge. This will also reduce the chances that some patients will be denied critical care resources that they would have received had they been in another hospital. When all hospitals in a region are near their capacity, or when transportation resources are no longer able to move patients to hospitals with lower occupancy, Provincial and Regional Critical Care Command Centres should clearly inform these hospitals that a major surge scenario is impending. Major surge in demand may be intermittent, requiring a regular review (e.g., every 12 hours) of occupancy to determine whether the triage protocol is still required or whether hospitals can decrease the level of triage.

The prospect of a major surge in demand for critical care should prompt discussions with patients or their substitute decision-maker to identify and document patient wishes and values and ensure current treatment plans are up to date. It is also appropriate for physicians and other healthcare providers to engage in advance care planning conversations with patients/SDMs in hospital or in community settings to explore the patients wishes and values and to clarity the treatment goals and options available if the patient were to become acutely or critically ill. Regardless of triage decisions at any level, all efforts should be made to treat patients supportively and to ensure all patients receive the right care, in the right place, at the right time to the greatest extent possible during the COVID pandemic.

If a major surge is imminent (but before level 1 triage is initiated), all patients who are currently receiving critical care resources should be reviewed, and those who would be excluded under a level 1 triage scenario should be identified in advance and they (or their substitute decision-makers) should be informed of the situation if possible. When a level 1 triage scenario has been initiated, these patients should begin to have life-sustaining measures withdrawn and be transferred to non-critical care beds, with appropriate palliative measures initiated (or other measures in accordance with the patients values, beliefs, and wishes). All patients need not have life-sustaining measures withdrawn at once. Rather, life-sustaining measures should be withdrawn sequentially starting with those patients who meet the greatest number of ineligibility criteria. Withdrawal of life-sustaining measures should be in proportion to demand and operational capacities. Each hospital should communicate the number of patients who would no longer receive critical care in a level 1 scenario to their Regional Critical Care Command Centre to assist with planning and coordination provincially. All new patients who develop critical illness in a level 1 triage scenario should be assessed against the level 1 criteria before receiving critical care resources.

If major surge escalates, all patients in their critical care beds who would be ineligible for critical care under a level 2 triage scenario should be identified and they (or their substitute decision-makers) should be informed that level 2 triage is imminent. The regional critical care command centre should continue to coordinate transportation of patients to optimize the utilization of all critical care resources before initiating a level 2 triage. If a level 2 triage scenario is initiated, hospitals should proceed in a similar manner to the steps described above. All new patients who develop critical illness after a level 2 triage scenario should be assessed against the level 2 criteria before receiving critical care resources. Hospitals should then prepare for a level 3 triage scenario, similar to the previous steps. Based on the principle of proportionality, the number of patients denied access to or withdrawn from critical care should not be more than the incoming demand requires based on the current and expected surge of critically ill patients. This means that triage levels should go up or down in relation to demand and should continue only as long as the major surge persists to minimize mortality and morbidity.

A. Triage in Hospital: Suggestions for Implementation
The triage approach recommended in this document may be implemented differently depending on the resources available to the hospital and the region in question, which may fluctuate over the course of the pandemic. Appreciating that the implementation of this approach will vary to some degree based on available human resources and other contextual factors at individual institutions, the following suggestions offer a starting point for local and regional planning.

1. Triage Process
In general, the triage process comprises four steps. This process represents an ideal, which may need to be modified to suit specific settings.

Step 1: Clarify Patient Goals of Care and Inform Patient/Family of Change in Standard of Care Due to Major Surge
In general, regardless of whether or not triage has been implemented, when a patient is admitted to hospital or assessed in the Emergency Department, the most responsible physician/most responsible provider (MRP) should explore the patients goals and aim to develop a plan of care that reflects those goals and respects the limitations of medical care. If the patient indicates a preference to receive life-sustaining measures in the event of clinical deterioration, but the MRP feels that this is not appropriate given the patients medical condition, the MRP should explain this and propose a less aggressive treatment approach. If a person expresses a desire not to receive life-sustaining treatment in the event of clinical deterioration, this should be recorded in the chart and the patient should not be referred for critical care. At this time, the patient or substitute decision-maker should also be informed that the hospital is moving towards triage and that the standard of care may be altered, including strict allocation of critical care based on the approach recommended in this document.

Step 2: Assess Patient Against Triage Criteria
Once the triage approach has been implemented, if an admitted patient meets (or is close to meeting) the eligibility criteria, provided that there is no order to withhold life-sustaining measures, the MRP should assess the patient to determine whether they meet the eligibility criteria and whether they meet any of the ineligibility criteria for the level of triage. A second physician, who would ideally be a member of the critical care team, rapid response team (RRT), or a designated triage physician, should verify whether the patient meets the eligibility and/or ineligibility criteria. Ideally, disagreements about eligibility/ineligibility criteria should be resolved by consensus of the two physicians who assessed the patient if possible. The patients triage assessment should be documented in the health record.

Step 3: Referral of Case to Triage Team
Following this assessment, the MRP should communicate the assessment to the hospital or regional triage team, who will review the decision. The triage team may also help to resolve any disagreement about whether the patient meets eligibility/ineligibility criteria. The triage team should confirm that, under the triage approach, admission to critical care will or will not be provided based on current critical care capacity. For clarity, the MRP has the clinical responsibility for determining whether the patient meets the eligibility and ineligibility criteria. The health care system, through the implementation of the triage approach, takes responsibility for determining that they cannot offer admission to critical care. The triage team is ultimately responsible for making decisions regarding the allocation of critical care resources according to the approved criteria for the appropriate level of surge (Level 1, 2, 3).

Step 4: Communication with Patients and Family/Substitute Decision-Maker(s)
The MRP will communicate the outcome of the triage decision (i.e., whether or not the patient will be admitted to critical care) to the patient or substitute decision-maker (see Appendix B for suggested language to disclose a triage decision), with support from other members of the interprofessional team (social work, spiritual care, etc.). The MRP will document the decision in the patients medical record. The MRP should continue to offer all other indicated medical treatments and write comfort orders to ensure that the patient receives appropriate palliative care (see Appendix D for suggested comfort medication orders).

Additional suggestions for implementation at the institutional level, including policies, tools, descriptions of roles and responsibilities of triage teams, and communications suggestions, have been developed by Hamilton Health Sciences and can be accessed here: https://macdrop.mcmaster.ca/s/PoGMyw848Wipz88

2. Triage Team
Triage teams have been recommended in other published guidance to support consistent, evidence-based and accountable decisions about the use of critical care resources in the context of a pandemic surge.17 Triage teams may be institution-based or regional. Suggestions for triage team roles and responsibilities can be found here: https://macdrop.mcmaster.ca/s/PoGMyw848Wipz88.

3. Patient and Public Communication
In the context of the COVID-19 pandemic, transparency is key to maintaining patient and public trust. This includes being transparent about why critical care triage may be needed in major surge, how triage decisions will be made and by whom, when an institution or region has initiated critical care triage for major surge, and how patients will be supported during this difficult time. Patient and public-facing communication materials (e.g., signage, information sheets) will be essential. Suggestions for how to communicate triage decisions to patients (or their substitute decision-maker) can be found in Appendix E. To ensure effective communication, some patients may require accommodated communication (e.g., plain language, use of communication devices) and access to interpretation services. Attendant care workers or other personal support persons may play essential roles in informing individual treatment plans and advising on an individual patients clinical history and functional status. This may require accommodation within institutional visitor policies to the extent possible to comply with infection control guidelines.

4. Clinician Support
Critical care triage in a major surge will entail a significant cognitive, psychological, and moral burden on clinicians and underlines the need to support and prepare critical care clinicians for major surge in advance. Clinical guidance, including explicit triage criteria, institutional supports, such as triage teams, and assurance of legal protection will go some distance to support clinicians. Additional clinician supports identified in stakeholder feedback include: i) education and training about the critical care triage approach for critical care teams, ii) creation of decision support tools, e.g., translating the critical care triage criteria into an accessible format for ease of use in clinical practice, iii) guidelines for emergency department staff and EMS, and iv) general information for clinicians in other clinical areas and settings about the critical care triage approach to foster effective collaboration among clinical teams.

5. Dispute Resolution
Disagreement amongst clinicians may arise regarding the eligibility/ineligibility of a patient for critical care. Although consensus-based decision-making is ideal, a mechanism for resolving disagreement may be needed. Options for dispute resolution may include additional consultation with appropriate medical specialists or discussion with the Triage Team. Where a patient/family disagrees with the outcome of a triage decision, the Triage Team may assist the MRP in communicating the rationale for their resource allocation decision, and the process by which triage decisions are made. Other members of the interprofessional team (e.g., social work, spiritual care, patient experience specialists, bioethicist, etc.) may also assist in supporting patients and families who are distressed by the outcome of the triage process. Given the context of critical care triage in a major surge, where an overwhelming number of critically ill patients must be assessed rapidly in a dynamic and over-taxed environment, a formal process for patients and families to appeal triage decisions may not be feasible or appropriate (e.g., if critical care is contrary to the patients wishes). Due process considerations (e.g., transparency about reasons for triage decisions) are especially important in this context. Hospitals should plan for how they might proactively prepare patients and families for possible outcomes of the triage process as well as how they would respond transparently and compassionately to patient or family concerns should these arise.

Concluding Recommendations:
The COVID-19 pandemic presents new challenges for the Ontario health system about how health resources will be used to meet patient and population needs. At time of writing, there is limited guidance for health systems about how a major surge in demand for critical care should be managed in a pandemic context. This document offers recommendations to inform the creation of a critical care triage approach in Ontario based on clinical and ethical considerations in the event of a major surge in demand for critical care in the COVID-19 pandemic. Given the novelty of this approach and its broader significance for all Ontarians, we offer two additional recommendations related to next steps for development of this work.

1. Communicating with the public: Transparency is key to maintaining public trust during a pandemic. Years of risk and outbreak communication science show that the public will support measures when transparency is the default setting for governments dealing with public health emergencies and when considerations of fairness have been addressed. In the context of critical care triage in a pandemic, this includes being transparent about: i) the need for these triage criteria and the accompanying legal powers needed to implement them in a public health emergency; ii) the ethical basis for the triage criteria (i.e., minimizing morbidity and mortality); and iii) the process through which the criteria were developed (i.e., based on consultations with a broad array of stakeholders). It is therefore recommended that this document be made public available and that any communication includes the ethical basis and process for the development of these recommendations.

2. Monitoring and iterative review of the approach: Given limited experience with critical care triage for major surge, it will be important to monitor, review and revise the approach to ensure it is achieving the aim for which it is intended (i.e., to maximize survival and recovery from critical illness of as many patients as possible within critical care resources in a major surge) and is not leading to unintended adverse consequences. This underlines the need for clear and consistent documentation practices across hospitals, the prospective capture of relevant clinical and other data about triage decisions, and a mechanism for mid-course correction that is nimble, transparent and accountable. This aligns closely with other calls for equity-related data collection to understand the impact of pandemic interventions on patients, particularly those who are marginalized in health care and may face systemic disadvantage for other reasons, and to mitigate negative impacts to the extent possible within the pandemic context.

References
1. Winsor S, Bensimon CM, Sibbald R, et al. Identifying prioritization criteria to supplement critical care triage protocols for the allocation of ventilators during a pandemic influenza. Healthc Q. 2014;17(2):44-51.
2. Frolic A, Kata A, Kraus P. Development of a critical care triage protocol for pandemic influenza: integrating ethics, evidence and effectiveness. Healthc Q. 2009;12(4):54-62.
3. RC. M, J. D, JR. D, et al. Triage of scarce critical care resources in COVID-19: an implementation guide for regional allocation: An expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest. 2020.
4. Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza. http://jcb.utoronto.ca/news/documents/pandemic_Stand-on-guard-for-thee_report_JCB2005.pdf Accessed Mar 25, 2020.
5. Ritvo P, Perez DF, Wilson K, et al. Canadian national surveys on pandemic influenza preparations: pre-pandemic and peri-pandemic findings. BMC Public Health. 2013;13:271.
6. Applying HHSs Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. https://dredf.org/avoiding-disability-based-discrimination-in-treatment-rationing/. Accessed April 12, 2020.
7. Evaluation Framework for Crisis Standard of Care Plans. http://www.bazelon.org/wp-content/uploads/2020/04/4-9-20-Evaluation-framework-for-crisis-standards-of-care-plans_final.pdf. Accessed April 12, 2020.
8. Kirby J. Enhancing the fairness of pandemic critical care triage. J Med Ethics. 2010;36(12):758-761.
9. Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
10. Brummel NE, Bell SP, Girard TD, et al. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med. 2017;196(1):64-72.
11. Shahpori R, Stelfox HT, Doig CJ, Boiteau PJ, Zygun DA. Sequential Organ Failure Assessment in H1N1 pandemic planning. Crit Care Med. 2011;39(4):827-832.
12. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020.
13. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020.
14. Christian MD, Toltzis P, Kanter RK, et al. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S109-119.
15. Antommaria AH, Powell T, Miller JE, Christian MD, Task Force for Pediatric Emergency Mass Critical C. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S163-168.
16. Gall C, Wetzel R, Kolker A, Kanter RK, Toltzis P. Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds. Crit Care Med. 2016;44(9):1762-1768.
17. Christian MD, Toltzis P, Kanter RK, Burkle FM, Jr., Vernon DD, Kissoon N. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S109-119.
18. Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175(11):1377-1381.
19. Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1(1):5.
20. Darmon M, Bourmaud A, Georges Q, et al. Changes in critically ill cancer patients’ short-term outcome over the last decades: results of systematic review with meta-analysis on individual data. Intensive Care Med. 2019;45(7):977-987.
21. Karvellas CJ, Garcia-Lopez E, Fernandez J, et al. Dynamic Prognostication in Critically Ill Cirrhotic Patients With Multiorgan Failure in ICUs in Europe and North America: A Multicenter Analysis. Crit Care Med. 2018;46(11):1783-1791.
22. Kylhammar D, Kjellstrom B, Hjalmarsson C, et al. A comprehensive risk stratification at early follow-up determines prognosis in pulmonary arterial hypertension. Eur Heart J. 2018;39(47):4175-4181.
23. Hemphill JC, 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897.
24. Fonarow GC, Saver JL, Smith EE, et al. Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke. J Am Heart Assoc. 2012;1(1):42-50.
25. Roozenbeek B, Lingsma HF, Lecky FE, et al. Prediction of outcome after moderate and severe traumatic brain injury: external validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models. Crit Care Med. 2012;40(5):1609-1617.
26. Fernando SM, McIsaac DI, Rochwerg B, et al. Frailty and associated outcomes and resource utilization following in-hospital cardiac arrest. Resuscitation. 2020;146:138-144.
27. Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105-1122.
28. Carson SS, Garrett J, Hanson LC, et al. A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation. Crit Care Med. 2008;36(7):2061-2069.
29. Leroy G, Devos P, Lambiotte F, Thevenin D, Leroy O. One-year mortality in patients requiring prolonged mechanical ventilation: multicenter evaluation of the ProVent score. Crit Care. 2014;18(4):R155.
30. Udeh CI, Hadder B, Udeh BL. Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation. Ann Am Thorac Soc. 2015;12(12):1845-1851.
31. Steiner T, Juvela S, Unterberg A, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013;35(2):93-112.
32. Hernaez R, Sola E, Moreau R, Gines P. Acute-on-chronic liver failure: an update. Gut. 2017;66(3):541-553.

Silva DS, Gibson JL, Robertson A, et al. Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public’s perspectives. BMC Public Health 2012; 12:241. https://doi.org/10.1186/1471-2458-12-241

Truog RD, Mitchell C, Daley GQ. The toughest triageallocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article

Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e-e74S.

Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.

Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. Hastings Center Report 2020; Apr 2. Available at: https://www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/

Appendix A. Backgrounder: Development of the Recommendations

This document was developed by the Bioethics Table based on a review of the literature on critical care triage in a pandemic, consultation with clinical experts, and feedback from health system stakeholders. Feedback has been addressed to the greatest extent possible in this current version where appropriate. This recommendations document is a green document within the overall 2020 COVID pandemic response in Ontario. It is acknowledged that the process for developing an approach to critical care triage in the context of a major surge in demand should remain sensitive and responsive to changing conditions and emerging evidence, and as such, should be on-going.

Development of Critical Care Triage Criteria
Early work on pandemic critical care triage was led by researchers in Ontario following the SARS outbreak and in developing provincial and national pandemic plans in the years leading up to the H1N1 pandemic. 9 At that time, critical care triage criteria using sequential organ failure assessment (SOFA) scores, which help to predict clinical outcomes (acuity and morality risk) of critically ill patients, was proposed. Over the last decade, a number of clinical developments, including novel therapies and new research evidence, have precipitated the need for an updated approach to critical care triage criteria in a pandemic context.

Below we outline the key considerations contributing to the updated critical care triage criteria outlined in this document:
* With greater experience, most experts no longer recommend the use of SOFA scores to prioritize patients in a pandemic context because the correlation with outcomes is not as strong as was previously believed. Many young patients are admitted with severe illness but ultimately survive, and the severity of acute illness does not imply greater or lower utility of treatment.
* Advances in clinical management of cancer mean that some individuals with metastatic cancer, who previously would have not benefited from intensive care support, have a reasonable expectation of surviving an ICU admission and living for years.19,20
* Critical care medicine is better able to prognosticate for patients with some types of chronic organ disease who develop critical illness, such as people with chronic liver disease using the Acute on Chronic Liver Failure (ACLF) grading system.21
* Organ donation has become more common and may offer substantial life prolongation for people with organ failure. Selected patients who are admitted to the ICU and assigned the highest priority for organ transplantation have a reasonably high expectation of receiving an organ and surviving to discharge. This would mean that anyone who is immediately postoperative from an organ transplant should not be denied ICU admission. However, patients who are being referred for ICU admission while awaiting an organ should only be admitted if organ transplantation is still proceeding (and this may not be the case if people who would be eligible for organ donation after neurological or circulatory death are not being admitted to the ICU) and they are assigned the highest priority for an organ transplant
* Critical care medicine has better prognostication tools for neurological injury, including: o For subarachnoid hemorrhage, the WFNS system.22
o For intracerebral hemorrhage, the ICH score.23
o For acute ischemic stroke, the NIH Stroke Scale.24
o For moderate or severe traumatic brain injury, the IMPACT score.25
* Clinical research indicates that age may be less relevant to predicting mortality than frailty, multimorbidity, or neurodegenerative disease.10,26,27 The Clinical Frailty Score is currently in widespread use throughout the healthcare system.
* There is also a greater appreciation of the concept of chronic critical illness, and the ability to identify ICU patients who have survived their acute illness but who are still requiring mechanical ventilation after 2 weeks and very unlikely to survive to a year using predictive tools such as the ProVent score.28-30

The critical care triage criteria were developed iteratively in consultation with Canadian medical experts representing specialties including critical care, emergency medicine, neurology, geriatrics, oncology, cardiology, nephrology, respirology, neurosurgery, hepatology, palliative care, and internal medicine in March and April 2020.

Appendix B: The Ontario Human Rights Code Prohibited Grounds of Discrimination

The Ontario Human Rights Code recognizes that discrimination occurs most often because of a person’s membership in a particular group in society. None of the grounds below should influence the allocation of critical care or medical resources; triage decisions should be based solely on the criteria included in this document.

The Code prohibits actions that discriminate against people based on a protected ground in a protected social area. Protected grounds relevant to the health care context include: * Age
* Ancestry, colour, race
* Citizenship
* Ethnic origin
* Place of origin
* Creed
* Disability
* Family status
* Marital status (including single status)
* Gender identity, gender expression
* Sex
* Sexual orientation

Appendix C. Triage Criteria Tools

TRISS Score Calculator
https://www.mdapp.co/trauma-injury-severity-score-triss-calculator-277/

Clinical Frailty Scale (Rockwood et al)
The CFS is only considered relevant in this triage approach when used to evaluate predicted mortality due to progressive illness or generalized deterioration in health status. (Adapted from: Leonardi, Bueno, Ahrens et al. (2018). Optimised care of elderly patients with acute coronary syndrome. European Heart Journal: Acute Cardiovascular Care. 7. 204887261876162. 10.1177/2048872618761621.) For a training module on the use of CFS, go to: https://rise.articulate.com/share/deb4rT02lvONbq4AfcMNRUudcd6QMts3#/

ProVent Score- calculated at 14 days:
One point for each of Age >50, platelet count <150, requiring hemodialysis, and requiring vasopressors. An additional point is given for age >=65, for a maximum score of 5. Scores of 4-5
at 14 days suggest a mortality rate of ~90% at 1 year. Scores of 2-3 at 14 days suggest a mortality rate of 56-80% at 1 year30.

Modified ICH Score23:
One point each for age >80, infratentorial origin, volume >30mL, intraventricular extension, use of oral anticoagulants, and Glasgow Coma Score of 5-12. Two points for a GCS of 3-4. Scores of 4-7 suggest a 30-day mortality rate of >80%. Scores of 3-7 suggest a mortality rate of >60%.

The World Federation of Neurological Surgeons grading system:
A combination of Glasgow Coma Score (GCS) and the presence or absence of focal neurological deficits31. A WFNS grade 5 (GCS 3-6) is associated with a >90% probability of a poor outcome. Grades 3-4 (GCS 7-12 or GCS 13-14 AND focal neurological deficits) are associated with a >50% probability of a poor outcome. Grade 2 (GCS 14 with no neurological deficits) is associated with a ~30% probability of a poor outcome.

National Institute of Health Stroke Scale (NIHSS): score 0-7 is associated with a 30-day mortality of 4.2%; 8-13 with a 30d mortality of 13.9%; 14-21 with a 30d mortality of 31.6%; and 22-42 with a 30d mortality of 53.5%24:.

The IMPACT Score25 predicts outcome at 6-months based on multiple demographic, clinical and radiographical factors using the calculator found at http://www.tbi-impact.org/?p=impact/calc

The ACLF grading system is based on the number of organ systems failing at the time of admission in a patient with chronic liver disease. Patients with more than 2 organ systems failing on presentation (ACLF Grades 2 and 3) have an >=80% risk of mortality at 6 months32. Those with ACLF Grade 1 have an approximately 50% mortality at 6 months32; ACLF grade 1 is defined as having chronic liver failure plus ONE of the following: * Creatinine >177 umol/L (2.0 mg/dL)
* Creatinine >132 umol/L (1.5 mg/dL) AND Hepatic encephalopathy grade 3-4
* Creatinine >132 umol/L (1.5 mg/dL) OR Hepatic encephalopathy grade 1-2 AND ONE OF: o Bilirbin >200umol/L (12mg/dL)
o INR >2.5
o pressor support required
o PaO2/FiO2 <200

For pulmonary hypertension, the ECS/ERS High Risk Criteria are22: * WHO Class 4 symptoms
* 6MWT <165m
* NT pro-BNP >1400 ng/L
* RA area >26 cm2
* RAP >14 mmHg
* CI <2.0 L/min/m2
* SvO2 <60%

Appendix D. Suggested order set for symptom management for COVID-19 patients (adapted with permission from Champlain Palliative Symptom Management Medication Order Form – Long Term Care)

Symptom
Medications
Recommended starting dose
Pain/Dyspnea
Hydromorphone 2mg/ml
0.5-1.0 mg SC q30min PRN*
Nausea/Delirium
Haloperidol 5mg/ml
1 mg subcut q2hourly
PRN **
Sedation
Midazolam 5 mg/ml
1-2 mg subcut q15 minutes PRN ***
Secretions
Scopolamine 0.4 mg/ml
0.4 mg subcut q4hourly PRN
Fever
Acetaminophen 650 mg suppositories
Administer q6hourly PR PRN
Urinary retention
Foley catheter 16 Fr
Insert catheter PRN
Dry mouth
Mouth swabs
Mouth care QID and PRNPlease call MD if patient receives more than 2 PRN of hydromorphone in 4 hours.

* may start at 0.25mg in a patient who is opioid naive, frail, or elderly ** relative contraindication in Parkinsons disease
*** can use higher doses for refractory dyspnea

Appendix E. Suggested language for clinicians providing support to a patient or family member who is denied critical care in the context of a major surge in demand for critical care resources

Template 1.
Normally, when somebody develops critical illness, the medical team would offer them intensive care (a combination of medications and machines to support their vital organs), provided that the medical team feels that they had a reasonable chance of survival. However, because of the COVID outbreak, we are currently unable to offer intensive care to everyone who is critically ill. As a result, our hospital is working under triage guidelines, which means that we are only offering intensive care to those who are most likely to be able to survive and recover from their critical illness. You probably have heard about this in the news all hospitals in the region are working under these guidelines.

I regret to inform you that we are unable to offer you intensive care treatments at this time, as a result of the triage guidelines. Because of your medical condition, the likelihood that you would survive even with intensive care is considered to be too low for us to offer intensive care. The team has made this decision based on the following information:__________________.

I have also asked for a second opinion from a colleague, Dr. ___________, who has concurred with my assessment. You may speak with him/her if you wish.

I am deeply sorry about this situation. This is not the way we ordinarily make these decisions, and I can only imagine how you must feel right now. I want you to know that even though we cannot offer intensive care, we will do everything else that could conceivably give you a chance of recovering, including: _________.

And I promise you that, no matter what, we will also use medication to treat any discomfort, such as pain or shortness of breath. We know that when we treat discomfort appropriately, this is not harmful and may actually help improve your condition.

Template 2.
As you know, you/your loved one has been receiving treatment in our Intensive Care Unit. Normally, when somebody is admitted to our Intensive Care Unit, the medical team continues to offer them intensive care until they recover, or it becomes apparent that there is no reasonable chance that they could recover even with continued intensive care. However, because of the COVID outbreak, we are currently unable to offer intensive care to everyone who is critically ill. As a result, our hospital is working under triage guidelines, which means that we are only offering to provide or continue intensive care for those who are most likely to be able to survive and recover from their critical illness. You probably have heard about this in the news all hospitals in the region are working under these guidelines.

I regret to inform you that we are unable to continue giving you/your loved one intensive care treatments at this time, as a result of the triage guidelines. Because of your medical condition, the likelihood that you would survive and recover even with continued intensive care is too low for us to offer intensive care. I have made this decision based on the following information:

[Either document the specific ineligibility criterion met by the patient, or a brief explanation for concluding that this person?s chances of survival fall below the threshold indicated in the triage document]

I have also asked for a second opinion from a colleague, Dr. ___________, who has concurred with my assessment. You may speak with him/her if you wish.

I am deeply sorry about this situation. This is not the way we ordinarily make these decisions, and I can only imagine how you must feel right now. I want you to know that even though we cannot continue intensive care, we will continue other therapies, including:

And I promise you that, no matter what, we will also use medication to treat any discomfort, such as pain or shortness of breath.We know that when we treat discomfort appropriately, this is not harmful and may actually help improve your condition. We have guidelines for how to keep people comfortable when we discontinue life-sustaining measures, and we will use those guidelines.

Text of July 7, 2020 Letter from Ontario Healths Medical Triage Protocol Committee to Disability Community Roundtable Participants

To: Roundtable Participants
From: Ontario COVID-19 Bioethics Table
Date: July 7, 2020
Re: Input on DRAFT / updated recommendations for critical care triage in the COVID-19 pandemic

Thank you for agreeing to meet with us. Attached please find updated draft recommendations for critical care triage in the COVID-19 pandemic for your review and feedback.

In March 2020, the COVID-19 Bioethics Table worked with health system clinical leaders and front-line health service providers to propose a critical care triage approach in the event of a major demand for critical care services in the COVID-19 pandemic. The draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals to prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions. Fortunately, a major surge in demand for critical care has so far been averted.

Following the release of the March 28th version, the COVID-19 Bioethics Table sought or received stakeholder and expert feedback. Much of this feedback has been incorporated where appropriate into the revised document. We are now sharing the updated recommendations with key stakeholders to ensure the issues and concerns that have been raised have been properly addressed, to hear any additional concerns or issues that ought to be addressed, and to inform our final recommendations to Ontario Health by July 31st.

We are grateful to the Ontario Human Rights Commission for its support in co-convening this Roundtable consultation with you. Our aim is to hear your perspectives on critical care triage in a pandemic context, to gain insight into the issues and concerns relevant to the communities you represent, and to invite your input on the overall triage approach. Some questions that we hope will help frame our discussion include:

1. In the context of a major surge for critical care, the revised recommendations articulate an ethical imperative to use available resources in a manner that saves as many lives as possible, with constraints to ensure that individuals are not excluded on the basis of any particular demographic, disease, or disability independent of an individual patients prognosis. Do you agree with this approach? If not, why not, and what might you suggest as an alternative?
2. Critical care triage has the potential to perpetuate or exacerbate pre-existing health and social inequities. The proposed approach seeks to mitigate the potential impact of implicit bias and systemic discrimination on vulnerable groups to the extent possible in a pandemic. To what extent are the proposed safeguards sufficient? What additional safeguards, if any, would you recommend be put in place to prevent or mitigate this outcome?
3. What key changes, if any, to the document or overall approach would you recommend? What would you not like to see changed?
4. Are there any other comments/feedback on the critical care triage recommendations you would like to share?
5. Looking forward, are there any other issues/concerns relevant to the pandemic response that you think the Bioethics Table should be aware of as it contributes to planning for potential Wave 2 of the COVID-19 pandemic in Fall and beyond?

The Bioethics Table is happy to receive additional thoughts or input you would like to share following the Roundtable. Please send your comments to us via email ([email protected]) by Monday, July 20 so that they can be considered in the recommendations we will be making to Ontario Health.

We look forward to next weeks conversation.

Sincerely,

Jennifer Gibson and Max Smith
Co-Chairs, Bioethics Table

Text of June 15, 2020 Letter from Ontario Health to the Ontario Human Rights Commission

Ontario Health
525 University Avenue, 5th Floor, Toronto ON, M5G 2L3

June 15, 2020

Raj Dhir?Executive Director?Ontario Human Rights Commission 180 Dundas Street West, 9th Floor Toronto, ON?M7A 2G5 Dear Mr. Dhir:

RE: COVID-19 triage protocol, data collection and essential support persons

Thank-you for your letter dated June 4, 2020 written on behalf of the Ontario Human Rights Commission (OHRC). We extend the same wishes for safety and good health to you and your team on this journey through the COVID-19 pandemic.

Ontario Health welcomes your letter and is pleased to have this opportunity to share our views on the issues you raised both at this time during the pandemic, but also at this time in Ontario Healths evolution in the health sector. Specifically, on behalf of Ontario Health, I want to confirm our commitment to recognizing the human rights of all Ontarians and to ensure that as much as possible, the principles of inclusion, diversity and equity are reflected in all of what Ontario Health does. This means both internally at Ontario Health as it matures and integrates the business of numerous former crown agencies, but also externally in how it exercises its mandate in the health system.

As you may know, we have a very important role to play supporting the Ministry of Health as part of their broader health system strategies through the mandate that has been established for us under the Connecting Care Act, 2019. COVID-19 elevated the importance of this role by shining a light on the importance of ensuring there is coordinated communication, collaboration and commitment to patients, residents, health outcomes and front-line workers from the many different health system providers.

From this vantage point, we view Ontario Health as having a very important and ongoing role to play to demonstrate its commitment to observing fundamental human rights for all Ontarians including those in racialized communities, people experiencing poverty, people with disabilities, older people and other Code-protected groups.

While I will defer to the Minister of Health to respond to you on behalf of the Government and the health system more broadly, it is important for Ontario Health to outline our perspective in the four areas you have written about:

1. Immediately and publicly rescind Ontario Healths March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic and undertake meaningful consultation on a new protocol.

Working with health system clinical leaders and front-line health service providers, a draft Clinical Triage Protocol for Major Surge in COVID-19 (Triage Protocol) was shared by the COVID-19 Bioethics Table in March 2020 as a clinical response to avert catastrophic health outcomes from COVID-19. Given the complexity of issues it presented at the time, the unprecedented reallocation and shift of resources in the health system to respond to COVID-19 and the uncertainties surrounding the virus itself, the Triage Protocol remains in draft. That said, it is a product of much consultation by the COVID-19 Bioethics Table (that works with the Critical Care Table) and with clinical and ethical leaders, following best practices in those areas from other jurisdictions who bravely fought COVID-19 before Ontario. While COVID-19 has unfortunately taken a tragic toll in certain parts of our health system, we are thankful that the need to apply the Triage Protocol has so far been averted as a result of our health system response. To my knowledge, the triage recommendations in the Triage Protocol have not yet been applied in Ontario.

At this time in the pandemic with our numbers of confirmed COVID cases decreasing, we have the opportunity to reflect on all aspects of the response, including the draft Triage Protocol. The intent of the COVID-19 Bioethics Table is to continue to seek feedback, which so far, has generated very helpful comments from stakeholders, including the ones you mention. The Bioethics Table is taking the thoughtful input received so far and including it in an updated draft which they are intending to share with the stakeholders they have consulted with – to ensure the issues and concerns that have been raised are properly addressed and before any further steps are taken on it (see Appendix with list of stakeholders). If there is a stakeholder group that has reached out to your office that is not on this list, please let us know, we would be happy to connect the Bioethics Table with them. It is our understanding that the Ministry is supportive of this direction. Our goal is to have a final document by the end of July, or to rescind it.

2. Quickly develop and release a plan for collecting disaggregated sociodemographic data on the response to COVID-19.

Early in the pandemic, Ontario Health consulted with experts in health equity and the collection of sociodemographic data to gather their advice on how best to understand the impact of COVID-19 on vulnerable populations. These experts included leaders from the Wellesley Institute, the Alliance for Healthier Communities, the University of Toronto, the Health Commons Solutions Lab, and the Upstream Lab. The advice we received had three components: (1) use existing Ontario data at the neighbourhood level to track and report on disparities between communities; (2) begin collection of individual sociodemographic data through the public health information system; (3) begin a longer-term solution to collect sociodemographic information through the OHIP registration form.

The data we routinely report to the Health Command Table on COVID-19 on incidence and prevalence includes information on disparities between neighbourhoods in Ontario using data from the Ontario Marginalization Index (i.e. educational attainment, income, unemployment, quality of housing and family structure characteristics, recent immigration, visible minority resident). This information is also available publicly at howsmyflattening.ca.

We understand from the Ministry of Health that the collection of race and ethnicity-based data at the individual level for COVID-19 is expected to begin within the next few?weeks. Public health case investigators will ask individuals newly diagnosed with COVID for race-based information as part of follow up and case management. The Ministry has worked with many stakeholder organizations and communities to advance this effort and is working with Public Health Ontario and the public health units to facilitate roll out of this important information.

To ensure that sociodemographic data collection at the individual level is sustainable and extends beyond this pandemic to other health issues and conditions, Ontario Health fully supports the feasibility of collecting this information through the OHIP registration form and we will await additional guidance from the Ministry.

3. Provide clear provincial direction on the duty to accommodate people with disabilities who need to access essential support persons(s) while receiving health services during the pandemic.

As you know, Ontario Health does not provide direct, front-line healthcare to patients. Ontario Health, however, is fully committed to accommodating people with disabilities and is able to support health service providers in fulfilling their important duties on the frontlines. While Ontario Health does not have the power or authority to direct health service providers in how they discharge their duties, we can play an active and supporting role to the Minister of Health in any directions to the broader health system. We will do our best to convey this message informally to our health system partners subject to any further formal advice or directions from the Ministry.

4. Consult and involve representatives of vulnerable groups and other human rights experts.

As mentioned earlier, Ontario Health continues to be in its formative days, having assumed six (6) existing corporations through Minister Transfer Orders since December 2019. While I have comfort that all of these former entities and their business practices were committed to protecting the human rights of vulnerable persons, the integration of these businesses presents Ontario Health with the opportunity to consider how we can build on their success and be the leader in this area both with our employees and the health system as a whole.

To this end, Ontario Health is already in the process of retaining a human rights expert who can provide meaningful guidance to our operations, policies and the way we interact and engage with stakeholders to observe our commitment to the Code and actively reflect the principles of diversity, equity and inclusion. We are grateful that the OHRC has offered to provide support as we embark on this process.

Once again, we thank the OHRC for reaching out at this time for the important reasons in your letter and for providing Ontario Health with the opportunity to express our shared commitment to protecting the human rights of all vulnerable populations and all Ontarians both through COVID-19 and afterwards. We look forward to hearing from the Ministry of Health in the areas noted above so we can collectively work together to achieve broadly accepted outcomes.

Regards,

ORIGINAL SIGNED BY

Matthew Anderson
President & CEO, Ontario Health

cc: Hon. Christine Elliot, Minister of Health
Hon. Merrilee Fullerton, Minister of Long-Term Care Hon. Doug Downey, Attorney General
Dr. David Williams, Chief Medical Office of Health Violetta Igneski, OHRC Commissioner Randall Arsenault, OHRC Commissioner

Appendix

Input was sought from individuals at:

The Ontario Human Rights Commission ?
ARCH Disability Law Centre ?
Muscular Dystrophy Canada ?
The Ontario Health COVID-19 Critical Care Planning Table ? Ontario critical care leads and other critical care physicians ?
The COVID-19 Bioethics Community of Practice (based at the Joint Centre for ?Bioethics and comprising all practicing bioethicists across the province working in ?health care settings) ?
Affiliated health institutions of Bioethics Table members (e.g., Health Sciences ?North, Hamilton Health Sciences, London Health Sciences, The Ottawa Hospital, ?Trillium Health Partners, etc.) ? The Wellesley Institute ?
Canadian Frailty Network ?
CorHealth

Also, input was received via letters (directed to Ontario Health or the Ministry of Health) from: ?

Ontario Hospital Association ?
Ontario Medical Association ?
Canadian Medical Protective Association ?
College of Physicians and Surgeons of Ontario ?
College of Nurses of Ontario ?
Healthcare Insurance Reciprocal of Canada ?
ARCH Disability Law Centre ?
Other disability rights organizations ?

Text of June 4, 2020 Letter from the Ontario Human Rights Code to Ontario Health

9th Floor 9e étage
180 Dundas Street West 180, rue Dundas Ouest
Toronto, ON M7A 2G5 Toronto (Ontario) M7A 2G5
Postal Code (Courier): M5G 1Z8 Code postal «courier»: M5G 1Z8

Executive Director and Directeur général et
Chief Legal Counsel avocat en chef
Ph: (416) 314-4562 Fax: (416) 325-2004

June 4, 2020

Mr. Matthew Anderson
President and CEO
Ontario Health
1075 Bay Street,
Toronto, ONM5S 2B1

Dear Mr. Anderson:

RE: COVID-19 triage protocol, data collection and essential support persons

I am writing on behalf of the Ontario Human Rights Commission (OHRC).

We hope this letter finds you and your team safe and healthy, and thank you for your ongoing efforts to address the COVID-19 pandemic.

On April 2, the OHRC released a policy statement and identified actions consistent with a human rights-based approach to managing the COVID-19 pandemic. The OHRC highlighted the need for government to:
* Provide all healthcare services related to COVID-19, including testing, triaging, treatment and possible vaccination, without stigma or discrimination
* Collect health and other human rights data on the response to the COVID-19 pandemic, disaggregated by the grounds of Indigenous ancestry, race, ethnic origin, place of origin, citizenship status, age, disability, sexual orientation, gender identity, social condition, etc.
* Recognize that any restrictive measures that deprive persons of their right to liberty must be carried out in accordance with the law and respect for fundamental human rights. This includes measures related to people in health and other care institutions
* Consult with human rights institutions and experts, Indigenous leaders and knowledge-keepers, vulnerable groups, as well as persons and communities affected by COVID-19, when making decisions, taking actions and allocating resources.

Over the last two months, the OHRC has met with a range of stakeholders representing racialized communities, people experiencing poverty, people with disabilities, older people and other Code-protected groups. These groups are concerned that certain aspects in the management of the COVID-19 pandemic are having a negative impact on their human rights, and have raised four immediate concerns:
1. Ontario Healths March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic violates the human rights of people with disabilities, older persons and other vulnerable groups, and has created fear in their communities
2. Lack of disaggregated data collection during the COVID-19 pandemic is putting the health and well-being of Code-protected groups at heightened risk
3. Rigid visitor restrictions in care settings are resulting in unequal access to health services and a failure to accommodate people who require essential support person(s) such as a family member, friend, or support worker to communicate or meet other disability-related needs
4. Lack of meaningful consultation and involvement is negatively affecting Code-protected and other vulnerable groups during the COVID-19 pandemic.

As you may know, the OHRC has previously written to Ontario about its concerns about the Clinical Triage Protocol and the lack of disaggregated data collection. We were advised that Ontario Health would be consulting with us.

As set out below, we are aware that there may be an intention to address some of these concerns. However, to ensure full compliance with the Ontario Human Rights Code, the OHRC urges the following actions:

1. Immediately and publicly rescind Ontario Healths March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic and undertake meaningful consultation on a new protocol.

Ontario Health released a Clinical Triage Protocol for Major Surge in COVID-19 Pandemic, dated March 28, 2020, to guide the use of emergency resources, such as ventilators, if Ontarios health system is overwhelmed and there is a shortage of these resources. There was no announcement to accompany the Protocol, and notwithstanding an undated letter from Ministers Elliot, Smith and Cho, which referred to it as a draft document, the OHRC has heard that health care practitioners continue to recognize the Protocol.

Stakeholders from disability rights organizations, such as ARCH Disability Law Centre, and older persons advocacy groups have voiced significant concerns that the Protocol creates stigma and fear, perpetuates historical disadvantage, and gives the impression that people with disabilities and elderly people are expendable and less worthy of protection. These groups were not consulted in the development of the Protocol. At the same time, they recognize that if the protocol is developed properly, it can serve to protect their communities. They are committed to the success of a protocol, but they need to be involved in developing it. The OHRC was able to quickly convene a consultation with these groups so we see no reason why Ontario Health cannot do the same.

The OHRC urges Ontario Health to:
a. Immediately and publicly rescind the version of the Clinical Triage Protocol for Major Surge in COVID-19 Pandemic released in March, and call on medical organizations to remove the document from their websites and not promote it as valid guidance
b. Share the revised draft version of the Protocol and commit to a public consultation with disability rights organizations, older persons advocacy groups, Indigenous, Black, racialized and other vulnerable groups.

2. Quickly develop and release a plan for collecting disaggregated socio-demographic data on the response to COVID-19.

The OHRC welcomes the Chief Medical Officer of Healths recent remarks, which were confirmed by the Minister of Health in the Legislature, that the government plans to collect socio-demographic data during the pandemic. However, the lack of a formal announcement and details on how and when data collection will roll out has created confusion.

As the OHRC said in its April 30 public statement, health and human rights experts agree that Ontario needs demographic data to effectively fight COVID-19. Strong data allows health care leaders to identify populations at heightened risk of infection or transmission, to efficiently deploy scarce health resources, and to ensure equal access to public health protections for all Ontarians.

The OHRC urges Ontario Health to:
a. Take immediate steps to clearly outline the nature and scope of the proposed collection of disaggregated socio-demographic data
b. Provide specific information on who Ontario/Ontario Health is consulting on the collection of disaggregated socio-demographic data, including, but not limited to Indigenous, Black, racialized and other vulnerable groups
c. Release a detailed and comprehensive data collection plan that includes collection mechanisms and timelines for the pandemic
d. Provide specific information on how Ontario/Ontario Health will report publicly on the data collected during the pandemic
e. Publicly commit to collecting disaggregated socio-demographic data in the health sector in a sustainable manner beyond the pandemic. This would be responsive to longstanding OHRC and stakeholder recommendations.

3. Provide clear provincial direction on the duty to accommodate people with disabilities who need to access essential support person(s) while receiving health services during the pandemic.

The government has provided guidance to care institutions about visitor access as a virus prevention measure during the COVID-19 pandemic. In its guidance, the government recommends that only essential visitors be permitted to enter facilities and provides examples of essential visitors as including, those who have a patient who is dying or very ill or a parent/guardian of an ill child or youth, a visitor of a patient undergoing surgery or a woman giving birth.

Many groups have raised concerns that care institutions are using this guidance to exclude support persons, attendants and communication assistants who provide essential disability-related accommodations. Without their essential support person, some people with disabilities cannot communicate effectively with health care providers about health concerns, make informed decisions about treatment or give or refuse consent to treatment.

The OHRC recognizes that everyones right to health includes a governments obligation to take the steps necessary for preventing, treating and controlling COVID-19. At the same time, under the Code, hospitals and other care institutions have a duty to accommodate a persons disability-related needs, unless doing so would cause undue hardship based on cost or health and safety.

The OHRC urges Ontario Health to:
a. Provide direction to health facilities that their interpretation of essential visitor should be broad enough to include paid and unpaid support persons, attendants and communication assistants authorized by the patient who provide supports that are essential to enable a patient with a disability to access health care services and communicate effectively with health care providers.

4. Consult and involve representatives of vulnerable groups and other human rights experts.

A human rights-based approach to managing the COVID-19 pandemic requires that government, institutions and other responsible organizations consult with, and involve, Code-protected groups. Lack of meaningful consultation is negatively impacting the human rights of vulnerable groups during the COVID-19 pandemic.

The OHRC urges Ontario Health to:
a. Consult with human rights experts, representatives of vulnerable groups, and persons and communities affected by COVID-19, when developing protocols, making recommendations or decisions and taking action on managing the COVID-19 pandemic including clinical triage, data collection, restrictions on visitors to care settings and other matters. When consulting groups or needing quick advice, the OHRC is available to help facilitate discussions in a timely manner.

The OHRC appreciates the ever-evolving circumstances surrounding COVID-19, and understands that the government is working to address issues on many fronts. However, is it crucial that vulnerable peoples human rights are upheld, systematically accounted for and properly accommodated while accessing health services during the pandemic. Applying a human rights-based approach and taking these actions as soon as possible, can help limit the spread of the virus while continuing to meet Ontarios human rights obligations.

Sincerely,

Original signed by

Raj Dhir
Executive Director

cc: Hon. Christine Elliot, Minister of Health
Hon. Merrilee Fullerton, Minister of Long-Term Care
Hon. Doug Downey, Attorney General
Dr. David Williams, Chief Medical Officer of Health
Violetta Igneski, OHRC Commissioner
Randall Arsenault, OHRC Commissioner

Text of the June 4, 2020 Letter from the Ontario Human Rights Commission to the Ontario Minister of Health

9th Floor 9e étage
180 Dundas Street West 180, rue Dundas Ouest
Toronto, ON M7A 2G5 Toronto (Ontario) M7A 2G5 Postal Code (Courier): M5G 1Z8 Code postal «courier»: M5G 1Z8

Executive Director and Directeur général et
Chief Legal Counsel avocat en chef
Ph: (416) 314-4562 Fax: (416) 325-2004

June 4, 2020

Hon. Christine Elliot
Minister of Health
College Park 5th Floor, 777 Bay Street
Toronto, ON M7A 2J3
[email protected]

Hon. Todd Smith
Minister of Children, Community and Social Services
Macdonald Block Room M2B-88,
77 Wellesley Street West
Toronto,ON M7A 1N3
[email protected]

Dear Minister Elliot and Minister Smith:

RE: COVID-19 Action Plan for Vulnerable People

I am writing on behalf of the Ontario Human Rights Commission (OHRC).

We hope this letter finds you and your team safe and healthy, and thank you for your ongoing efforts to address the COVID-19 pandemic.

The OHRC welcomes the April 23 release of the governments COVID-19 Action Plan for Vulnerable People (the Plan) as a first step toward addressing the disproportionate impact that the pandemic is having on Ontarios most vulnerable people. However, to ensure that the human rights of vulnerable people are protected in a way that is consistent with Ontarios Human Rights Code, the Plan requires expanded scope and detail, which must be done in consultation with vulnerable groups and human rights experts.

Over the past few months, the OHRC has met with stakeholders from various sectors on human rights related to the COVID-19 pandemic. We heard significant concerns about the lack of consultation with affected groups. We also heard that while the Plan mentions certain vulnerable groups, it does not capture other vulnerable communities. The Plan also lacks clarity around how prevention, treatment and control initiatives are being designed to protect and benefit the most vulnerable groups in those communities.

In our April 2 policy statement and actions for a human rights-based approach to managing the COVID-19 pandemic, the OHRC called on the government to uphold the human rights of vulnerable groups by taking the following actions:
* Anticipate, assess and address the disproportionate impact of COVID-19 and related restrictions on vulnerable groups that already disproportionately experience human rights violations
* Make sure vulnerable groups have equitable access to health care and other measures to address COVID-19, including financial and other assistance
* Consult with human rights institutions and experts, Indigenous leaders and knowledge-keepers, vulnerable groups, as well as persons and communities affected by COVID-19, when making decisions, taking actions and allocating resources.

Despite our early advice, the OHRC has not yet been invited to COVID-19 planning forums and tables. Nor have we been able to gain access to specific and timely information to better understand the human rights implications of the governments COVID-19 initiatives.

The OHRCs specific requests for more details on the implementation of the Plan and its effect on vulnerable groups have gone unanswered.

In our April 30 submission on Ontarios next Poverty Reduction Strategy, the OHRC highlighted that social and economic crises, especially a health pandemic like COVID-19, exacerbate the existing inequalities vulnerable populations already experience, such as poorer health and poverty. An inadequate response to the needs of vulnerable groups also undermines the effectiveness of Ontarios overall response to COVID-19, placing at risk everyones well-being and potentially exacerbating an anticipated second wave of the pandemic.

To effectively protect the rights of Ontarios most vulnerable people, Ontario must take immediate action to expand and implement its Plan for vulnerable groups. The OHRC urges the government to make clear, detailed and public commitments in the following areas:

1. Expand the scope of the Plan to ensure the needs of other vulnerable communities are properly addressed. Examples of communities that are currently excluded include:
* People experiencing homelessness who are not currently using the shelter system (for example, hidden homeless people and people living in encampments) * Highly mobile populations of people who use drugs
* People experiencing poverty and living in multi-generational and sometimes crowded housing while also working in high-risk settings, such as long-term care, food processing facilities and the service sector
* In-patients in mental health facilities, including in addictions and withdrawal programs and in residential treatment programs for children and youth * Frail seniors in assisted living
* Indigenous people living in urban and rural communities, and not in congregate care * Seasonal migrant workers living in shared housing facilities.

2. Provide detailed, public information on how the roll-out of expanded testing, screening, tracking and surveillance will reach and benefit high-risk and vulnerable populations. Information should include a plan for: * How many tests will be done for vulnerable groups each day * How mobile populations will be reached
* How asymptomatic people from high risk and vulnerable groups will be tested, tracked and monitored.

3. Consult and work with vulnerable groups that will be affected by the Plan by including Indigenous partners, stakeholder/advocacy groups representing vulnerable people and human rights experts, and involve them in provincial planning tables and committees.

4. Provide specific and detailed guidance to law enforcement to ensure that COVID-19 prevention measures are not implemented in a way that disproportionately targets or penalizes people who have difficulty or are unable to follow physical distancing restrictions and other requirements, such as people experiencing homelessness and people with certain types of disabilities. Guidance should also include appropriate ways to promote education and awareness.

5. Identify indicators and collect data to measure whether the Plan, including these additional actions, is benefiting high-risk and vulnerable populations.

6. Report publicly and regularly on the implementation status of the Plan, including these additional actions, in detail, including the results of the data collected to measure whether the plan is benefiting high-risk and vulnerable populations.

The OHRC appreciates the ever-evolving circumstances surrounding COVID-19, and understands that the government is working to address issues on many fronts. However, as many experts note, the spread of COVID-19 among Ontarios most vulnerable populations could prove catastrophic. Taking the recommended actions as soon as possible can help limit the spread of the virus while continuing to uphold Ontarios human rights obligations.

Sincerely,

Original signed by

Raj Dhir
Executive Director

cc: Hon. Merrilee Fullerton, Minister of Long-Term Care
Dr. David Williams, Chief Medical Officer of Health
Matthew Anderson, President and CEO of Ontario Health
Hon. Doug Downey, Attorney General
Violetta Igneski, OHRC Commissioner
Randall Arsenault, OHRC Commissioner

1 Further details regarding the process by which this document was developed can be found in Appendix A.
2 Critical Care Services Ontario. Ontarios Critical Care Surge Capacity Management Plan: Moderate Surge Response Guide Version 2.3. Government of Ontario, September 2019, p. 6.
3 An earlier version of this document was distributed to Ontario hospitals on March 28, 2020. The current document provides updated recommendations based on additional consultation and stakeholder feedback to clarify the scope and limits of critical care triage in the COVID-19 pandemic, the ethical underpinnings of the approach (including significance of human rights), the nature and purpose of the critical care triage criteria, and key considerations for implementation. It also includes recommendations for continuing consultation and stakeholder engagement.
4 Critical care services meet the needs of patients facing an immediate life-threatening health conditionspecifically, that in which vital system organs are at risk of failing. Using advanced therapeutic, monitoring and diagnostic technology, the objective of critical care is to maintain organ system functioning and improve the patients condition such that his or her underlying injury or illness can then be treated. (https://www.criticalcareontario.ca/EN/AboutUs/Pages/What-is-Critical-Care.aspx)
5 Silva DS, Gibson JL, Robertson A, et al. Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public’s perspectives. BMC Public Health 2012; 12:241. https://doi.org/10.1186/1471-2458-12-241 6 Add missing refs.
7 Determining the timeframe in which death is likely to occur is challenging. Prognostication requires clinical judgement based on each patients unique clinical circumstances. To enhance prognostic certainty, the involvement of clinical judgement of more than one physician is common medical practice.
8 Skye C. Colonialism of The Curve: Indigenous Communities & Bad COVID Data. Toronto: Yellowhead Institute, Ryerson University, 2020. https://yellowheadinstitute.org/2020/05/12/colonialism-of-the-curve-indigenous-communities-and-bad-covid-data/; Nestel S. Colour-coded health care: the impact of race and racisms on Canadians health. Toronto: Wellesley Institute, 2012. http://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Coded-Health-Care-Sheryl-Nestel.pdf;
9 Ontario Human Rights Commission. Policy statement on a human rights-based approach to managing the COVID-19 pandemic. 02 April 2020. Available at: http://www.ohrc.on.ca/en/policy-statement-human-rights-based-approach-managing-covid-19-pandemic. 10 Such as: age, sex, socioeconomic status, Indigenous status, race, ethnicity, sex, gender identity and expression, sexual orientation, creed, family status, marital status, geography, and home setting (including homelessness). See also Appendix B: Prohibited grounds of discrimination for a list of prohibited grounds). http://www.ohrc.on.ca/en/ontario-human-rights-code
11 Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. Hastings Center Report 2020; Apr 2. Available at: https://www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/; Applying HHSs Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. https://dredf.org/avoiding-disability-based-discrimination-in-treatment-rationing/. Accessed April 12, 2020; Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.
12 Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e-e74S; Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S; Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. Hastings Center Report 2020; Apr 2. Available at: https://www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/
13 Truog RD, Mitchell C, Daley GQ. The toughest triageallocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article

cThe use of an acute illness score (e.g., sequential organ failure assessment (SOFA) score) would be difficult to justify given that even people with high SOFA scores may have a ~50% chance of surviving an acute viral respiratory illness.11 And if one only looks at those who do not meet any of the ineligibility criteria at levels 1-3, the survival rate would likely be even higher. It is currently unknown whether the prognosis of COVID-19 illness is similar to other viral illnesses. Early data suggests that the admission SOFA scores for non-survivors was low, and thus unhelpful for distinguishing them from survivors. 12-13 Moreover, mortality risk from acute illness does not easily translate into medical utility. It is not clear whether the greatest benefit would be seen in those with mild, moderate, or severe illness.
15 Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.
16 Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.

17 Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e61S-e74S; US Veterans Health Administration National Center for Healthcare Ethics. Meeting the challenge of pandemic influenza: ethical guidance for leaders and health care professionals in the Veterans Health Administration, July 2010. Available at: https://www.ethics.va.gov/docs/pandemicflu/Meeting_the_Challenge_of_Pan_Flu-Ethical_Guidance_VHA_20100701.pdf; Emanuel EJ et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020 Mar 23; Truog RD, Mitchell C, Daley GQ. The toughest triageallocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article




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In A Second COVID-19 Wave, If There Aren’t Enough Ventilators for All Patients Needing Them, A new Draft Ontario Medical Triage Protocol Would Continue to Discriminate Against COVID-19Patients with Disabilities


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/

In A Second COVID-19 Wave, If There Aren’t Enough Ventilators for All Patients Needing Them, A new Draft Ontario Medical Triage Protocol Would Continue to Discriminate Against COVID-19Patients with Disabilities

July 16, 2020

          SUMMARY

 1. What’s the Serious Issue?

Despite having four months to fix this serious problem, in the COVID-19 crisis the Ford Government has still not rooted out the current danger to people with disabilities, induced by a protocol that Ontario Health sent to all hospitals last spring. That protocol lets hospitals violate basic human rights of COVID-19 patients with disabilities if a surge in COVID-19 cases meant there’s not enough ventilators for all critical patients needing them. Despite months of efforts by disability advocates, a new draft “medical triage protocol” which the Government has under consideration, and which we reveal to the public here while it is open for input, leaves the danger of disability discrimination in place.

Thankfully, Ontario now has no ventilator shortage. However a second wave of COVID-19 cases later this year could create a surge in demand for ventilators. To date, the Ford Government’s troubling handling of what to do if there are too few ventilators for COVID-19 patients has been improperly shrouded in secrecy.

Early in the COVID-19 crisis, Ontario Health, part of the Ontario Government, sent a very troubling March 28, 2020 medical triage protocol to Ontario hospitals. It spelled out what to do if there is more demand for life-saving ventilators than there are ventilators to go around. The Government did not make that protocol public. After it was leaked early last April to some within the disability community, disability advocates slammed it and called for it to be rescinded and replaced.

 2. What’s New on This Issue?

Here is the late-breaking news on this issue, backed by Government documents that we are making public in this Update.

  1. We now confirm that the Government sent the original March 28, 2020 medical triage protocol to Ontario hospitals. A July 7, 2020 letter from Ontario Health’s team drafting the triage protocol, set out below, states:

“The draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals to prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions.”

  1. It is now clear and beyond dispute that the Government has still not rescinded that original March 28, 2020 medical triage protocol. Disability advocates including the AODA Alliance, as well as the Ontario Human Rights Commission, have called on the Government to rescind that original medical triage protocol, because it violates the human rights of patients with disabilities. Ontario Health’s June 15, 2020 letter to the Ontario Human Rights Commission, set out below, states the following regarding the medical triage protocol:

“Our goal is to have a final document by the end of July, or to rescind it. “

  1. A Government-appointed committee of physicians and bioethicists that have been assigned to lead the work in this area have written a new revised draft of the medical triage protocol. We among others have received it. We are here making it public, setting it out below, along with related correspondence between the Ontario Human Rights Commission and Ontario Health.
  1. On July 15, 2020, a number of members of Ontario Health’s committee of physicians and bioethicists, assigned to lead this protocol’s development, held a two-hour virtual consultation with several disability community representatives, including the AODA Alliance. This is the first time the AODA Alliance had an opportunity to speak with those leading this issue for the Ford Government. We were not named on that Committee’s list of organizations it had consulted, or to be consulted. This virtual meeting came some three months after a senior official involved in the development of the initial protocol announced on province-wide television that it was a top priority for the Government to consult on this protocol.

As detailed further below, the disability advocates consulted at that meeting unanimously showed that the revised draft medical triage protocol still creates a real and serious danger of discrimination against patients with disabilities.

  1. Ontario Health’s team developing this new draft medical triage protocol aims to submit to the Ford Government its recommendation for a revised medical triage protocol by July 31, 2020. Written submissions can be sent to that team by writing [email protected] up to July 20, 2020.
  1. The ARCH Disability Law Centre, which has played a tremendous leadership role on this issue, will be making a written submission by July 20, 2020 in which the AODA Alliance will contribute our input. We will make it public as quickly as we can.

 3. What’s Wrong With the New Revised Draft Medical Triage Protocol?

Here is a summary of just some of the many serious problems with the revised draft medical triage protocol that is set out below.

  1. This new revised draft medical triage protocol does not effectively undo the damage that the March 28, 2020 protocol caused for people with disabilities. The Government had spread that harmful earlier protocol across Ontario’s health care system. Any revised protocol must fully and effectively undo that damage.
  1. The draft revised protocol continues to discriminate against patients with disabilities. It includes some vague references to human rights. Those references are entirely insufficient to eliminate the discrimination that the original protocol and this revised draft protocol each cause. As but one example, the revised draft protocol, like the original one, continues to use the Clinical Frailty Scale, which itself presents real and serious disability human rights concerns. Its prominence in the protocol has been reduced but its use has not been eliminated. Whether or not there are any studies on that scale does not detract from the fact that that scale should not be used.
  1. On April 14, 2020, the AODA Alliance made public a Discussion Paper on this issue. It set out clear illustrations of things that need to be spelled out in the medical triage protocol to address the risk of discrimination against patients with disabilities. The committee drafting the protocol has seen that Discussion Paper. However, the revised medical triage protocol does not include any of the Discussion Paper’s proposals, nor does it cure any of the harms to patients with disabilities that the Discussion Paper illustrates. The protocol should be amended to include all the specific directions and recommendations in the AODA Alliance’s Discussion Paper.
  1. The revised draft medical triage protocol uses vague criteria that any two doctors might interpret very differently. It speaks of patients with “a low probability of surviving more than a few months”. One doctor might think that means 2 to 3 months. Another doctor might think that means 6 to 8 months. Its directions must be far clearer and less open to arbitrarily different applications from one doctor to the next.
  1. The revised medical triage protocol uses lofty and vague language such as its references to ethics, equity, human rights, and fairness. However, those lofty terms will do nothing to stop a well-intentioned doctor or hospital from taking action that discriminates against patients with disabilities. Indeed, as is the case here, many if not most of the barriers facing people with disabilities are created without any intent to harm people with disabilities.

For example, the revised draft medical triage protocol states:

“Triage decisions should treat similar cases similarly based on clinical criteria, i.e., those with similar prognoses should be treated similarly.”

The medical triage protocol might thereby be meant to implement the authors’ notions of fairness and equality. However, this flies in the face of the Supreme Court of Canada’s important ruling in its landmark decision on the meaning of equality rights, Andrews v. Law Society of British Columbia [1989] 1 SCR 143, where the Court proclaimed:

“Thus, mere equality of application to similarly situated groups or individuals does not afford a realistic test for a violation of equality rights.”

  1. If there is a shortage of ventilators during a second wave of COVID-19, this revised draft medical triage protocol in effect creates a “death panel” of two doctors who will decide in an individual case in an individual hospital who gets the ventilators and who does not, among all the patients who need them. It requires no prior training on this issue for the doctors chosen to play that role. It provides no fair procedures or due process to the very patient whose life hangs in the balance. The patient and their family have no right to be heard by those deciding the patient’s fate. There is no assurance that the family can get their family doctor to chime in and add their voice to the discussion. There is no right of appeal to anyone else in the hospital.

There is no duty on the doctors or hospitals to give the patient or their family basic rights advice. This is so even though the revised draft medical triage protocol gives superficial and inadequate lip service to due process concerns, stating:

“Due process considerations (e.g., transparency about reasons for triage decisions) are especially important in this context. Hospitals should plan for how they might proactively prepare patients and families for possible outcomes of the triage process as well as how they would respond transparently and compassionately to patient or family concerns should these arise.”

Appendix E to the revised draft protocol sets out a sample of what a doctor might tell a patient and their family if it has been decided to refuse them a needed ventilator due to a ventilator shortage. That seriously deficient text gives the patient and family no rights advice or other basic information of what they can do if they wish to dispute the decision and to have it reconsidered.

The revised draft Medical triage protocol in substance wrongly and summarily rejects the idea of any appeal, stating:

“critically ill patients must be assessed rapidly in a dynamic and over-taxed environment, a formal process for patients and families to appeal triage decisions may not be feasible or appropriate (e.g., if critical care is contrary to the patient’s wishes).”

 4. For More Background

* The April 7, 2020 virtual public forum on the impact of COVID-19on people with disabilities, jointly organized by the AODA Alliance and the Ontario Autism Coalition. During this event, ARCH Disability Law Centre executive director Robert Lattanzio first made public the existence of the original March 28, 2020 medical triage protocol, and the disability human rights problems that it creates.

* The April 8, 2020 open letter, spearheaded by ARCH, identifying the serious disability human rights violations in the original March 28, 2020 medical triage protocol.

* The AODA Alliance’s April 14, 2020 Discussion Paper on what the medical triage protocol should include. In the three months since this was made public, no negative feedback was received about its recommendations.

* The Ford Government’s April 21, 2020 announcement that it would consult community and human rights experts on the medical triage protocol. It claimed that the March 28, 2020 protocol was only a “draft” even though it was never marked “draft.

* The ARCH Disability Law Centre’s detailed May 13, 2020 analysis of the serious disability human rights violations, which the AODA Alliance endorses.

* To learn more about the many barriers that impede patients with disabilities in Ontario’s health care system, read the AODA Alliance’s February 25, 2020 Framework on what the promised Health Care Accessibility Standard should include, to be enacted under the Accessibility for Ontarians with Disabilities Act.

* The AODA Alliance’s health care web page, to learn more about the advocacy efforts to tear down the barriers facing people with disabilities in Ontario’s health care system.

* The AODA Alliance’s COVID-19 web page details the coalition’s efforts to advocate for the needs of people with disabilities during the COVID-19 pandemic.

Below we set out:

 

* The second draft Critical Care Medical Triage Protocol.

 

* the July 7, 2020 letter from the Ontario COVID-19 Bioethics Table of Ontario Health to organizations taking part in the July 15, 2020 roundtable on the triage protocol and people with disabilities.

* the June 15, 2020 letter from Ontario Health to the Ontario Human Rights Commission

* the June 4, 2020 letter from the Ontario Human Rights Commission to Ontario Health

* the June 4, 2020 Ontario Human Rights Commission letter to the Ontario Minister of Health

We always invite your feedback. Write us as [email protected]

          MORE DETAILS

 

 Text of the Revised Draft Ontario Medical Triage Protocol

 

 

Critical Care Triage for Major Surge in the COVID-19 Pandemic:

Updated Recommendations

 

Note: This document offers recommendations developed by provincial experts in bioethics in consultation with clinical experts and informed by stakeholder feedback. It reflects best knowledge and advice at the time of writing and is subject to revision based on changing conditions and new evidence in the COVID pandemic.[1]

 

Overview:

During the COVID-19 pandemic, a major surge in demand for critical care may exceed available health system capacity. Difficult decisions would need to be made about how critical care resources should be allocated to meet patient needs. Although advanced health systems have experience with and are well-prepared to manage minor and moderate surges in demand for critical care, there is limited clinical and ethical guidance for how a major surge in demand for critical care should be managed. In Ontario, major surge is defined as: “an unusually high increase in demand that overwhelms the health care resources of individual hospitals and regions for an extended period of time, where an organized response at the provincial or national level is required.”[2] The purpose of this document is to propose a critical care triage approach for major surge in the COVID-19 pandemic, to raise key ethical and clinical considerations for critical care triage in this context, and to offer suggestions for implementation of the critical care triage approach in the Ontario health system if needed.[3]

Critical care triage in the COVID-19 pandemic should aim to maximize the survival and recovery of as many critically ill patients[4] as possible and as equitably as possible within available critical care resources. In a pandemic, critical care triage for major surge will inevitably involve an alternative standard of care. For this reason, critical care triage for major surge should be considered an option of last resort – to be invoked only when all existing local or regional critical care resources have been used, all reasonable attempts have been made to move patients to or resources from areas with greater critical resource availability, and only for as long as the major surge lasts – and would require an emergency order in order to be implemented in Ontario. When not all patient needs can be met within resource constraints, triage is the systematic and consistent process of determining priorities for treatment based on objective and explicit clinical criteria. This is especially important in the context of a major surge, when the number of patients with critical illness exceeds critical care capacity. In the absence of explicit triage criteria and a systematic and consistent process of triage, inconsistencies in clinical practice may result in increased mortality and morbidity.

Critical care triage for a major surge should be predictable and apply to an entire region rather than to individual hospitals alone. In the current COVID-19 pandemic context, the decision to initiate triage falls under the authority of, and would be made by, the Ontario Health Critical Care Command Centre with full situational awareness of the existing critical care resources and demand for critical care. In a major surge, a proportionate response to increasing and decreasing levels of demand on scarce critical care resources is essential. The degree of triage should be calibrated to the degree of demand in order to limit the possibility that a patient will be denied critical care resources unnecessarily. As critical care demand increases in a major surge, triage criteria should become proportionately more stringent; similarly, as critical care demand decreases in a major surge, triage criteria should become proportionately less stringent. Triage criteria and their application should be evaluated at regular intervals to ensure that the overarching goal of maximizing survival and recovery of critically ill patients within available critical care resources is met.

Critical care triage for major surge in the COVID-19 pandemic should be guided by ethical principles. Relevant ethical principles include medical utility, proportionality, fairness, equity, beneficence (including non-abandonment), respect for autonomy, and accountability. Respect for human rights and solidarity with all community members are key values of an ethical triage approach. In a major surge in demand for critical care resources, the necessity of critical care triage does not change the fact that the lives of all Ontarians are of equal moral worth and that all patients must be cared for and receive appropriate symptom management. Those who do not receive critical care resources due to triage should continue to receive other appropriate treatments and supports, including palliative care if needed. Importantly, critical care triage may have a differential impact on some patient populations who may be disadvantaged due to pre-existing health and social inequities or conscious or unconscious bias in clinical settings. Evidence of systemic bias against specific groups should be considered as reason to review and potentially revise these triage recommendations and their application.

Guiding Ethical Principles:

The overall purpose of a triage system in a pandemic is to minimize mortality and morbidity for a population overall as opposed to an individual mortality and morbidity risk. There are published frameworks outlining ethical principles to guide triage systems.1-4 Recent studies of Canadian perspectives on priority setting of critical care resources in a pandemic indicate a preference for maximizing the number of lives saved,5,[5] followed by the application of a fair procedure for prioritization of people with similar likelihood of benefit.1,[6] In addition, there is published guidance on how triage systems can minimize risk of discrimination based on factors unrelated to a patient’s clinical needs and mitigate discriminatory application of such frameworks in practice.6-8 This body of work informs the ethical underpinnings of the proposed triage approach.

In the context of a major surge in demand for critical care in a pandemic, the following ethical principles are foremost:

  1. Medical Utility – Aim to derive the maximum benefit from critical care resources by prioritizing those patients who are most likely to survive their critical illness. When resources are scarce in a pandemic, patients who are very likely to die from their critical illness or who are very likely to die in the near future[7] even if they recovered from their critical illness would have a lower priority for critical care resources.
  2. Proportionality – Ensure that the number of individuals who are negatively affected by the use of critical care triage criteria in a pandemic does not exceed what would be required to accommodate the surge in demand. Given that critical care capacity and demand can be dynamic, access to critical care should be restricted only to the extent necessary to achieve maximum benefit within resource constraints and should become less restrictive as resources become available or the surge abates.
  3. Fairness – Ensure all patients have a fair chance to benefit from critical care by allocating critical care resources on the basis of clinical criteria relevant to predicting the patient’s likelihood of survival. Triage decisions should treat similar cases similarly based on clinical criteria, i.e., those with similar prognoses should be treated similarly. In the event that clinical criteria are not sufficient to prioritize one patient over another, a fair procedure should be used.
  4. Equity and Respect for Human Rights – Affirm and safeguard the equal moral worth of all people in Ontario by implementing measures to minimize the risk of perpetuating or exacerbating the effects of systemic discrimination or marginalization on access to health care[8] and to uphold individual human rights to the extent possible in a pandemic emergency.[9] This includes ensuring triage decisions: i) are based on objective clinical criteria grounded in best available evidence and not any particular demographic,[10] disease, or disability independent of an individual patient’s prognosis,[11] ii) involve an individual assessment of a patient’s clinical condition in relation to the triage criteria and not to a judgment of the individual’s social value, quality of life or long-term survival, and iii) are supported by accommodations as appropriate for an individual patient to the extent possible in an infection control context (see Respect for Autonomy below).
  5. Beneficence – Act in a way that promotes patients’ well-being to the greatest extent possible given resource constraints by clarifying patient goals of care (i.e., patient wishes, beliefs, and values regarding their treatment) in relation to their critical care needs, providing continuity of care for all patients appropriate to their clinical circumstances, including those whose critical care needs cannot be met, and ensuring no patient is left without care. Although resource scarcity in a pandemic may limit the ability to meet all patient needs, maintaining a caring relationship with all patients is essential.
  6. Respect for Autonomy – Ensure all patients have a chance to make their goals and wishes known and to have treatment provided in alignment with these goals and wishes wherever possible. Patients (or their substitute decision-makers) may need support to make free and informed decisions about their care. To ensure effective communication and informed decision-making, individual patients may require accommodations (e.g., plain language, use of communication devices, interpretation services) and/or participation of attendant care worker or other support person to the extent possible in an infection control context.
  7. Accountability – Remain answerable for decisions made in the context of triage. This means communicating triage decisions, including the criteria used to make those decisions, in an open and honest manner to patients or their substitute decision-makers and to the broader community served. It also involves monitoring the implementation of the triage approach to ensure decisions are based in best clinical evidence and expertise supported by ethical reasoning. Triage decisions, criteria, and processes should be evaluated at regular intervals at local, regional and provincial levels to assess the extent to which they are clinically and ethically justified.

 

In a pandemic context, there is an intrinsic tension between some of the ethical principles outlined above. On the one hand, a criteria-based triage approach that focuses on an individual clinical assessment of predicted mortality and not on any other factors (demographic, quality of life, social standing, etc.) offers a defensible way to reconcile some of the tensions between the principle of medical utility (saving the most lives possible) and the principle of equity (mitigating systemic discrimination or implicit bias in health care). On the other hand, for patients who might wish but who are found ineligible for critical care in a major surge, the pandemic context creates a tension between the principles of medical utility and respect for autonomy, and underscores the importance of the principle of beneficence to ensure all patients receive care even if critical care treatment is not available. The evolving COVID pandemic context in Ontario reveals pre-existing health and social inequities in health care, which a triage approach by itself will be unable to resolve. However, the potential adverse consequences of a triage approach for vulnerable groups can be mitigated in a few ways, including: i) the systematic collection of data on triage outcomes to monitor the effect of the triage approach on vulnerable groups, and ii) proactive measures taken ‘upstream’ in the community and across the health system to prevent members of vulnerable groups from exposure to COVID-19 in the first place. Some of these tensions may not be fully resolved in a pandemic. For this reason, the principles of proportionality and accountability are essential bulwarks for an ethical triage approach under difficult pandemic circumstances.

 

Clinical Triage Criteria for Critical Care in a Major Surge:

Explicit criteria-based triage decision-making has been recommended in other published guidance for critical care in a pandemic.[12] Use of explicit criteria fosters consistency, advances medical utility and fairness, and supports accountability. It may also alleviate clinician burden at a time of high stress.[13] Eligibility and ineligibility criteria are specified below based on the best available evidence and expert opinion regarding predicted mortality. A patient should meet one of the eligibility criteria and should not meet any of the ineligibility criteria for access to critical care. Where there is insufficient evidence to support a reasonable clinical judgement regarding whether a patient meets ineligibility criteria, a decision of ineligibility should be avoided. In all cases, an individualized review of each patient’s clinical condition should be performed, ensuring not to assume that any specific diagnosis is determinative of prognosis or near-term survival without an analysis of current and best available evidence and the individual’s ability to respond to treatment. Please note: these criteria apply only to patients aged 18 years and should only be used in the context of a major surge in demand for critical care.

Eligibility criteria were outlined by Christian et al.9 and are repeated here:

Variable Eligibility Criteria for Critical Care Admission
Requirement for invasive ventilator support Refractory hypoxemia (SpO2 <90% on FiO2 0.85) OR

Respiratory acidosis with pH <7.2 OR

Clinical evidence of respiratory failure OR

Inability to protect or maintain airway

Hypotension Low systolic BP (e.g., SBP <90 mm Hg for most adults) OR

relative hypotension with clinical evidence of shock (altered level of consciousness, decreased urine output, end-organ hypoperfusion), refractory to volume resuscitation requiring vasopressor/inotrope support that cannot be managed on a medical ward

SpO2 = oxygen saturation as measured by pulse oximetry

 

Ineligibility criteria for critical care triage in a pandemic have typically fallen under two categories: (1) criteria that indicate a low probability of surviving an acute episode of critical illness, and (2) criteria that indicate a low probability of surviving more than a few months regardless of the acute episode of critical illness.9 These categories are not mutually exclusive, as life-limiting illnesses affect prognosis from acute illness, and acute illness affects the trajectory of chronic illness. The criteria outlined below would limit eligibility for critical care if someone is very likely to die from their critical illness or are very likely to die in the near future even if they recovered from their critical illness. Please note: these criteria are not exhaustive and are meant to reflect known evidence and/or clinical experience-based prognostic indicators for specific conditions. Some medical conditions not listed may also indicate a similarly poor prognosis, and such patients should be triaged accordingly. Conversely, some medical conditions listed may not indicate a poor prognosis in specific situations and such patients should not be found ineligible. Clinicians should use their best clinical judgment informed by these clinical triage criteria as appropriate to determine whether an individual patient’s clinical circumstances would indicate that they should receive critical care resources. The tools listed in the table below can be found in Appendix C.

Criterion Level 1 Triage Scenario (Aiming to exclude people with >~80% predicted mortality) Level 2 Triage Scenario (Aiming to exclude people with >~50% predicted mortality) Level 3 Triage Scenario (Aiming to exclude people with ~>30% predicted mortality)
A Severe Trauma with predicted mortality >80% based on TRISS score Severe Trauma with predicted mortality >50% based on TRISS score Trauma with predicted mortality >30% based on TRISS score
B Severe burns with any 2 of: Age >60, >40% total body surface area affected, inhalation injury Same as Level 1 Same as Level 1
C Cardiac arrest

  • Unwitnessed cardiac arrest
  • Witnessed cardiac arrest with non-shockable rhythm
  • Recurrent cardiac arrest
Same as Level 1 Cardiac arrest
D Progressive, late or end-stage illness marked by severe cognitive impairment, clinically defined as an inability to independently perform basic activities of daily living at baseline (2-4 weeks before admission). This criterion does not refer to all conditions that cause cognitive impairment or all conditions clinically defined by an inability to independently perform basic activities of daily living – see explanatory note at end of table. Same as Level 1 Progressive, end-stage illness marked by moderate or severe cognitive impairment, clinically defined as an inability to independently perform multiple instrumental activities of daily living (IADLs – e.g., finances, medications, transportation) or any of the basic activities of daily living (BADLs – e.g., bathing, dressing, feeding) at baseline (2-4 weeks before admission). This criterion does not refer to all conditions that cause cognitive impairment or all conditions clinically defined by an inability to independently perform instrumental or basic activities of daily living – see explanatory note at end of table.
E Progressive, end-stage neurodegenerative disease Same as Level 1 Progressive neurodegenerative disease
F Metastatic malignant disease with any of the following:

·       ECOG class >=2

·       Disease progressing or stable on treatment

·       Active treatment plan with >80% predicted mortality during or soon after critical illness

·       Unproven (experimental) treatment plan

·       Treatment plan that would only be started if the patient recovers from critical illness

Metastatic malignant disease with any of the following:

·       ECOG class >=2

·       Disease progressing or stable on treatment

·       Active treatment plan with >50% predicted mortality during or soon after critical illness

·       Unproven (experimental) treatment plan

·       Treatment plan that would only be started if the patient recovers from critical illness

Metastatic malignant disease
G Advanced and irreversible immunocompromised Same as Level 1 Same as Level 1
H Severe and irreversible neurologic event with >80% risk of death or poor outcome based on:

  • For Intracerebral Hemorrhage a modified ICH score of 4-7
  • For Subarachnoid Hemorrhage, a WFNS grade 5 (GCS 3-6)
  • For Traumatic Brain Injury, the IMPACT score
  • Acute ischemic stroke alone would not be excluded at this level
Severe and irreversible neurologic event with >50% risk of death or poor outcome based on:

  • For Intracerebral Hemorrhage a modified ICH score of 3-7
  • For Subarachnoid Hemorrhage, a WFNS grade 3-5 (GCS 3-12 OR GCS 13-14 AND focal neurological deficits)
  • For Traumatic Brain Injury, the IMPACT score
  • For acute ischemic stroke, an NIHSS of 22-42.
Irreversible neurologic event/condition with >30% risk of death or poor outcome based on:

  • For Intracerebral Hemorrhage a modified ICH score of 2-7
  • For Subarachnoid Hemorrhage, a WFNS grade 2-5 (GCS <15)
  • For Traumatic Brain Injury, the IMPACT score
  • For acute ischemic stroke, an NIHSS of 14-42.
I End-stage organ failure meeting the following criteria:

Heart

·        Chronic End-stage Heart Failure with NYHA Class 4 symptoms, ineligible for advanced therapies (mechanical support, transplant)

Lung

·        COPD with chronic home O2 >12h per day or breathlessness at rest

·        Cystic Fibrosis with FEV1 <20% predicted when measured at time of clinical stability

·        Pulmonary fibrosis with VC or TLC <60% predicted, baseline PaO2 <55 mmHg, or secondary pulmonary hypertension

·        For pulmonary hypertension, anyone with ESC/ERS high risk criteria (see below)

Liver

·       Chronic Liver Disease with failure of 2 or more organ systems (ACLF Grades 2-3)

·       MELD score >=25

Note that patients who meet these criteria may be eligible for ICU admission if they are currently on an organ donation waiting list and would be given highest priority if admitted to ICU (e.g., status 4/4F for liver transplantation). This does not include people who have been referred to a transplant service but have not yet been listed for a transplantation. This also would not apply if organ donation processes are halted due to triage conditions precluding organ procurement.

End-stage organ failure meeting the following criteria:

Heart

·        Chronic End-stage Heart Failure with NYHA Class 3 or 4 symptoms, ineligible for advanced therapies (mechanical support, transplant) PLUS any of:

o   High/increasing BNP

o   Cardiorenal syndrome

o   Recent discharge (<30d) or multiple admissions for CHF in past 6 months

Lung

·        COPD with

o   Chronic home O2 OR

o   >=1 admission for COPD in past 12 months AND has to stop for shortness of breath when walking at own pace

·        Cystic Fibrosis with FEV1 <20% predicted when measured at time of clinical stability

·        Pulmonary fibrosis with VC or TLC <60% predicted, baseline PaO2 <55 mmHg, or secondary pulmonary hypertension

·        For pulmonary hypertension, anyone with ESC/ERS high risk criteria (see below)

Liver

·       Chronic Liver Disease with failure of 1 or more organ systems (ACLF Grades 1-3)

·       MELD score >=15

Note that patients who meet these criteria may be eligible for ICU admission if they are currently on an organ donation waiting list and would be given highest priority if admitted to ICU (e.g., status 4/4F for liver transplantation). This does not include people who have been referred to a transplant service but have not yet been listed for a transplantation. This also would not apply if organ donation processes are halted due to triage conditions precluding organ procurement.

End-stage organ failure with one-year mortality risk >30% as suggested by an unscheduled admission for an exacerbation or complication of their chronic illness in the past 12 months or previous organ transplant with evidence of chronic rejection or chronic organ dysfunction in the transplanted organ. Note that some admissions (e.g., catheter or access infections) may not suggest an elevated risk of mortality, and for some less common conditions (e.g., CF) unscheduled admissions may not suggest an elevated risk of mortality and specialist input should be sought.
J Anyone with a Clinical Frailty Score of >=7 (on the 9-point tool) at baseline (2-4 weeks before admission) due to a progressive illness or generalized deterioration of health status (see explanatory note at end of table) Anyone with a Clinical Frailty Score of >=5 (on the 9-point tool) at baseline (2-4 weeks before admission) due to a progressive illness or generalized deterioration of health status (see explanatory note at end of table) Same as Level 2
K Elective palliative surgery Same as Level 1 Elective or emergency palliative surgery
L Anyone receiving mechanical ventilation for >=14 days with a ProVent score of 4-5. Anyone receiving mechanical ventilation for >=14 days with a ProVent score of 2-5. Anyone receiving mechanical ventilation for >=14 days who is not improving
M Any other clinical condition that is judged to have a >80% chance of mortality during or soon after critical illness Any other clinical condition that is judged to have a >50% chance of mortality during or soon after critical illness Any other clinical condition that is judged to have a >30% chance of mortality during or soon after critical illness

Explanatory Note:

Criterion D (progressive, end-stage illness marked by severe cognitive impairment) and criterion J (clinical frailty due to a progressive illness or generalized deterioration of health status) would be relevant ineligibility criteria for progressive and life-limiting conditions, such as Alzheimer’s disease or high level of multi-morbidity, which are known to be associated with a higher risk of mortality during or soon after an episode of critical illness.10 By contrast, criterion D and criterion J would not be ineligibility criteria for non-progressive conditions with cognitive impairment, clinical frailty, or dependency, such as developmental disability, spinal cord injury, or traumatic brain injury, because these are not necessarily associated with a higher risk of death during or soon after an episode of critical illness. To be clear, the clinical focus of critical care triage decision in major surge should be on the prognosis (predicted mortality) of the individual in question and not any particular demography, disease or disability. The clinical criteria are not intended to exclude nor to deprioritize all people with clinical frailty, multimorbidity, and cognitive impairment or all individuals with a given diagnosis.

 

Additional Considerations at Level 3:

At Level 3, only patients with the lowest risk of death in the near future would be eligible for critical care. However, if demand for critical care continues to exceed available resources, there may come a point where there may be little clinical evidence to guide triage decisions on the basis of medical utility.[14] As a result, triage decisions must appeal to fairness.

Fairness would suggest that those patients who are already receiving critical care and are benefiting from it should continue to receive it. In other words, demand for critical care from new patients does not justify withdrawing life-sustaining measures from admitted patients with a similar prospect of benefitting from them. Decisions to withdraw life-sustaining measures from someone already admitted to critical care should be driven by clinical considerations. In practice, this would involve a frequent reassessment of admitted patients by the clinical team for any indication that the patient is no longer responding to treatment, or where the patient’s clinical trajectory suggests that their chances of recovery have substantially worsened from when they were admitted. It is important to reiterate that a decision to withdraw critical care should be based solely on clinical considerations, integrating all relevant information, and not on any demography, disease, or disability, or other factors. As with all triage decisions, such patients should be referred for a second opinion to confirm the assessment (i.e., that the person’s chance of survival is poor).

Fairness would also suggest that, when an opportunity emerges to admit a new patient into critical care and a triage decision must be made between multiple patients who cannot be distinguished on the basis of medical utility (i.e., all meet an eligibility criterion and do not meet any ineligibility criteria), then a system of random selection among eligible and not-yet-admitted patients should be implemented. Random selection upholds the principle of fairness in situations where it is not possible to rely on medical utility to make clinical decisions.[15] It mitigates against the potential of explicit or unconscious bias in decision-making and demonstrates the value of humility when uncertainty is high. Random selection also has other advantages as a decision-making strategy in the context of an overwhelming surge of critically ill patients: it is already a well-established practice for making decisions in situations of uncertainty or equipoise in medicine (e.g., randomized controlled trials); it reduces the moral and psychological burden of deciding who receives life-saving treatment, which can lead to moral injury and burnout after repeated cases; it is efficient when decisions need to be made rapidly; and it allows for procedural transparency and accountability. When decisions are made through random selection, this should be done with one or more witnesses, and a record of the outcome of the process of randomization should be documented.

 

Critical Care Triage Approach:

Critical care triage for major surge in a pandemic should be well-coordinated, consistent, predictable, and responsive to an evolving pandemic context.[16] A three-level triage approach is proposed. A proportionate response to increasing levels of demand on scarce resources is essential. As system pressures increase, triage criteria become proportionately more stringent. The degree of triage should be calibrated to the degree of demand in order to limit the possibility that a patient will be denied critical care resources unnecessarily.

In the current COVID-19 pandemic context, the decision to initiate critical care triage for major surge would fall under the authority of, and would be made by, the provincial Critical Care Command Centre with full situational awareness of existing critical care resources and demands. Each hospital should be aware of the precise number of critically ill and mechanically-ventilated patients they can accommodate with their resources (including consumables), staff, and space. The timing and degree of the surge in demand is likely to be variable in different institutions and regions, so as one hospital or region approaches their maximum capacity, significant efforts should be taken to transfer patients to, or resources from, hospitals with lower occupancy to ensure that all resources are maximally used prior to the initiation of critical care triage for major surge. This will also reduce the chances that some patients will be denied critical care resources that they would have received had they been in another hospital. When all hospitals in a region are near their capacity, or when transportation resources are no longer able to move patients to hospitals with lower occupancy, Provincial and Regional Critical Care Command Centres should clearly inform these hospitals that a major surge scenario is impending. Major surge in demand may be intermittent, requiring a regular review (e.g., every 12 hours) of occupancy to determine whether the triage protocol is still required or whether hospitals can decrease the level of triage.

The prospect of a major surge in demand for critical care should prompt discussions with patients or their substitute decision-maker to identify and document patient wishes and values and ensure current treatment plans are up to date. It is also appropriate for physicians and other healthcare providers to engage in advance care planning conversations with patients/SDMs in hospital or in community settings to explore the patient’s wishes and values and to clarity the treatment goals and options available if the patient were to become acutely or critically ill. Regardless of triage decisions at any level, all efforts should be made to treat patients supportively and to ensure all patients receive the right care, in the right place, at the right time to the greatest extent possible during the COVID pandemic.

If a major surge is imminent (but before level 1 triage is initiated), all patients who are currently receiving critical care resources should be reviewed, and those who would be excluded under a level 1 triage scenario should be identified in advance and they (or their substitute decision-makers) should be informed of the situation if possible. When a level 1 triage scenario has been initiated, these patients should begin to have life-sustaining measures withdrawn and be transferred to non-critical care beds, with appropriate palliative measures initiated (or other measures in accordance with the patient’s values, beliefs, and wishes). All patients need not have life-sustaining measures withdrawn at once. Rather, life-sustaining measures should be withdrawn sequentially starting with those patients who meet the greatest number of ineligibility criteria. Withdrawal of life-sustaining measures should be in proportion to demand and operational capacities. Each hospital should communicate the number of patients who would no longer receive critical care in a level 1 scenario to their Regional Critical Care Command Centre to assist with planning and coordination provincially. All new patients who develop critical illness in a level 1 triage scenario should be assessed against the level 1 criteria before receiving critical care resources.

If major surge escalates, all patients in their critical care beds who would be ineligible for critical care under a level 2 triage scenario should be identified and they (or their substitute decision-makers) should be informed that level 2 triage is imminent. The regional critical care command centre should continue to coordinate transportation of patients to optimize the utilization of all critical care resources before initiating a level 2 triage. If a level 2 triage scenario is initiated, hospitals should proceed in a similar manner to the steps described above. All new patients who develop critical illness after a level 2 triage scenario should be assessed against the level 2 criteria before receiving critical care resources. Hospitals should then prepare for a level 3 triage scenario, similar to the previous steps. Based on the principle of proportionality, the number of patients denied access to or withdrawn from critical care should not be more than the incoming demand requires based on the current and expected surge of critically ill patients. This means that triage levels should go up or down in relation to demand and should continue only as long as the major surge persists to minimize mortality and morbidity.

  1. Triage in Hospital: Suggestions for Implementation

The triage approach recommended in this document may be implemented differently depending on the resources available to the hospital and the region in question, which may fluctuate over the course of the pandemic. Appreciating that the implementation of this approach will vary to some degree based on available human resources and other contextual factors at individual institutions, the following suggestions offer a starting point for local and regional planning.

 

  1. Triage Process

In general, the triage process comprises four steps. This process represents an ideal, which may need to be modified to suit specific settings.

Step 1: Clarify Patient Goals of Care and Inform Patient/Family of Change in Standard of Care Due to Major Surge

In general, regardless of whether or not triage has been implemented, when a patient is admitted to hospital or assessed in the Emergency Department, the most responsible physician/most responsible provider (MRP) should explore the patient’s goals and aim to develop a plan of care that reflects those goals and respects the limitations of medical care. If the patient indicates a preference to receive life-sustaining measures in the event of clinical deterioration, but the MRP feels that this is not appropriate given the patient’s medical condition, the MRP should explain this and propose a less aggressive treatment approach. If a person expresses a desire not to receive life-sustaining treatment in the event of clinical deterioration, this should be recorded in the chart and the patient should not be referred for critical care. At this time, the patient or substitute decision-maker should also be informed that the hospital is moving towards triage and that the standard of care may be altered, including strict allocation of critical care based on the approach recommended in this document.

Step 2: Assess Patient Against Triage Criteria

Once the triage approach has been implemented, if an admitted patient meets (or is close to meeting) the eligibility criteria, provided that there is no order to withhold life-sustaining measures, the MRP should assess the patient to determine whether they meet the eligibility criteria and whether they meet any of the ineligibility criteria for the level of triage. A second physician, who would ideally be a member of the critical care team, rapid response team (RRT), or a designated triage physician, should verify whether the patient meets the eligibility and/or ineligibility criteria. Ideally, disagreements about eligibility/ineligibility criteria should be resolved by consensus of the two physicians who assessed the patient if possible. The patient’s triage assessment should be documented in the health record.

Step 3: Referral of Case to Triage Team

Following this assessment, the MRP should communicate the assessment to the hospital or regional triage team, who will review the decision. The triage team may also help to resolve any disagreement about whether the patient meets eligibility/ineligibility criteria. The triage team should confirm that, under the triage approach, admission to critical care will or will not be provided based on current critical care capacity. For clarity, the MRP has the clinical responsibility for determining whether the patient meets the eligibility and ineligibility criteria. The health care system, through the implementation of the triage approach, takes responsibility for determining that they cannot offer admission to critical care. The triage team is ultimately responsible for making decisions regarding the allocation of critical care resources according to the approved criteria for the appropriate level of surge (Level 1, 2, 3).

Step 4: Communication with Patients and Family/Substitute Decision-Maker(s)

The MRP will communicate the outcome of the triage decision (i.e., whether or not the patient will be admitted to critical care) to the patient or substitute decision-maker (see Appendix B for suggested language to disclose a triage decision), with support from other members of the interprofessional team (social work, spiritual care, etc.). The MRP will document the decision in the patient’s medical record. The MRP should continue to offer all other indicated medical treatments and write comfort orders to ensure that the patient receives appropriate palliative care (see Appendix D for suggested comfort medication orders).

Additional suggestions for implementation at the institutional level, including policies, tools, descriptions of roles and responsibilities of triage teams, and communications suggestions, have been developed by Hamilton Health Sciences and can be accessed here: https://macdrop.mcmaster.ca/s/PoGMyw848Wipz88

 

  1. Triage Team

Triage teams have been recommended in other published guidance to support consistent, evidence-based and accountable decisions about the use of critical care resources in the context of a pandemic surge.[17] Triage teams may be institution-based or regional. Suggestions for triage team roles and responsibilities can be found here: https://macdrop.mcmaster.ca/s/PoGMyw848Wipz88.

  1. Patient and Public Communication

In the context of the COVID-19 pandemic, transparency is key to maintaining patient and public trust. This includes being transparent about why critical care triage may be needed in major surge, how triage decisions will be made and by whom, when an institution or region has initiated critical care triage for major surge, and how patients will be supported during this difficult time. Patient and public-facing communication materials (e.g., signage, information sheets) will be essential. Suggestions for how to communicate triage decisions to patients (or their substitute decision-maker) can be found in Appendix E. To ensure effective communication, some patients may require accommodated communication (e.g., plain language, use of communication devices) and access to interpretation services. Attendant care workers or other personal support persons may play essential roles in informing individual treatment plans and advising on an individual patient’s clinical history and functional status. This may require accommodation within institutional visitor policies to the extent possible to comply with infection control guidelines.

 

  1. Clinician Support

Critical care triage in a major surge will entail a significant cognitive, psychological, and moral burden on clinicians and underlines the need to support and prepare critical care clinicians for major surge in advance. Clinical guidance, including explicit triage criteria, institutional supports, such as triage teams, and assurance of legal protection will go some distance to support clinicians. Additional clinician supports identified in stakeholder feedback include: i) education and training about the critical care triage approach for critical care teams, ii) creation of decision support tools, e.g., translating the critical care triage criteria into an accessible format for ease of use in clinical practice, iii) guidelines for emergency department staff and EMS, and iv) general information for clinicians in other clinical areas and settings about the critical care triage approach to foster effective collaboration among clinical teams.

 

  1. Dispute Resolution

Disagreement amongst clinicians may arise regarding the eligibility/ineligibility of a patient for critical care. Although consensus-based decision-making is ideal, a mechanism for resolving disagreement may be needed. Options for dispute resolution may include additional consultation with appropriate medical specialists or discussion with the Triage Team. Where a patient/family disagrees with the outcome of a triage decision, the Triage Team may assist the MRP in communicating the rationale for their resource allocation decision, and the process by which triage decisions are made. Other members of the interprofessional team (e.g., social work, spiritual care, patient experience specialists, bioethicist, etc.) may also assist in supporting patients and families who are distressed by the outcome of the triage process. Given the context of critical care triage in a major surge, where an overwhelming number of critically ill patients must be assessed rapidly in a dynamic and over-taxed environment, a formal process for patients and families to appeal triage decisions may not be feasible or appropriate (e.g., if critical care is contrary to the patient’s wishes). Due process considerations (e.g., transparency about reasons for triage decisions) are especially important in this context. Hospitals should plan for how they might proactively prepare patients and families for possible outcomes of the triage process as well as how they would respond transparently and compassionately to patient or family concerns should these arise.

 

Concluding Recommendations:

The COVID-19 pandemic presents new challenges for the Ontario health system about how health resources will be used to meet patient and population needs. At time of writing, there is limited guidance for health systems about how a major surge in demand for critical care should be managed in a pandemic context. This document offers recommendations to inform the creation of a critical care triage approach in Ontario based on clinical and ethical considerations in the event of a major surge in demand for critical care in the COVID-19 pandemic. Given the novelty of this approach and its broader significance for all Ontarians, we offer two additional recommendations related to next steps for development of this work.

  1. Communicating with the public: Transparency is key to maintaining public trust during a pandemic. Years of risk and outbreak communication science show that the public will support measures when transparency is the “default” setting for governments dealing with public health emergencies and when considerations of fairness have been addressed. In the context of critical care triage in a pandemic, this includes being transparent about: i) the need for these triage criteria and the accompanying legal powers needed to implement them in a public health emergency; ii) the ethical basis for the triage criteria (i.e., minimizing morbidity and mortality); and iii) the process through which the criteria were developed (i.e., based on consultations with a broad array of stakeholders). It is therefore recommended that this document be made public available and that any communication includes the ethical basis and process for the development of these recommendations.
  1. Monitoring and iterative review of the approach: Given limited experience with critical care triage for major surge, it will be important to monitor, review and revise the approach to ensure it is achieving the aim for which it is intended (i.e., to maximize survival and recovery from critical illness of as many patients as possible within critical care resources in a major surge) and is not leading to unintended adverse consequences. This underlines the need for clear and consistent documentation practices across hospitals, the prospective capture of relevant clinical and other data about triage decisions, and a mechanism for mid-course correction that is nimble, transparent and accountable. This aligns closely with other calls for equity-related data collection to understand the impact of pandemic interventions on patients, particularly those who are marginalized in health care and may face systemic disadvantage for other reasons, and to mitigate negative impacts to the extent possible within the pandemic context.

 

 

References <needs updating>

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  2. Frolic A, Kata A, Kraus P. Development of a critical care triage protocol for pandemic influenza: integrating ethics, evidence and effectiveness. Healthc Q. 2009;12(4):54-62.
  3. RC. M, J. D, JR. D, et al. Triage of scarce critical care resources in COVID-19: an implementation guide for regional allocation: An expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest. 2020.
  4. Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenzawww.utoronto.ca/jcb/home/documents/pandemic.pdf. http://jcb.utoronto.ca/news/documents/pandemic_Stand-on-guard-for-thee_report_JCB2005.pdf Accessed Mar 25, 2020.
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  6. Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. https://dredf.org/avoiding-disability-based-discrimination-in-treatment-rationing/. Accessed April 12, 2020.
  7. Evaluation Framework for Crisis Standard of Care Plans. http://www.bazelon.org/wp-content/uploads/2020/04/4-9-20-Evaluation-framework-for-crisis-standards-of-care-plans_final.pdf. Accessed April 12, 2020.
  8. Kirby J. Enhancing the fairness of pandemic critical care triage. J Med Ethics. 2010;36(12):758-761.
  9. Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
  10. Brummel NE, Bell SP, Girard TD, et al. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med. 2017;196(1):64-72.
  11. Shahpori R, Stelfox HT, Doig CJ, Boiteau PJ, Zygun DA. Sequential Organ Failure Assessment in H1N1 pandemic planning. Crit Care Med. 2011;39(4):827-832.
  12. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020.
  13. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020.
  14. Christian MD, Toltzis P, Kanter RK, et al. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S109-119.
  15. Antommaria AH, Powell T, Miller JE, Christian MD, Task Force for Pediatric Emergency Mass Critical C. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S163-168.
  16. Gall C, Wetzel R, Kolker A, Kanter RK, Toltzis P. Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds. Crit Care Med. 2016;44(9):1762-1768.
  17. Christian MD, Toltzis P, Kanter RK, Burkle FM, Jr., Vernon DD, Kissoon N. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S109-119.
  18. Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175(11):1377-1381.
  19. Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1(1):5.
  20. Darmon M, Bourmaud A, Georges Q, et al. Changes in critically ill cancer patients’ short-term outcome over the last decades: results of systematic review with meta-analysis on individual data. Intensive Care Med. 2019;45(7):977-987.
  21. Karvellas CJ, Garcia-Lopez E, Fernandez J, et al. Dynamic Prognostication in Critically Ill Cirrhotic Patients With Multiorgan Failure in ICUs in Europe and North America: A Multicenter Analysis. Crit Care Med. 2018;46(11):1783-1791.
  22. Kylhammar D, Kjellstrom B, Hjalmarsson C, et al. A comprehensive risk stratification at early follow-up determines prognosis in pulmonary arterial hypertension. Eur Heart J. 2018;39(47):4175-4181.
  23. Hemphill JC, 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897.
  24. Fonarow GC, Saver JL, Smith EE, et al. Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke. J Am Heart Assoc. 2012;1(1):42-50.
  25. Roozenbeek B, Lingsma HF, Lecky FE, et al. Prediction of outcome after moderate and severe traumatic brain injury: external validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models. Crit Care Med. 2012;40(5):1609-1617.
  26. Fernando SM, McIsaac DI, Rochwerg B, et al. Frailty and associated outcomes and resource utilization following in-hospital cardiac arrest. Resuscitation. 2020;146:138-144.
  27. Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105-1122.
  28. Carson SS, Garrett J, Hanson LC, et al. A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation. Crit Care Med. 2008;36(7):2061-2069.
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  31. Steiner T, Juvela S, Unterberg A, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013;35(2):93-112.
  32. Hernaez R, Sola E, Moreau R, Gines P. Acute-on-chronic liver failure: an update. Gut. 2017;66(3):541-553.

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Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article

Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e-e74S.

Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.

Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. Hastings Center Report 2020; Apr 2. Available at: https://www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/

Appendix A. Backgrounder: Development of the Recommendations <to be updated>

 

This document was developed by the Bioethics Table based on a review of the literature on critical care triage in a pandemic, consultation with clinical experts, and feedback from health system stakeholders. Feedback has been addressed to the greatest extent possible in this current version where appropriate. This recommendations document is a green document within the overall 2020 COVID pandemic response in Ontario. It is acknowledged that the process for developing an approach to critical care triage in the context of a major surge in demand should remain sensitive and responsive to changing conditions and emerging evidence, and as such, should be on-going.

Development of Critical Care Triage Criteria

Early work on pandemic critical care triage was led by researchers in Ontario following the SARS outbreak and in developing provincial and national pandemic plans in the years leading up to the H1N1 pandemic. 9 At that time, critical care triage criteria using sequential organ failure assessment (SOFA) scores, which help to predict clinical outcomes (acuity and morality risk) of critically ill patients, was proposed. Over the last decade, a number of clinical developments, including novel therapies and new research evidence, have precipitated the need for an updated approach to critical care triage criteria in a pandemic context.

Below we outline the key considerations contributing to the updated critical care triage criteria outlined in this document:

  • With greater experience, most experts no longer recommend the use of SOFA scores to prioritize patients in a pandemic context because the correlation with outcomes is not as strong as was previously believed. Many young patients are admitted with severe illness but ultimately survive, and the severity of acute illness does not imply greater or lower utility of treatment.
  • Advances in clinical management of cancer mean that some individuals with metastatic cancer, who previously would have not benefited from intensive care support, have a reasonable expectation of surviving an ICU admission and living for years.19,20
  • Critical care medicine is better able to prognosticate for patients with some types of chronic organ disease who develop critical illness, such as people with chronic liver disease using the Acute on Chronic Liver Failure (ACLF) grading system.21
  • Organ donation has become more common and may offer substantial life prolongation for people with organ failure. Selected patients who are admitted to the ICU and assigned the highest priority for organ transplantation have a reasonably high expectation of receiving an organ and surviving to discharge. This would mean that anyone who is immediately postoperative from an organ transplant should not be denied ICU admission. However, patients who are being referred for ICU admission while awaiting an organ should only be admitted if organ transplantation is still proceeding (and this may not be the case if people who would be eligible for organ donation after neurological or circulatory death are not being admitted to the ICU) and they are assigned the highest priority for an organ transplant
  • Critical care medicine has better prognostication tools for neurological injury, including:
    • For subarachnoid hemorrhage, the WFNS system.22
    • For intracerebral hemorrhage, the ICH score.23
    • For acute ischemic stroke, the NIH Stroke Scale.24
    • For moderate or severe traumatic brain injury, the IMPACT score.25
  • Clinical research indicates that age may be less relevant to predicting mortality than frailty, multimorbidity, or neurodegenerative disease.10,26,27 The Clinical Frailty Score is currently in widespread use throughout the healthcare system.
  • There is also a greater appreciation of the concept of chronic critical illness, and the ability to identify ICU patients who have survived their acute illness but who are still requiring mechanical ventilation after 2 weeks and very unlikely to survive to a year using predictive tools such as the ProVent score.28-30

 

The critical care triage criteria were developed iteratively in consultation with Canadian medical experts representing specialties including critical care, emergency medicine, neurology, geriatrics, oncology, cardiology, nephrology, respirology, neurosurgery, hepatology, palliative care, and internal medicine in March and April 2020.

 

 

Appendix B: The Ontario Human Rights Code Prohibited Grounds of Discrimination

 

The Ontario Human Rights Code recognizes that discrimination occurs most often because of a person’s membership in a particular group in society. None of the grounds below should influence the allocation of critical care or medical resources; triage decisions should be based solely on the criteria included in this document.

The Code prohibits actions that discriminate against people based on a protected ground in a protected social area. Protected grounds relevant to the health care context include:

  • Age
  • Ancestry, colour, race
  • Citizenship
  • Ethnic origin
  • Place of origin
  • Creed
  • Disability
  • Family status
  • Marital status (including single status)
  • Gender identity, gender expression
  • Sex
  • Sexual orientation

 

 

 

 

 

 

Appendix C. Triage Criteria Tools

TRISS Score Calculator

https://www.mdapp.co/trauma-injury-severity-score-triss-calculator-277/

 

Clinical Frailty Scale (Rockwood et al)

The CFS is only considered relevant in this triage approach when used to evaluate predicted mortality due to progressive illness or generalized deterioration in health status. (Adapted from: Leonardi, Bueno, Ahrens et al. (2018). Optimised care of elderly patients with acute coronary syndrome. European Heart Journal: Acute Cardiovascular Care. 7. 204887261876162. 10.1177/2048872618761621.) For a training module on the use of CFS, go to: https://rise.articulate.com/share/deb4rT02lvONbq4AfcMNRUudcd6QMts3#/

ProVent Score- calculated at 14 days:

One point for each of Age >50, platelet count <150, requiring hemodialysis, and requiring vasopressors. An additional point is given for age >=65, for a maximum score of 5. Scores of 4-5 at 14 days suggest a mortality rate of ~90% at 1 year. Scores of 2-3 at 14 days suggest a mortality rate of 56-80% at 1 year30.

Modified ICH Score23:

One point each for age >80, infratentorial origin, volume >30mL, intraventricular extension, use of oral anticoagulants, and Glasgow Coma Score of 5-12. Two points for a GCS of 3-4. Scores of 4-7 suggest a 30-day mortality rate of >80%. Scores of 3-7 suggest a mortality rate of >60%.

The World Federation of Neurological Surgeons grading system:

A combination of Glasgow Coma Score (GCS) and the presence or absence of focal neurological deficits31. A WFNS grade 5 (GCS 3-6) is associated with a >90% probability of a poor outcome. Grades 3-4 (GCS 7-12 or GCS 13-14 AND focal neurological deficits) are associated with a >50% probability of a poor outcome. Grade 2 (GCS 14 with no neurological deficits) is associated with a ~30% probability of a poor outcome.

National Institute of Health Stroke Scale (NIHSS): score 0-7 is associated with a 30-day mortality of 4.2%; 8-13 with a 30d mortality of 13.9%; 14-21 with a 30d mortality of 31.6%; and 22-42 with a 30d mortality of 53.5%24:.

The IMPACT Score25 predicts outcome at 6-months based on multiple demographic, clinical and radiographical factors using the calculator found at http://www.tbi-impact.org/?p=impact/calc

The ACLF grading system is based on the number of organ systems failing at the time of admission in a patient with chronic liver disease. Patients with more than 2 organ systems failing on presentation (ACLF Grades 2 and 3) have an >=80% risk of mortality at 6 months32. Those with ACLF Grade 1 have an approximately 50% mortality at 6 months32; ACLF grade 1 is defined as having chronic liver failure plus ONE of the following:

  • Creatinine >177 umol/L (2.0 mg/dL)
  • Creatinine >132 umol/L (1.5 mg/dL) AND Hepatic encephalopathy grade 3-4
  • Creatinine >132 umol/L (1.5 mg/dL) OR Hepatic encephalopathy grade 1-2 AND ONE OF:
    • Bilirbin >200umol/L (12mg/dL)
    • INR >2.5
    • pressor support required
    • PaO2/FiO2 <200

For pulmonary hypertension, the ECS/ERS High Risk Criteria are22:

  • WHO Class 4 symptoms
  • 6MWT <165m
  • NT pro-BNP >1400 ng/L
  • RA area >26 cm2
  • RAP >14 mmHg
  • CI <2.0 L/min/m2
  • SvO2 <60%

 

 

Appendix D. Suggested order set for symptom management for COVID-19 patients (adapted with permission from Champlain Palliative Symptom Management Medication Order Form – Long Term Care)

Symptom Medications Recommended starting dose
Pain/Dyspnea Hydromorphone 2mg/ml 0.5-1.0 mg SC q30min PRN*
Nausea/Delirium Haloperidol 5mg/ml 1 mg subcut q2hourly

PRN **

Sedation Midazolam 5 mg/ml 1-2 mg subcut q15 minutes PRN ***
Secretions Scopolamine 0.4 mg/ml 0.4 mg subcut q4hourly PRN
Fever Acetaminophen 650 mg suppositories Administer q6hourly PR PRN
Urinary retention Foley catheter 16 Fr Insert catheter PRN
Dry mouth Mouth swabs Mouth care QID and PRN

Please call MD if patient receives more than 2 PRN of hydromorphone in 4 hours.

* may start at 0.25mg in a patient who is opioid naive, frail, or elderly

** relative contraindication in Parkinson’s disease

*** can use higher doses for refractory dyspnea

 

 

 

Appendix E. Suggested language for clinicians providing support to a patient or family member who is denied critical care in the context of a major surge in demand for critical care resources    

Template 1.

Normally, when somebody develops critical illness, the medical team would offer them intensive care (a combination of medications and machines to support their vital organs), provided that the medical team feels that they had a reasonable chance of survival. However, because of the COVID outbreak, we are currently unable to offer intensive care to everyone who is critically ill. As a result, our hospital is working under triage guidelines, which means that we are only offering intensive care to those who are most likely to be able to survive and recover from their critical illness. You probably have heard about this in the news – all hospitals in the region are working under these guidelines.

I regret to inform you that we are unable to offer you intensive care treatments at this time, as a result of the triage guidelines. Because of your medical condition, the likelihood that you would survive even with intensive care is considered to be too low for us to offer intensive care. The team has made this decision based on the following information:__________________.

I have also asked for a second opinion from a colleague, Dr. ___________, who has concurred with my assessment. You may speak with him/her if you wish.

I am deeply sorry about this situation. This is not the way we ordinarily make these decisions, and I can only imagine how you must feel right now. I want you to know that even though we cannot offer intensive care, we will do everything else that could conceivably give you a chance of recovering, including: _________.

And I promise you that, no matter what, we will also use medication to treat any discomfort, such as pain or shortness of breath. We know that when we treat discomfort appropriately, this is not harmful and may actually help improve your condition.

 

Template 2.

As you know, you/your loved one has been receiving treatment in our Intensive Care Unit. Normally, when somebody is admitted to our Intensive Care Unit, the medical team continues to offer them intensive care until they recover, or it becomes apparent that there is no reasonable chance that they could recover even with continued intensive care. However, because of the COVID outbreak, we are currently unable to offer intensive care to everyone who is critically ill. As a result, our hospital is working under triage guidelines, which means that we are only offering to provide or continue intensive care for those who are most likely to be able to survive and recover from their critical illness. You probably have heard about this in the news – all hospitals in the region are working under these guidelines.

I regret to inform you that we are unable to continue giving you/your loved one intensive care treatments at this time, as a result of the triage guidelines. Because of your medical condition, the likelihood that you would survive and recover even with continued intensive care is too low for us to offer intensive care. I have made this decision based on the following information:

[Either document the specific ineligibility criterion met by the patient, or a brief explanation for concluding that this person’s chances of survival fall below the threshold indicated in the triage document]

I have also asked for a second opinion from a colleague, Dr. ___________, who has concurred with my assessment. You may speak with him/her if you wish.

I am deeply sorry about this situation. This is not the way we ordinarily make these decisions, and I can only imagine how you must feel right now. I want you to know that even though we cannot continue intensive care, we will continue other therapies, including:

And I promise you that, no matter what, we will also use medication to treat any discomfort, such as pain or shortness of breath. We know that when we treat discomfort appropriately, this is not harmful and may actually help improve your condition. We have guidelines for how to keep people comfortable when we discontinue life-sustaining measures, and we will use those guidelines.

 Text of July 7, 2020 Letter from Ontario Health’s Medical Triage Protocol Committee to Disability Community Roundtable Participants

To:       Roundtable Participants

From: Ontario COVID-19 Bioethics Table

Date:   July 7, 2020

Re:       Input on DRAFT / updated recommendations for critical care triage in the COVID-19 pandemic

Thank you for agreeing to meet with us. Attached please find updated draft recommendations for critical care triage in the COVID-19 pandemic for your review and feedback.

In March 2020, the COVID-19 Bioethics Table worked with health system clinical leaders and front-line health service providers to propose a critical care triage approach in the event of a major demand for critical care services in the COVID-19 pandemic. The draft recommendations were shared by Ontario Health with hospitals on March 28, 2020 to help hospitals to prepare for the possibility of a major surge in critical care demand and to prevent catastrophic health outcomes as have been seen in other jurisdictions. Fortunately, a major surge in demand for critical care has so far been averted.

Following the release of the March 28th version, the COVID-19 Bioethics Table sought or received stakeholder and expert feedback. Much of this feedback has been incorporated where appropriate into the revised document. We are now sharing the updated recommendations with key stakeholders to ensure the issues and concerns that have been raised have been properly addressed, to hear any additional concerns or issues that ought to be addressed, and to inform our final recommendations to Ontario Health by July 31st.

We are grateful to the Ontario Human Rights Commission for its support in co-convening this Roundtable consultation with you. Our aim is to hear your perspectives on critical care triage in a pandemic context, to gain insight into the issues and concerns relevant to the communities you represent, and to invite your input on the overall triage approach. Some questions that we hope will help frame our discussion include:

  1. In the context of a major surge for critical care, the revised recommendations articulate an ethical imperative to use available resources in a manner that saves as many lives as possible, with constraints to ensure that individuals are not excluded on the basis of any particular demographic, disease, or disability independent of an individual patient’s prognosis. Do you agree with this approach? If not, why not, and what might you suggest as an alternative?
  2. Critical care triage has the potential to perpetuate or exacerbate pre-existing health and social inequities. The proposed approach seeks to mitigate the potential impact of implicit bias and systemic discrimination on vulnerable groups to the extent possible in a pandemic. To what extent are the proposed safeguards sufficient? What additional safeguards, if any, would you recommend be put in place to prevent or mitigate this outcome?
  3. What key changes, if any, to the document or overall approach would you recommend? What would you not like to see changed?
  4. Are there any other comments/feedback on the critical care triage recommendations you would like to share?
  5. Looking forward, are there any other issues/concerns relevant to the pandemic response that you think the Bioethics Table should be aware of as it contributes to planning for potential Wave 2 of the COVID-19 pandemic in Fall and beyond?

The Bioethics Table is happy to receive additional thoughts or input you would like to share following the Roundtable. Please send your comments to us via email ([email protected]) by Monday, July 20 so that they can be considered in the recommendations we will be making to Ontario Health.

We look forward to next week’s conversation.

Sincerely,

Jennifer Gibson and Max Smith

Co-Chairs, Bioethics Table

 Text of June 15, 2020 Letter from Ontario Health to the Ontario Human Rights Commission

Ontario Health

525 University Avenue, 5th Floor, Toronto ON, M5G 2L3

June 15, 2020

Raj Dhir
Executive Director
Ontario Human Rights Commission 180 Dundas Street West, 9th Floor Toronto, ON
M7A 2G5

Dear Mr. Dhir:

RE: COVID-19 triage protocol, data collection and essential support persons

Thank-you for your letter dated June 4, 2020 written on behalf of the Ontario Human Rights Commission (OHRC). We extend the same wishes for safety and good health to you and your team on this journey through the COVID-19 pandemic.

Ontario Health welcomes your letter and is pleased to have this opportunity to share our views on the issues you raised both at this time during the pandemic, but also at this time in Ontario Health’s evolution in the health sector. Specifically, on behalf of Ontario Health, I want to confirm our commitment to recognizing the human rights of all Ontarians and to ensure that as much as possible, the principles of inclusion, diversity and equity are reflected in all of what Ontario Health does. This means both internally at Ontario Health as it matures and integrates the business of numerous former crown agencies, but also externally in how it exercises its mandate in the health system.

As you may know, we have a very important role to play supporting the Ministry of Health as part of their broader health system strategies through the mandate that has been established for us under the Connecting Care Act, 2019. COVID-19 elevated the importance of this role by shining a light on the importance of ensuring there is coordinated communication, collaboration and commitment to patients, residents, health outcomes and front-line workers from the many different health system providers.

From this vantage point, we view Ontario Health as having a very important and ongoing role to play to demonstrate its commitment to observing fundamental human rights for all Ontarians including those in racialized communities, people experiencing poverty, people with disabilities, older people and other Code-protected groups.

While I will defer to the Minister of Health to respond to you on behalf of the Government and the health system more broadly, it is important for Ontario Health to outline our perspective in the four areas you have written about:

  1. Immediately and publicly rescind Ontario Health’s March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic and undertake meaningful consultation on a new protocol.

Working with health system clinical leaders and front-line health service providers, a draft Clinical Triage Protocol for Major Surge in COVID-19 (Triage Protocol) was shared by the COVID-19 Bioethics Table in March 2020 as a clinical response to avert catastrophic health outcomes from COVID-19. Given the complexity of issues it presented at the time, the unprecedented reallocation and shift of resources in the health system to respond to COVID-19 and the uncertainties surrounding the virus itself, the Triage Protocol remains in draft. That said, it is a product of much consultation by the COVID-19 Bioethics Table (that works with the Critical Care Table) and with clinical and ethical leaders, following best practices in those areas from other jurisdictions who bravely fought COVID-19 before Ontario. While COVID-19 has unfortunately taken a tragic toll in certain parts of our health system, we are thankful that the need to apply the Triage Protocol has so far been averted as a result of our health system response. To my knowledge, the triage recommendations in the Triage Protocol have not yet been applied in Ontario.

At this time in the pandemic with our numbers of confirmed COVID cases decreasing, we have the opportunity to reflect on all aspects of the response, including the draft Triage Protocol. The intent of the COVID-19 Bioethics Table is to continue to seek feedback, which so far, has generated very helpful comments from stakeholders, including the ones you mention. The Bioethics Table is taking the thoughtful input received so far and including it in an updated draft which they are intending to share with the stakeholders they have consulted with – to ensure the issues and concerns that have been raised are properly addressed and before any further steps are taken on it (see Appendix with list of stakeholders). If there is a stakeholder group that has reached out to your office that is not on this list, please let us know, we would be happy to connect the Bioethics Table with them. It is our understanding that the Ministry is supportive of this direction. Our goal is to have a final document by the end of July, or to rescind it.

  1. Quickly develop and release a plan for collecting disaggregated sociodemographic data on the response to COVID-19.

Early in the pandemic, Ontario Health consulted with experts in health equity and the collection of sociodemographic data to gather their advice on how best to understand the impact of COVID-19 on vulnerable populations. These experts included leaders from the Wellesley Institute, the Alliance for Healthier Communities, the University of Toronto, the Health Commons Solutions Lab, and the Upstream Lab. The advice we received had three components: (1) use existing Ontario data at the neighbourhood level to track and report on disparities between communities; (2) begin collection of individual sociodemographic data through the public health information system; (3) begin a longer-term solution to collect sociodemographic information through the OHIP registration form.

The data we routinely report to the Health Command Table on COVID-19 on incidence and prevalence includes information on disparities between neighbourhoods in Ontario using data from the Ontario Marginalization Index (i.e. educational attainment, income, unemployment, quality of housing and family structure characteristics, recent immigration, visible minority resident). This information is also available publicly at howsmyflattening.ca.

We understand from the Ministry of Health that the collection of race and ethnicity-based data at the individual level for COVID-19 is expected to begin within the next few
weeks. Public health case investigators will ask individuals newly diagnosed with COVID for race-based information as part of follow up and case management. The Ministry has worked with many stakeholder organizations and communities to advance this effort and is working with Public Health Ontario and the public health units to facilitate roll out of this important information.

To ensure that sociodemographic data collection at the individual level is sustainable and extends beyond this pandemic to other health issues and conditions, Ontario Health fully supports the feasibility of collecting this information through the OHIP registration form and we will await additional guidance from the Ministry.

  1. Provide clear provincial direction on the duty to accommodate people with disabilities who need to access essential support persons(s) while receiving health services during the pandemic.

As you know, Ontario Health does not provide direct, front-line healthcare to patients. Ontario Health, however, is fully committed to accommodating people with disabilities and is able to support health service providers in fulfilling their important duties on the frontlines. While Ontario Health does not have the power or authority to direct health service providers in how they discharge their duties, we can play an active and supporting role to the Minister of Health in any directions to the broader health system. We will do our best to convey this message informally to our health system partners subject to any further formal advice or directions from the Ministry.

  1. Consult and involve representatives of vulnerable groups and other human rights experts.

As mentioned earlier, Ontario Health continues to be in its formative days, having assumed six (6) existing corporations through Minister Transfer Orders since December 2019. While I have comfort that all of these former entities and their business practices were committed to protecting the human rights of vulnerable persons, the integration of these businesses presents Ontario Health with the opportunity to consider how we can build on their success and be the leader in this area both with our employees and the health system as a whole.

To this end, Ontario Health is already in the process of retaining a human rights expert who can provide meaningful guidance to our operations, policies and the way we interact and engage with stakeholders to observe our commitment to the Code and actively reflect the principles of diversity, equity and inclusion. We are grateful that the OHRC has offered to provide support as we embark on this process.

Once again, we thank the OHRC for reaching out at this time for the important reasons in your letter and for providing Ontario Health with the opportunity to express our shared commitment to protecting the human rights of all vulnerable populations and all Ontarians both through COVID-19 and afterwards. We look forward to hearing from the Ministry of Health in the areas noted above so we can collectively work together to achieve broadly accepted outcomes.

Regards,

ORIGINAL SIGNED BY

Matthew Anderson

President & CEO, Ontario Health

cc: Hon. Christine Elliot, Minister of Health

Hon. Merrilee Fullerton, Minister of Long-Term Care Hon. Doug Downey, Attorney General

Dr. David Williams, Chief Medical Office of Health Violetta Igneski, OHRC Commissioner

Randall Arsenault, OHRC Commissioner

Appendix

Input was sought from individuals at:

  • The Ontario Human Rights Commission
  • ARCH Disability Law Centre
  • Muscular Dystrophy Canada
  • The Ontario Health COVID-19 Critical Care Planning Table
  • Ontario critical care leads and other critical care physicians
  • The COVID-19 Bioethics Community of Practice (based at the Joint Centre for 
Bioethics and comprising all practicing bioethicists across the province working in 
health care settings)
  • Affiliated health institutions of Bioethics Table members (e.g., Health Sciences 
North, Hamilton Health Sciences, London Health Sciences, The Ottawa Hospital, 
Trillium Health Partners, etc.)
  • The Wellesley Institute
  • Canadian Frailty Network
  • CorHealth

Also, input was received via letters (directed to Ontario Health or the Ministry of Health) from:

  • Ontario Hospital Association
  • Ontario Medical Association
  • Canadian Medical Protective Association
  • College of Physicians and Surgeons of Ontario
  • College of Nurses of Ontario
  • Healthcare Insurance Reciprocal of Canada
  • ARCH Disability Law Centre
  • Other disability rights organizations

 Text of June 4, 2020 Letter from the Ontario Human Rights Code to Ontario Health

9th Floor                                      9e étage
180 Dundas Street West            180, rue Dundas Ouest
Toronto, ON M7A 2G5               Toronto (Ontario) M7A 2G5

Postal Code (Courier): M5G 1Z8        Code postal «courier»: M5G 1Z8

Executive Director and          Directeur général et

Chief Legal Counsel    avocat en chef

Ph: (416) 314-4562     Fax: (416) 325-2004

June 4, 2020

Mr. Matthew Anderson

President and CEO

Ontario Health

1075 Bay Street,

Toronto, ON M5S 2B1

Dear Mr. Anderson:

RE: COVID-19 triage protocol, data collection and essential support persons

I am writing on behalf of the Ontario Human Rights Commission (OHRC).

We hope this letter finds you and your team safe and healthy, and thank you for your ongoing efforts to address the COVID-19 pandemic.

On April 2, the OHRC released a policy statement and identified actions consistent with a human rights-based approach to managing the COVID-19 pandemic. The OHRC highlighted the need for government to:

  • Provide all healthcare services related to COVID-19, including testing, triaging, treatment and possible vaccination, without stigma or discrimination
  • Collect health and other human rights data on the response to the COVID-19 pandemic, disaggregated by the grounds of Indigenous ancestry, race, ethnic origin, place of origin, citizenship status, age, disability, sexual orientation, gender identity, social condition, etc.
  • Recognize that any restrictive measures that deprive persons of their right to liberty must be carried out in accordance with the law and respect for fundamental human rights. This includes measures related to people in health and other care institutions
  • Consult with human rights institutions and experts, Indigenous leaders and knowledge-keepers, vulnerable groups, as well as persons and communities affected by COVID-19, when making decisions, taking actions and allocating resources.

Over the last two months, the OHRC has met with a range of stakeholders representing racialized communities, people experiencing poverty, people with disabilities, older people and other Code-protected groups. These groups are concerned that certain aspects in the management of the COVID-19 pandemic are having a negative impact on their human rights, and have raised four immediate concerns:

  1. Ontario Health’s March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic violates the human rights of people with disabilities, older persons and other vulnerable groups, and has created fear in their communities
  2. Lack of disaggregated data collection during the COVID-19 pandemic is putting the health and well-being of Code-protected groups at heightened risk
  3. Rigid visitor restrictions in care settings are resulting in unequal access to health services and a failure to accommodate people who require essential support person(s) such as a family member, friend, or support worker to communicate or meet other disability-related needs
  4. Lack of meaningful consultation and involvement is negatively affecting Code-protected and other vulnerable groups during the COVID-19 pandemic.

As you may know, the OHRC has previously written to Ontario about its concerns about the Clinical Triage Protocol and the lack of disaggregated data collection. We were advised that Ontario Health would be consulting with us.

As set out below, we are aware that there may be an intention to address some of these concerns. However, to ensure full compliance with the Ontario Human Rights Code, the OHRC urges the following actions:

  1. Immediately and publicly rescind Ontario Health’s March 2020 Clinical Triage Protocol for Major Surge in COVID-19 Pandemic and undertake meaningful consultation on a new protocol.

Ontario Health released a Clinical Triage Protocol for Major Surge in COVID-19 Pandemic, dated March 28, 2020, to guide the use of emergency resources, such as ventilators, if Ontario’s health system is overwhelmed and there is a shortage of these resources. There was no announcement to accompany the Protocol, and notwithstanding an undated letter from Ministers Elliot, Smith and Cho, which referred to it as a “draft” document, the OHRC has heard that health care practitioners continue to recognize the Protocol.

Stakeholders from disability rights organizations, such as ARCH Disability Law Centre, and older persons’ advocacy groups have voiced significant concerns that the Protocol creates stigma and fear, perpetuates historical disadvantage, and gives the impression that people with disabilities and elderly people are expendable and less worthy of protection. These groups were not consulted in the development of the Protocol. At the same time, they recognize that if the protocol is developed properly, it can serve to protect their communities. They are committed to the success of a protocol, but they need to be involved in developing it. The OHRC was able to quickly convene a consultation with these groups so we see no reason why Ontario Health cannot do the same.

The OHRC urges Ontario Health to:

  1. Immediately and publicly rescind the version of the Clinical Triage Protocol for Major Surge in COVID-19 Pandemic released in March, and call on medical organizations to remove the document from their websites and not promote it as valid guidance
  2. Share the revised draft version of the Protocol and commit to a public consultation with disability rights organizations, older person’s advocacy groups, Indigenous, Black, racialized and other vulnerable groups.
  1. Quickly develop and release a plan for collecting disaggregated socio-demographic data on the response to COVID-19.

The OHRC welcomes the Chief Medical Officer of Health’s recent remarks, which were confirmed by the Minister of Health in the Legislature, that the government plans to collect socio-demographic data during the pandemic. However, the lack of a formal announcement and details on how and when data collection will roll out has created confusion.

As the OHRC said in its April 30 public statement, health and human rights experts agree that Ontario needs demographic data to effectively fight COVID-19. Strong data allows health care leaders to identify populations at heightened risk of infection or transmission, to efficiently deploy scarce health resources, and to ensure equal access to public health protections for all Ontarians.

The OHRC urges Ontario Health to:

  1. Take immediate steps to clearly outline the nature and scope of the proposed collection of disaggregated socio-demographic data
  2. Provide specific information on who Ontario/Ontario Health is consulting on the collection of disaggregated socio-demographic data, including, but not limited to Indigenous, Black, racialized and other vulnerable groups
  3. Release a detailed and comprehensive data collection plan that includes collection mechanisms and timelines for the pandemic
  4. Provide specific information on how Ontario/Ontario Health will report publicly on the data collected during the pandemic
  5. Publicly commit to collecting disaggregated socio-demographic data in the health sector in a sustainable manner beyond the pandemic. This would be responsive to longstanding OHRC and stakeholder recommendations.
  1. Provide clear provincial direction on the duty to accommodate people with disabilities who need to access essential support person(s) while receiving health services during the pandemic.

The government has provided guidance to care institutions about visitor access as a virus prevention measure during the COVID-19 pandemic. In its guidance, the government recommends that only “essential visitors” be permitted to enter facilities and provides examples of essential visitors as including, “…those who have a patient who is dying or very ill or a parent/guardian of an ill child or youth, a visitor of a patient undergoing surgery or a woman giving birth.”

Many groups have raised concerns that care institutions are using this guidance to exclude support persons, attendants and communication assistants who provide essential disability-related accommodations. Without their essential support person, some people with disabilities cannot communicate effectively with health care providers about health concerns, make informed decisions about treatment or give or refuse consent to treatment.

The OHRC recognizes that everyone’s right to health includes a government’s obligation to take the steps necessary for preventing, treating and controlling COVID-19. At the same time, under the Code, hospitals and other care institutions have a duty to accommodate a person’s disability-related needs, unless doing so would cause undue hardship based on cost or health and safety.

The OHRC urges Ontario Health to:

  1. Provide direction to health facilities that their interpretation of “essential visitor” should be broad enough to include paid and unpaid support persons, attendants and communication assistants authorized by the patient who provide supports that are essential to enable a patient with a disability to access health care services and communicate effectively with health care providers.
  1. Consult and involve representatives of vulnerable groups and other human rights experts.

 

A human rights-based approach to managing the COVID-19 pandemic requires that government, institutions and other responsible organizations consult with, and involve, Code-protected groups. Lack of meaningful consultation is negatively impacting the human rights of vulnerable groups during the COVID-19 pandemic.

The OHRC urges Ontario Health to:

  1. Consult with human rights experts, representatives of vulnerable groups, and persons and communities affected by COVID-19, when developing protocols, making recommendations or decisions and taking action on managing the COVID-19 pandemic including clinical triage, data collection, restrictions on visitors to care settings and other matters. When consulting groups or needing quick advice, the OHRC is available to help facilitate discussions in a timely manner.

The OHRC appreciates the ever-evolving circumstances surrounding COVID-19, and understands that the government is working to address issues on many fronts. However, is it crucial that vulnerable people’s human rights are upheld, systematically accounted for and properly accommodated while accessing health services during the pandemic. Applying a human rights-based approach and taking these actions as soon as possible, can help limit the spread of the virus while continuing to meet Ontario’s human rights obligations.

Sincerely,

Original signed by

Raj Dhir

Executive Director

cc:        Hon. Christine Elliot, Minister of Health

Hon. Merrilee Fullerton, Minister of Long-Term Care

Hon. Doug Downey, Attorney General

Dr. David Williams, Chief Medical Officer of Health

Violetta Igneski, OHRC Commissioner

Randall Arsenault, OHRC Commissioner

 Text of the June 4, 2020 Letter from the Ontario Human Rights Commission to the Ontario Minister of Health

9th Floor                                               9e étage
180 Dundas Street West                     180, rue Dundas Ouest
Toronto, ON M7A 2G5                        Toronto (Ontario) M7A 2G5

Postal Code (Courier): M5G 1Z8        Code postal «courier»: M5G 1Z8

Executive Director and          Directeur général et

Chief Legal Counsel                 avocat en chef

Ph: (416) 314-4562                  Fax: (416) 325-2004

June 4, 2020

Hon. Christine Elliot
Minister of Health
College Park 5th Floor, 777 Bay Street

Toronto, ON M7A 2J3

[email protected]

Hon. Todd Smith

Minister of Children, Community and Social Services

Macdonald Block Room M2B-88,

77 Wellesley Street West

Toronto, ON M7A 1N3

[email protected]

Dear Minister Elliot and Minister Smith:

RE: COVID-19 Action Plan for Vulnerable People

I am writing on behalf of the Ontario Human Rights Commission (OHRC).

We hope this letter finds you and your team safe and healthy, and thank you for your ongoing efforts to address the COVID-19 pandemic.

The OHRC welcomes the April 23 release of the government’s COVID-19 Action Plan for Vulnerable People (the Plan) as a first step toward addressing the disproportionate impact that the pandemic is having on Ontario’s most vulnerable people. However, to ensure that the human rights of vulnerable people are protected in a way that is consistent with Ontario’s Human Rights Code, the Plan requires expanded scope and detail, which must be done in consultation with vulnerable groups and human rights experts.

Over the past few months, the OHRC has met with stakeholders from various sectors on human rights related to the COVID-19 pandemic. We heard significant concerns about the lack of consultation with affected groups. We also heard that while the Plan mentions certain vulnerable groups, it does not capture other vulnerable communities. The Plan also lacks clarity around how prevention, treatment and control initiatives are being designed to protect and benefit the most vulnerable groups in those communities.

In our April 2 policy statement and actions for a human rights-based approach to managing the COVID-19 pandemic, the OHRC called on the government to uphold the human rights of vulnerable groups by taking the following actions:

  • Anticipate, assess and address the disproportionate impact of COVID-19 and related restrictions on vulnerable groups that already disproportionately experience human rights violations
  • Make sure vulnerable groups have equitable access to health care and other measures to address COVID-19, including financial and other assistance
  • Consult with human rights institutions and experts, Indigenous leaders and knowledge-keepers, vulnerable groups, as well as persons and communities affected by COVID-19, when making decisions, taking actions and allocating resources.

Despite our early advice, the OHRC has not yet been invited to COVID-19 planning forums and tables. Nor have we been able to gain access to specific and timely information to better understand the human rights implications of the government’s COVID-19 initiatives.

The OHRC’s specific requests for more details on the implementation of the Plan and its effect on vulnerable groups have gone unanswered.

In our April 30 submission on Ontario’s next Poverty Reduction Strategy, the OHRC highlighted that social and economic crises, especially a health pandemic like COVID-19, exacerbate the existing inequalities vulnerable populations already experience, such as poorer health and poverty. An inadequate response to the needs of vulnerable groups also undermines the effectiveness of Ontario’s overall response to COVID-19, placing at risk everyone’s well-being and potentially exacerbating an anticipated “second wave” of the pandemic.

To effectively protect the rights of Ontario’s most vulnerable people, Ontario must take immediate action to expand and implement its Plan for vulnerable groups. The OHRC urges the government to make clear, detailed and public commitments in the following areas:

  1. Expand the scope of the Plan to ensure the needs of other vulnerable communities are properly addressed. Examples of communities that are currently excluded include:
  • People experiencing homelessness who are not currently using the shelter system (for example, hidden homeless people and people living in encampments)
  • Highly mobile populations of people who use drugs
  • People experiencing poverty and living in multi-generational and sometimes crowded housing while also working in high-risk settings, such as long-term care, food processing facilities and the service sector
  • In-patients in mental health facilities, including in addictions and withdrawal programs and in residential treatment programs for children and youth
  • Frail seniors in assisted living
  • Indigenous people living in urban and rural communities, and not in congregate care
  • Seasonal migrant workers living in shared housing facilities.
  1. Provide detailed, public information on how the roll-out of expanded testing, screening, tracking and surveillance will reach and benefit high-risk and vulnerable populations. Information should include a plan for:
  • How many tests will be done for vulnerable groups each day
  • How mobile populations will be reached
  • How asymptomatic people from high risk and vulnerable groups will be tested, tracked and monitored.
  1. Consult and work with vulnerable groups that will be affected by the Plan by including Indigenous partners, stakeholder/advocacy groups representing vulnerable people and human rights experts, and involve them in provincial planning tables and committees.
  1. Provide specific and detailed guidance to law enforcement to ensure that COVID-19 prevention measures are not implemented in a way that disproportionately targets or penalizes people who have difficulty or are unable to follow physical distancing restrictions and other requirements, such as people experiencing homelessness and people with certain types of disabilities. Guidance should also include appropriate ways to promote education and awareness.
  1. Identify indicators and collect data to measure whether the Plan, including these additional actions, is benefiting high-risk and vulnerable populations.
  1. Report publicly and regularly on the implementation status of the Plan, including these additional actions, in detail, including the results of the data collected to measure whether the plan is benefiting high-risk and vulnerable populations.

 

The OHRC appreciates the ever-evolving circumstances surrounding COVID-19, and understands that the government is working to address issues on many fronts. However, as many experts note, the spread of COVID-19 among Ontario’s most vulnerable populations could prove catastrophic. Taking the recommended actions as soon as possible can help limit the spread of the virus while continuing to uphold Ontario’s human rights obligations.

Sincerely,

Original signed by

Raj Dhir

Executive Director

cc:        Hon. Merrilee Fullerton, Minister of Long-Term Care

Dr. David Williams, Chief Medical Officer of Health

Matthew Anderson, President and CEO of Ontario Health

Hon. Doug Downey, Attorney General

Violetta Igneski, OHRC Commissioner

Randall Arsenault, OHRC Commissioner

[1] Further details regarding the process by which this document was developed can be found in Appendix A.

[2] Critical Care Services Ontario. Ontario’s Critical Care Surge Capacity Management Plan: Moderate Surge Response Guide Version 2.3. Government of Ontario, September 2019, p. 6.

[3] An earlier version of this document was distributed to Ontario hospitals on March 28, 2020. The current document provides updated recommendations based on additional consultation and stakeholder feedback to clarify the scope and limits of critical care triage in the COVID-19 pandemic, the ethical underpinnings of the approach (including significance of human rights), the nature and purpose of the critical care triage criteria, and key considerations for implementation. It also includes recommendations for continuing consultation and stakeholder engagement.

[4] “Critical care services meet the needs of patients facing an immediate life-threatening health condition—specifically, that in which vital system organs are at risk of failing. Using advanced therapeutic, monitoring and diagnostic technology, the objective of critical care is to maintain organ system functioning and improve the patient’s condition such that his or her underlying injury or illness can then be treated.” (https://www.criticalcareontario.ca/EN/AboutUs/Pages/What-is-Critical-Care.aspx)

[5] Silva DS, Gibson JL, Robertson A, et al. Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public’s perspectives. BMC Public Health 2012; 12:241. https://doi.org/10.1186/1471-2458-12-241

[6] Add missing refs.

[7] Determining the timeframe in which death is likely to occur is challenging. Prognostication requires clinical judgement based on each patient’s unique clinical circumstances. To enhance prognostic certainty, the involvement of clinical judgement of more than one physician is common medical practice.

[8] Skye C. Colonialism of The Curve: Indigenous Communities & Bad COVID Data. Toronto: Yellowhead Institute, Ryerson University, 2020. https://yellowheadinstitute.org/2020/05/12/colonialism-of-the-curve-indigenous-communities-and-bad-covid-data/; Nestel S. Colour-coded health care: the impact of race and racisms on Canadian’s health. Toronto: Wellesley Institute, 2012. http://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Coded-Health-Care-Sheryl-Nestel.pdf; <additional references to be added>

[9] Ontario Human Rights Commission. Policy statement on a human rights-based approach to managing the COVID-19 pandemic. 02 April 2020. Available at: http://www.ohrc.on.ca/en/policy-statement-human-rights-based-approach-managing-covid-19-pandemic.

[10] Such as: age, sex, socioeconomic status, Indigenous status, race, ethnicity, sex, gender identity and expression, sexual orientation, creed, family status, marital status, geography, and home setting (including homelessness). See also Appendix B: Prohibited grounds of discrimination for a list of prohibited grounds). http://www.ohrc.on.ca/en/ontario-human-rights-code

[11] Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. Hastings Center Report 2020; Apr 2. Available at: https://www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/; Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. https://dredf.org/avoiding-disability-based-discrimination-in-treatment-rationing/. Accessed April 12, 2020; Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.

[13] Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article

cThe use of an acute illness score (e.g., sequential organ failure assessment (SOFA) score) would be difficult to justify given that even people with high SOFA scores may have a ~50% chance of surviving an acute viral respiratory illness.11 And if one only looks at those who do not meet any of the ineligibility criteria at levels 1-3, the survival rate would likely be even higher. It is currently unknown whether the prognosis of COVID-19 illness is similar to other viral illnesses. Early data suggests that the admission SOFA scores for non-survivors was low, and thus unhelpful for distinguishing them from survivors. 12-13 Moreover, mortality risk from acute illness does not easily translate into medical utility. It is not clear whether the greatest benefit would be seen in those with mild, moderate, or severe illness.

[15] Biddison D, Berkowitz KA, Courtney B, De Jong MJ, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e145S-e155S.

[16] Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.

[17] Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146(4): e61S-e74S; US Veterans Health Administration National Center for Healthcare Ethics. Meeting the challenge of pandemic influenza: ethical guidance for leaders and health care professionals in the Veterans Health Administration, July 2010. Available at: https://www.ethics.va.gov/docs/pandemicflu/Meeting_the_Challenge_of_Pan_Flu-Ethical_Guidance_VHA_20100701.pdf; Emanuel EJ et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020 Mar 23; Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. NEJM 2020; 23 March. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=recirc_curatedRelated_article



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Send Us Your Feedback Very Quickly on Our Draft Brief to the Ontario Government on the Urgent Needs of K-12 Students with Disabilities During the COVID-19 Crisis


Accessibility for Ontarians with Disabilities Act Alliance Update United for a Barrier-Free Society for All People with Disabilities
Web: http://www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: http://www.facebook.com/aodaalliance/

June 11, 2020

SUMMARY

We are rushing to prepare and submit a brief to the Ford Government on what it must do now and as schools eventually re-open to meet the urgent needs of students with disabilities during the COVID-19 crisis. We have assembled a draft brief, which we set out below. We want your feedback and ideas. We need them fast. We want to get this brief submitted to the Government as quickly as we can. We are sorry this is so rushed. Life during COVID-19 feels like an endless blitz for the AODA Alliance!

Send your feedback to us by June 16, 2020 by emailing us at [email protected] and feel free to share this draft brief with others. We welcome feedback from anyone who wants to offer it to us.

Stay safe!

MORE DETAILS

A Brief to the Ontario Government on Key Measures Needed to Address the Urgent Learning Needs of Students with Disabilities in Ontario During the COVID-19 Crisis During Distance Learning and in the Eventual Re-Opening of Schools

June 11, 2020

NOTE: This is only a draft. The AODA Alliance seeks input and additional ideas no later than June 16, 2020. Send feedback to [email protected]

1. Pressing Need for A Comprehensive Ministry of Education Plan of Action to Address Urgent Needs of Students with Disabilities During the COVID-19 Crisis

Since the COVID-19 crisis began, the AODA Alliance has been urging the Ontario Government to develop and announce a comprehensive plan to meet the urgent need of students with disabilities during the COVID-19 crisis. This has been needed so over 70 school boards dont have to each re-invent the wheel in deciding what the needs of students with disabilities are and how best to meet them. To date, the Ontario Government has not done what we have urged.

The need for this provincial plan remains pressing during the period of distance learning due to school closures. It is also needed to ensure that students with disabilities urgent needs are met across Ontario when schools eventually re-open. Ontario needs to also be prepared in case of the realistic possibility that distance learning will have to continue in the fall, either because school re-opening is further delayed, or because a second wave of COVID-19 would require another round of school closures.

To date, the Ontario Government has primarily if not totally focused its education strategy during the COVID-19 pandemic on students without disabilities. Almost as an afterthought, it then reminded school boards that they should also accommodate students with special education needs.

We therefore recommend that:

#1. The Ministry of Education should immediately develop, announce and implement a comprehensive plan for meeting the urgent learning needs of students with disabilities during the COVID-19 crisis. This plan should include during this time of distance learning, during an eventual return to school, and in case of a future COVID-19 wave that requires another round of school closures.

2. Need for a Provincial Students with Disabilities Command Table

To deal with the need for rapid planning during the COVID-19 crisis, the Ontario Government has commendably set up its own command tables to deal with critical areas, like health care planning and planning for the safe operation of the economy during this crisis. This enables the Government to have critical expertise at the table that makes key decisions.

There is a pressing need for a students with disabilities command table within the Government to plan for the urgent learning needs of students with disabilities during the COVID-19 pandemic. No such table or concentrated expertise centre exists now within Ontarios Ministry of Education. We have been pressing for this for three months without success. That table needs to be staffed by professionals with focused expertise on providing education to students with disabilities.

This is not meant to be an advisory or consultative table. It needs to be a planning and implementation table that can quickly make decisions and effectively connect with the front lines in the education system, where the action is.

This need is not fulfilled by the Minister of Education having had some consultative meetings with the Ministers Advisory Committee on Special Education (MACSE), which still has vacancies, or with the AODA K-12 Education Standards Development Committee. Those bodies are only advisory. They do not have the capacity of a Ministry command table. Of course, their input should be welcomed and valued.

We therefore recommend that:

#2. The Ministry of Education should immediately establish a Students with Disabilities Education Command Table to oversee the development and implementation of a Government action plan for meeting the urgent learning needs of students with disabilities during the COVID-19 crisis, and to swiftly react to issues for students with disabilities as they arise.

3. Preventing a Rash of Refusals to Admit Students with Disabilities to School When Schools Re-Open

Ontarios Education Act lets a school principal refuse to admit to school any person whose presence in the school or classroom would in the principals judgment be detrimental to the physical or mental well-being of the pupils”. Disability advocates have repeatedly criticized this as an excessive, arbitrary and unfair power. The Education Act and the Ministry of Education leave to school boards and individual principals an extremely wide discretion over when, how and why to exclude a student from school under this power. The Education Act does not even require principals to give a parent their reasons for excluding a student from school, nor does it cap the duration of the students exclusion from school.

Disproportionately, this excessive power has been used against some students with disabilities. School boards have not always tracked when or why or how many students are excluded from school under this power. Long before this COVID-19 crisis, parent advocates have called for this power to be reduced and regulated. See for example the January 30, 2019 joint news release by the AODA Alliance and the Ontario Autism Coalition. To date, the Ontario Government has not agreed to any significant reform of this excessive power.

In September 2018, the Ontario Human Rights Commission released a new policy on accessible education for students with disabilities. Its recommendations to the Ontario Government included, among other things:

“9. Identify and end the practice of exclusion wherein principals ask parents to keep primary and secondary students with disabilities home from school for part or all of the school day (and the role that an improper use of section 265(1)(m) of the Education Act may be playing in this practice).”

There is a serious risk that some principals will feel at liberty to use this power to exclude some students with disabilities from school during school re-openings in the midst of the COVID-19 pandemic, especially before any effective vaccine is invented and widely available. This is especially so if school boards do not effectively plan for the inclusion and accommodation of students with disabilities at school during this school re-opening process. They may do so either because they dont know how to accommodate some students with disabilities during social distancing, or because the Ontario Government and/or their school board has not given them the directions and resources they need to be able to effectively include and accommodate those students.

The need to reform practices regarding a school principals power to refuse to admit a student to school has become even more pressing in light of the COVID-19 pandemic. It is essential that school re-openings this fall do not lead to the creation of two classes of students, those allowed to return to school and those who are excluded from school, especially if this disproportionately divides along disability lines. A principal can feel a real temptation to use the power to refuse to admit such students to school during a COVID-19 school re-opening because it would seem to solve the problem of having to plan for those students needs at school.

The Ontario Government has been willing to give directions to a school board about the use of its power to refuse to admit students to school in other contexts. It can do so here as well. The Ontario Ministry of Education has very recently given directions to the Peel District School Board to keep and report data on exclusions of students from school by race. In directive number 9, the Ministry stipulates that:

The Board shall centrally track disaggregated race-based data on suspensions (in-school and out-of-school), expulsions and exclusions, and report publicly through the Annual Equity Accountability Report Card.

We therefore recommend that:

#3. The Ministry of Education should immediately issue a policy direction to all school boards, imposing restrictions on when and how a principal may exclude a student from school. including directions that:

a) During the re-opening at schools, students with disabilities have an equal right to attend schools as do students without disabilities. The power to refuse to admit a student to school should not be used in a way that disproportionately burdens students with disabilities or that creates a barrier to their right to attend school.

b) A principal who refuses to admit a student to school during the school re-opening process should be required to immediately give the student and their family written notice of their decision to do so, including written reasons for the refusal to admit, the duration of the refusal to admit and notice of the familys right to appeal this refusal to admit to the school board.

c) A principal who refuses to admit a student to school for all or part of the school day should be required to report this in writing to their school boards senior management, including the reasons for the exclusion, its duration and whether the student has a disability. Each school board should be required to compile this information and to report it on a bi-monthly basis to the board of trustees, the public and the Ministry of Education (with individual information totally anonymized). The Ministry should promptly make public on a school board by school board basis the information it receives on numbers, reasons and durations of refusals to admit during post- COVID-19 school re-opening.

4. Need for Specific COVID-19 Individual Education Plans for Individual Students with Disabilities Before and During Transitioning to Return to School

For students with disabilities the distance learning during COVID-19 will have created different deficits and challenges. The transition back to school will present challenges that will vary from student to student.

Students IEPs were all written while students were in school, with no contemplation of the COVID-19 crisis or the challenges and hardships of distance learning and then of transition back to school. All students with disabilities will need their IEP modified to address these unforeseen needs.

They each need a COVID-19 specific IEP. This should be done now and over the summer, not in the fall when students are hopefully already back in school. This will require action now. It may require new resources to enable this to be worked on over the summer.

As noted earlier, there is a real possibility that distance learning will continue in the fall or may have to resume due to a second wave of COVID-19. IEPs need to now anticipate and address these needs.

We therefore recommend that:

#4. For each student with disabilities, each school board should now:

a) Contact the family of each student with disabilities, preferably by phone rather than email, to discuss and identify the students progress during the shutdown, the students specific and individualized disability-related deficits and needs arising from and during distance learning due to the COVID-19crisis and the students needs and challenges related to eventual return to school (including any vulnerabilities of other family members due to the COVID-19 pandemic), and;

b) add to their IEP specific goals and activities to effectively address their disability-related needs during distance learning, and in connection with transition back to school.

5. Need for Provincial and School Board Rapid Response Teams to Address Recurring Urgent Needs of Students with Disabilities

During the COVID-19 crisis, Ontario’s education system continues to try to navigate uncharted territory. No matter how much planning for the needs of students with disabilities takes place as we here recommend, unexpected surprises will crop up. school boards and the Ministry of Education each need to be able to quickly detect these, and to nimbly respond to them.

Parents, teachers and principals need a central point in the school board to report difficult challenges. Each school board needs to feed this information to a single point at the Ministry that is staying on top of things, for rapid responses to recurring issues around the province.

We therefore recommend that:

#5. The Ministry of Education should assign staff to assist its Students with Disabilities Command Table by serving as a central rapid response team to receive feedback from school boards on recurring issues facing students with disabilities and to help find solutions to be shared with school boards.

#6. The Ministry should direct that each school board shall establish a similar central rapid response team within the board to receive feedback from teachers and principals about problems they are encountering serving students with disabilities during the COVID-19 period, that can quickly network with other similar offices at other school boards, and that can report recurring issues to the Ministry.

6. Surge Needed in Specialized Supports for Students with Disabilities

All students will have fallen behind to some extent during the months when schools were closed. This hardship falls especially on students with disabilities who have additional specialized curriculum to learn, related to their disabilities, or who need specialized supports to learn which are unavailable during distance learning.

When students return to school, students with disabilities who need those supports will need a surge in the hours of support provided to them to help them catch up and adjust to the return to school. School boards cannot simply pull those resources out of the air. School boards will need added funding to hire those staff, and provincial help finding them if there are shortages.

For example, students with vision loss are unable to get the full benefit of teachers of the visually impaired (TVIs) teaching hands-on braille reading when schools are closed. School boards will need to engage additional TVIs to help ramp up the surge in TVI hours to be provided to students. There is now a shortage of TVIs in Ontario. The Ministry will need to lead the effort to provide a surge of TVIs to help school boards fill this gap during the return to school. Comparable needs can similarly be identified for students with other disabilities where such specialized educational support is needed.

We therefore recommend that:

#7. The Ministry of Education should plan for, fund and coordinate the provision by school boards of a surge in specialized disability supports to those students with disabilities who will need them when students return to school.

7. Planning for Needs of Students with Disabilities Who Cannot Themselves Ensure Social Distancing

As an illustration of the last issue discussed, any return to school while COVID-19 continues to exist in our community will require students to engage in social distancing. If schools re-open, they will be doing so mindful of the fact that many students will not be able to consistently and reliably engage in social distancing, frequent hand washing and other important protective activities. Many are too young to ensure that they can fully understand the need to do so and comply. For some older children, it may seem cool to periodically break the rules. For many, it will be impossible to remain attentive to these precautions all the time.

For any number of students with disabilities, social distancing and related safe practices may pose additional challenges. For some, wearing a mask may not be possible due to such things as sensory integration or behavioural issues.

Some students with disabilities require an education assistant (EA) or special needs assistant (SNA) for all or part of the day to fully take part in school activities. For some of these students, it will not be possible to remain two meters away while providing the support or assistance that the student needs. Some will require close assistance for eating, hand-washing and other personal needs.

Pre-COVID-19 staffing levels for EAs and SNAs did not account for these additional requirements. EAs and SNAs were not experienced with or trained for this before COVID-19. It is not sufficient to now send them an email with instructions, or a link to a training video, and thereafter to assume that they will be fully equipped to handle these duties. In addition to new in-person training, they will need to have constant access to good quality personal protective equipment (PPE), like masks.

We therefore recommend that:

#8. The Ministry of Educations plan for school re-openings must include detailed instructions on required measures for ensuring that students with disabilities are safe from COVID-19 during any return to school. This requires additional planning in advance by school boards and additional funding to school boards to hire and train the additional SNAs and EAs they will need to ensure the safety of students with disabilities.

8. Ensuring Full Accessibility of Digital Platforms Used for Remote Classes or Synchronous Learning

We do not here wade into the dispute between the Ford Government and some teachers unions about whether or when a teacher should conduct online classes for their students in real time over the internet, sometimes called synchronous learning. We insist, however, that whenever an online real time class or synchronous learning takes place, or any other online meeting involving students with disabilities or their parents in connection with their education, it must be conducted via a fully accessible digital meeting platform.

When the Ontario Government moved our education system from the physical classroom to the virtual classroom in late March, it should have ensured from the start that the choice of digital classroom platforms was fully accessible. The Ontario Government did not do so, nor did it monitor school boards to see what platforms they were using. Put simply, the Ontario Government entirely dropped the ball on this critical accessibility concern to the detriment of students, teachers and parents with disabilities. It did so based on a transparently erroneous starting point. The Ministry of Education took the position that it was up to each school board to decide which online virtual meeting platform to use based on its assessment of its local needs. Yet these disability accessibility needs do not vary from school board to school board.

As a belated partial attempt to address this problem, the Minister of Education wrote school boards on or around May 26, 2020 about several issues regarding distance learning. That memo stated, among other things:

Boards must ensure that the platforms they use for connecting with students and families are fully accessible for persons with disabilities.

However, that direction provides no assistance to school boards on which platforms to use or avoid, or how to figure this out. It still leaves it to each school board to investigate this as much or as little as they wish, and then to duplicate the same investigations of this issue over and over across Ontario.

This issue remains a live one and will continue into the fall. It is not clear when schools will re-open. Our education system may still be running on 100% distance learning at the start of the fall school term. Even when schools re-open, there is a real likelihood that some distance learning will continue in some blended model of in-school and distance education. As noted earlier, if a second wave of COVID-19 hits, as has happened elsewhere, requiring another round of school closures, Ontario will have to return to 100% distance learning.

We therefore recommend that:

#9. The Ministry of Education should immediately engage an arms-length digital accessibility consultant to evaluate the comparative accessibility of different digital meeting platforms available for use in Ontario schools. The Ministry should immediately send the resulting report and comparison to all school boards and make it public. The Ministry should direct which platforms may be used and which may not be used for virtual or synchronous classes or parent/school meetings, based on their accessibility.

9. Ensuring Digital Accessibility of Ontario Government and TVO Online Learning Resources

Over three months into the COVID-19 crisis, the Ontario Government has still not ensured that the online content that it provides to school boards, teachers, parents and students meets accessibility requirements for computer-users with disabilities. The AODA Alliance has been raising concerns with the Government about this since early in the pandemic. We have seen no public commitment to the needed corrective action. We have raised our concerns at senior levels within TVO and the Ministry of Education. The Government and TVO were required to comply with these accessibility requirements well before the advent of the COVID-19 pandemic.

We therefore recommend that:

#10. The Ministry of Education should immediately direct TVO to make its online learning content accessible to people with disabilities, and to promptly make public a plan of action to achieve this goal, with specific milestones and time lines.

#11. The Ministry of Education should make public a plan of action to swiftly make its own online learning content accessible for people with disabilities, setting out milestones and time lines, and should report to the public on its progress.

10. Stop Making Learning Resources Available Only in PDF Format

Throughout this pandemic, as well as beforehand, the Ministry of Education and too many school boards have continued to make important digital information available to the public, including to parents, teachers and students, only in pdf format. That format can present accessibility problems for people with disabilities. When a document is made public in PDF format, it should also be made public in an accessible format, such as MS Word. This is an important time to start this long-overdue practice.

We therefore recommend that:

#12. The Ministry of Education should direct all its staff and all school boards that whenever making digital information public in a PDF format, it must at the same time also be made available in an accessible format such as an accessible MS Word document.

11. One Size Fits All Does Not Fit for Return to School

To avoid chaos, a return to school should not be done all at once using a one-size-fits-all approach. Because we are in uncharted waters, it makes sense to go about this gradually and try different approaches at different locations to see what works. To avoid students with disabilities from being treated as after-thoughts who have to try to fit into a chaotic situation that was not designed with their needs in mind, it can be worthwhile to enable students with disabilities to return to school first, and for teaching staff to ensure their needs are met, before trying to also cope with an onslaught of all other students.

We therefore recommend that:

#13. The provincial plans for return to school should include these features:

a) Rather than having all students across Ontario return to school at once, in a one-size-fits-all strategy, the Ontario Government should lead a strategic return to school process, trying out different approaches to see what works most effectively. For example, opening a few schools first to detect recurring problems and plan to prevent them would assist with opening of other schools across Ontario.

b) The Ontario Government should try having the most vulnerable students, including students with disabilities, return to school first to facilitate their effective accommodation and orientation before all other students return to school.

12. Need for A Rapid Method to Spread the Word to Teachers and Parents About Effective Teaching Strategies for Students with Disabilities During COVID-19

Teachers and parents of students with disabilities are struggling around Ontario to cope with distance learning and the barriers it can create for many students with disabilities. Teachers and parents are creating novel work-arounds to address this.

Yet the Ontario Government has not been effectively canvassing the front lines of teachers and parents to gather these up and share them around the province, so all can benefit without having to re-invent the wheel I n the midst of a traumatic pandemic. We have called on the Ontario Government for the past three months to do this without success. We modelled one way of doing this by our successful May 4, 2020 online virtual town hall on teaching students with disabilities during the COVID-19 crisis (jointly organized with the Ontario Autism Coalition). As far as we have been able to learn, the Ontario Government has neither taken up that idea nor has it shared with school boards the link to our May 4, 2020 virtual town hall so that they can all benefit from it. We have repeatedly asked the Ministry of Education to share that link with school boards.

In the meantime, to fill this gap, several school boards have commendably been trying to do this themselves. They have themselves been compiling good ideas and sharing them within their own board.

This is a huge and wasteful duplication of effort. The Ontario Government should be centrally accumulating and compiling all these resources, as well as researching what other jurisdictions have compiled from their own experience. These should be rapidly made available to front line teachers and parents in a way that is easy to access, not by a blizzard of endless links that few if anyone will have the time to explore.

This effort should have been done weeks ago. it is not too late, since distance learning will remain part of our lives in whole or in part until a vaccine for COVID-19 is created and widely administered.

We therefore recommend that:

#14. The Ministry of Education should immediately put in place an effective proactive team to gather teaching strategies for students with disabilities during distance learning from front line teachers, parents and school boards and make these easily available to the front lines on an ongoing basis. These should be supplemented by strategies that the Ministry researches from other jurisdictions that have innovated creative solutions.

13. Distance Learning Must Be Maintained for Students Who Cannot Return to School

There will be students who cannot return to school when others do. Their disability may make it impossible to accommodate them in school under the restrictions that apply during the COVID-19 pandemic. The school board will have a duty to accommodate them unless the school board can prove that it is impossible to do so without undue hardship. Some students may not be able to return to school because their parents or other family members with whom they live are so medically vulnerable or immune-compromised that the family must take heightened precautions to avoid the risk of contracting COVID-19.

In those cases, even if other students are learning at school, the school board must provide effective and accessible distance learning for those students who must remain at home. This may include home visits from teaching staff.

We therefore recommend that:

#15 The plans for return to school must include measures for ensuring that those who cannot return to school at the same time can secure effective distance learning, including home visits (with social distancing) from teaching staff.

14. Creating Provincial Resources for Parents to Prepare Their Students for Return to School

Some students with disabilities will need extensive preparation at home for their eventual return to school, including learning about social distancing and other new school practices due to COVID-19. Some parents will need a great deal of time to deal with this. Each school board or teacher and family should not have to duplicate these efforts by inventing their own curriculum, social stories or other resources.

We therefore recommend that:

#16. The Ministry of Education should prepare teaching materials for teachers and parents to use, addressing different disability-related learning needs, for preparing students with disabilities for the return to school, to address such changes as social distancing.

15. New Protocols Needed for Safe School Bussing

There were ample problems with bussing of students with disabilities to school before the COVID-19 crisis. In any return to school, heightened safeguards will be needed, including frequent sanitization of busses, ensuring students are seated more than 2 meters from each other and ensuring that the driver has PPE and doesnt risk spreading COVID-19. It is not realistic to expect that this will all simply happen with private sector bussing companies who employ casual and part time drivers working at low wages.

We therefore recommend that:

#17. The Ministry of Education should create, fund and effectively enforce new standards for safe bussing practices for students with disabilities during any return to school while COVID-19 remains a community threat.




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Send Us Your Feedback Very Quickly on Our Draft Brief to the Ontario Government on the Urgent Needs of K-12 Students with Disabilities During the COVID-19 Crisis


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/

Send Us Your Feedback Very Quickly on Our Draft Brief to the Ontario Government on the Urgent Needs of K-12 Students with Disabilities During the COVID-19 Crisis

June 11, 2020

          SUMMARY

We are rushing to prepare and submit a brief to the Ford Government on what it must do now and as schools eventually re-open to meet the urgent needs of students with disabilities during the COVID-19 crisis. We have assembled a draft brief, which we set out below. We want your feedback and ideas. We need them fast. We want to get this brief submitted to the Government as quickly as we can. We are sorry this is so rushed. Life during COVID-19 feels like an endless blitz for the AODA Alliance!

Send your feedback to us by June 16, 2020 by emailing us at [email protected] and feel free to share this draft brief with others. We welcome feedback from anyone who wants to offer it to us.

Stay safe!

          MORE DETAILS

A Brief to the Ontario Government on Key Measures Needed to Address the Urgent Learning Needs of Students with Disabilities in Ontario During the COVID-19 Crisis During Distance Learning and in the Eventual Re-Opening of Schools

June 11, 2020

NOTE: This is only a draft. The AODA Alliance seeks input and additional ideas no later than June 16, 2020. Send feedback to [email protected]

1. Pressing Need for A Comprehensive Ministry of Education Plan of Action to Address Urgent Needs of Students with Disabilities During the COVID-19 Crisis

Since the COVID-19 crisis began, the AODA Alliance has been urging the Ontario Government to develop and announce a comprehensive plan to meet the urgent need of students with disabilities during the COVID-19 crisis. This has been needed so over 70 school boards don’t have to each re-invent the wheel in deciding what the needs of students with disabilities are and how best to meet them. To date, the Ontario Government has not done what we have urged.

The need for this provincial plan remains pressing during the period of distance learning due to school closures. It is also needed to ensure that students with disabilities’ urgent needs are met across Ontario when schools eventually re-open. Ontario needs to also be prepared in case of the realistic possibility that distance learning will have to continue in the fall, either because school re-opening is further delayed, or because a second wave of COVID-19 would require another round of school closures.

To date, the Ontario Government has primarily if not totally focused its education strategy during the COVID-19 pandemic on students without disabilities. Almost as an afterthought, it then reminded school boards that they should also accommodate students with special education needs.

We therefore recommend that:

#1. The Ministry of Education should immediately develop, announce and implement a comprehensive plan for meeting the urgent learning needs of students with disabilities during the COVID-19 crisis. This plan should include during this time of distance learning, during an eventual return to school, and in case of a future COVID-19 wave that requires another round of school closures.

2. Need for a Provincial “Students with Disabilities Command Table”

To deal with the need for rapid planning during the COVID-19 crisis, the Ontario Government has commendably set up its own “command tables” to deal with critical areas, like health care planning and planning for the safe operation of the economy during this crisis. This enables the Government to have critical expertise at the table that makes key decisions.

There is a pressing need for a “students with disabilities command table” within the Government to plan for the urgent learning needs of students with disabilities during the COVID-19 pandemic. No such table or concentrated expertise centre exists now within Ontario’s Ministry of Education. We have been pressing for this for three months without success. That table needs to be staffed by professionals with focused expertise on providing education to students with disabilities.

This is not meant to be an advisory or consultative table. It needs to be a planning and implementation table that can quickly make decisions and effectively connect with the front lines in the education system, where the action is.

This need is not fulfilled by the Minister of Education having had some consultative meetings with the Minister’s Advisory Committee on Special Education (MACSE), which still has vacancies, or with the AODA K-12 Education Standards Development Committee. Those bodies are only advisory. They do not have the capacity of a Ministry command table. Of course, their input should be welcomed and valued.

We therefore recommend that:

#2. The Ministry of Education should immediately establish a “Students with Disabilities Education Command Table” to oversee the development and implementation of a Government action plan for meeting the urgent learning needs of students with disabilities during the COVID-19 crisis, and to swiftly react to issues for students with disabilities as they arise.

3. Preventing a Rash of Refusals to Admit Students with Disabilities to School When Schools Re-Open

Ontario’s Education Act lets a school principal refuse to admit to school any “person whose presence in the school or classroom would in the principal’s judgment be detrimental to the physical or mental well-being of the pupils…”. Disability advocates have repeatedly criticized this as an excessive, arbitrary and unfair power. The Education Act and the Ministry of Education leave to school boards and individual principals an extremely wide discretion over when, how and why to exclude a student from school under this power. The Education Act does not even require principals to give a parent their reasons for excluding a student from school, nor does it cap the duration of the student’s exclusion from school.

Disproportionately, this excessive power has been used against some students with disabilities. School boards have not always tracked when or why or how many students are excluded from school under this power. Long before this COVID-19 crisis, parent advocates have called for this power to be reduced and regulated. See for example the January 30, 2019 joint news release by the AODA Alliance and the Ontario Autism Coalition. To date, the Ontario Government has not agreed to any significant reform of this excessive power.

In September 2018, the Ontario Human Rights Commission released a new policy on accessible education for students with disabilities. Its recommendations to the Ontario Government included, among other things:

“9. Identify and end the practice of exclusion wherein principals ask parents to keep primary and secondary students with disabilities home from school for part or all of the school day (and the role that an improper use of section 265(1)(m) of the Education Act may be playing in this practice).”

There is a serious risk that some principals will feel at liberty to use this power to exclude some students with disabilities from school during school re-openings in the midst of the COVID-19 pandemic, especially before any effective vaccine is invented and widely available. This is especially so if school boards do not effectively plan for the inclusion and accommodation of students with disabilities at school during this school re-opening process. They may do so either because they don’t know how to accommodate some students with disabilities during social distancing, or because the Ontario Government and/or their school board has not given them the directions and resources they need to be able to effectively include and accommodate those students.

The need to reform practices regarding a school principal’s power to refuse to admit a student to school has become even more pressing in light of the COVID-19 pandemic. It is essential that school re-openings this fall do not lead to the creation of two classes of students, those allowed to return to school and those who are excluded from school, especially if this disproportionately divides along disability lines. A principal can feel a real temptation to use the power to refuse to admit such students to school during a COVID-19 school re-opening because it would seem to solve the problem of having to plan for those students’ needs at school.

The Ontario Government has been willing to give directions to a school board about the use of its power to refuse to admit students to school in other contexts. It can do so here as well. The Ontario Ministry of Education has very recently given directions to the Peel District School Board to keep and report data on exclusions of students from school by race. In directive number 9, the Ministry stipulates that:

“The Board shall centrally track disaggregated race-based data on suspensions (in-school and out-of-school), expulsions and exclusions, and report publicly through the Annual Equity Accountability Report Card.”

We therefore recommend that:

#3. The Ministry of Education should immediately issue a policy direction to all school boards, imposing restrictions on when and how a principal may exclude a student from school. including directions that:

  1. a) During the re-opening at schools, students with disabilities have an equal right to attend schools as do students without disabilities. The power to refuse to admit a student to school should not be used in a way that disproportionately burdens students with disabilities or that creates a barrier to their right to attend school.
  1. b) A principal who refuses to admit a student to school during the school re-opening process should be required to immediately give the student and their family written notice of their decision to do so, including written reasons for the refusal to admit, the duration of the refusal to admit and notice of the family’s right to appeal this refusal to admit to the school board.
  1. c) A principal who refuses to admit a student to school for all or part of the school day should be required to report this in writing to their school board’s senior management, including the reasons for the exclusion, its duration and whether the student has a disability. Each school board should be required to compile this information and to report it on a bi-monthly basis to the board of trustees, the public and the Ministry of Education (with individual information totally anonymized). The Ministry should promptly make public on a school board by school board basis the information it receives on numbers, reasons and durations of refusals to admit during post- COVID-19 school re-opening.

4. Need for Specific COVID-19 Individual Education Plans for Individual Students with Disabilities Before and During Transitioning to Return to School

For students with disabilities the distance learning during COVID-19 will have created different deficits and challenges. The transition back to school will present challenges that will vary from student to student.

Students’ IEPs were all written while students were in school, with no contemplation of the COVID-19 crisis or the challenges and hardships of distance learning and then of transition back to school. All students with disabilities will need their IEP modified to address these unforeseen needs.

They each need a COVID-19 –specific IEP. This should be done now and over the summer, not in the fall when students are hopefully already back in school. This will require action now. It may require new resources to enable this to be worked on over the summer.

As noted earlier, there is a real possibility that distance learning will continue in the fall or may have to resume due to a second wave of COVID-19. IEPs need to now anticipate and address these needs.

We therefore recommend that:

#4. For each student with disabilities, each school board should now:

  1. a) Contact the family of each student with disabilities, preferably by phone rather than email, to discuss and identify the student’s progress during the shutdown, the student’s specific and individualized disability-related deficits and needs arising from and during distance learning due to the COVID-19crisis and the student’s needs and challenges related to eventual return to school (including any vulnerabilities of other family members due to the COVID-19 pandemic), and;
  1. b) add to their IEP specific goals and activities to effectively address their disability-related needs during distance learning, and in connection with transition back to school.

5. Need for Provincial and School Board Rapid Response Teams to Address Recurring Urgent Needs of Students with Disabilities

During the COVID-19 crisis, Ontario’s education system continues to try to navigate uncharted territory. No matter how much planning for the needs of students with disabilities takes place as we here recommend, unexpected surprises will crop up. school boards and the Ministry of Education each need to be able to quickly detect these, and to nimbly respond to them.

Parents, teachers and principals need a central point in the school board to report difficult challenges. Each school board needs to feed this information to a single point at the Ministry that is staying on top of things, for rapid responses to recurring issues around the province.

We therefore recommend that:

#5. The Ministry of Education should assign staff to assist its Students with Disabilities Command Table by serving as a central rapid response team to receive feedback from school boards on recurring issues facing students with disabilities and to help find solutions to be shared with school boards.

#6. The Ministry should direct that each school board shall establish a similar central rapid response team within the board to receive feedback from teachers and principals about problems they are encountering serving students with disabilities during the COVID-19 period, that can quickly network with other similar offices at other school boards, and that can report recurring issues to the Ministry.

6. Surge Needed in Specialized Supports for Students with Disabilities

All students will have fallen behind to some extent during the months when schools were closed. This hardship falls especially on students with disabilities who have additional specialized curriculum to learn, related to their disabilities, or who need specialized supports to learn which are unavailable during distance learning.

When students return to school, students with disabilities who need those supports will need a surge in the hours of support provided to them to help them catch up and adjust to the return to school. School boards cannot simply pull those resources out of the air. School boards will need added funding to hire those staff, and provincial help finding them if there are shortages.

For example, students with vision loss are unable to get the full benefit of teachers of the visually impaired (TVIs) teaching hands-on braille reading when schools are closed. School boards will need to engage additional TVIs to help ramp up the surge in TVI hours to be provided to students. There is now a shortage of TVIs in Ontario. The Ministry will need to lead the effort to provide a surge of TVIs to help school boards fill this gap during the return to school. Comparable needs can similarly be identified for students with other disabilities where such specialized educational support is needed.

We therefore recommend that:

#7. The Ministry of Education should plan for, fund and coordinate the provision by school boards of a surge in specialized disability supports to those students with disabilities who will need them when students return to school.

7. Planning for Needs of Students with Disabilities Who Cannot Themselves Ensure Social Distancing

As an illustration of the last issue discussed, any return to school while COVID-19 continues to exist in our community will require students to engage in social distancing. If schools re-open, they will be doing so mindful of the fact that many students will not be able to consistently and reliably engage in social distancing, frequent hand washing and other important protective activities. Many are too young to ensure that they can fully understand the need to do so and comply. For some older children, it may seem cool to periodically break the rules. For many, it will be impossible to remain attentive to these precautions all the time.

For any number of students with disabilities, social distancing and related safe practices may pose additional challenges. For some, wearing a mask may not be possible due to such things as sensory integration or behavioural issues.

Some students with disabilities require an education assistant (EA) or special needs assistant (SNA) for all or part of the day to fully take part in school activities. For some of these students, it will not be possible to remain two meters away while providing the support or assistance that the student needs. Some will require close assistance for eating, hand-washing and other personal needs.

Pre-COVID-19 staffing levels for EAs and SNAs did not account for these additional requirements. EAs and SNAs were not experienced with or trained for this before COVID-19. It is not sufficient to now send them an email with instructions, or a link to a training video, and thereafter to assume that they will be fully equipped to handle these duties. In addition to new in-person training, they will need to have constant access to good quality personal protective equipment (PPE), like masks.

We therefore recommend that:

#8. The Ministry of Education’s plan for school re-openings must include detailed instructions on required measures for ensuring that students with disabilities are safe from COVID-19 during any return to school. This requires additional planning in advance by school boards and additional funding to school boards to hire and train the additional SNAs and EAs they will need to ensure the safety of students with disabilities.

8. Ensuring Full Accessibility of Digital Platforms Used for Remote Classes or “Synchronous Learning”

We do not here wade into the dispute between the Ford Government and some teachers’ unions about whether or when a teacher should conduct online classes for their students in real time over the internet, sometimes called “synchronous learning”. We insist, however, that whenever an online real time class or synchronous learning takes place, or any other online meeting involving students with disabilities or their parents in connection with their education, it must be conducted via a fully accessible digital meeting platform.

When the Ontario Government moved our education system from the physical classroom to the virtual classroom in late March, it should have ensured from the start that the choice of digital classroom platforms was fully accessible. The Ontario Government did not do so, nor did it monitor school boards to see what platforms they were using. Put simply, the Ontario Government entirely dropped the ball on this critical accessibility concern to the detriment of students, teachers and parents with disabilities. It did so based on a transparently erroneous starting point. The Ministry of Education took the position that it was up to each school board to decide which online virtual meeting platform to use based on its assessment of its local needs. Yet these disability accessibility needs do not vary from school board to school board.

As a belated partial attempt to address this problem, the Minister of Education wrote school boards on or around May 26, 2020 about several issues regarding distance learning. That memo stated, among other things:

“Boards must ensure that the platforms they use for connecting with students and families are fully accessible for persons with disabilities.”

However, that direction provides no assistance to school boards on which platforms to use or avoid, or how to figure this out. It still leaves it to each school board to investigate this as much or as little as they wish, and then to duplicate the same investigations of this issue over and over across Ontario.

This issue remains a live one and will continue into the fall. It is not clear when schools will re-open. Our education system may still be running on 100% distance learning at the start of the fall school term. Even when schools re-open, there is a real likelihood that some distance learning will continue in some blended model of in-school and distance education. As noted earlier, if a second wave of COVID-19 hits, as has happened elsewhere, requiring another round of school closures, Ontario will have to return to 100% distance learning.

We therefore recommend that:

#9. The Ministry of Education should immediately engage an arms-length digital accessibility consultant to evaluate the comparative accessibility of different digital meeting platforms available for use in Ontario schools. The Ministry should immediately send the resulting report and comparison to all school boards and make it public. The Ministry should direct which platforms may be used and which may not be used for virtual or synchronous classes or parent/school meetings, based on their accessibility.

9. Ensuring Digital Accessibility of Ontario Government and TVO Online Learning Resources

Over three months into the COVID-19 crisis, the Ontario Government has still not ensured that the online content that it provides to school boards, teachers, parents and students meets accessibility requirements for computer-users with disabilities. The AODA Alliance has been raising concerns with the Government about this since early in the pandemic. We have seen no public commitment to the needed corrective action. We have raised our concerns at senior levels within TVO and the Ministry of Education. The Government and TVO were required to comply with these accessibility requirements well before the advent of the COVID-19 pandemic.

We therefore recommend that:

#10. The Ministry of Education should immediately direct TVO to make its online learning content accessible to people with disabilities, and to promptly make public a plan of action to achieve this goal, with specific milestones and time lines.

#11. The Ministry of Education should make public a plan of action to swiftly make its own online learning content accessible for people with disabilities, setting out milestones and time lines, and should report to the public on its progress.

10. Stop Making Learning Resources Available Only in PDF Format

Throughout this pandemic, as well as beforehand, the Ministry of Education and too many school boards have continued to make important digital information available to the public, including to parents, teachers and students, only in pdf format. That format can present accessibility problems for people with disabilities. When a document is made public in PDF format, it should also be made public in an accessible format, such as MS Word. This is an important time to start this long-overdue practice.

We therefore recommend that:

#12. The Ministry of Education should direct all its staff and all school boards that whenever making digital information public in a PDF format, it must at the same time also be made available in an accessible format such as an accessible MS Word document.

11. One Size Fits All Does Not Fit for Return to School

To avoid chaos, a return to school should not be done all at once using a one-size-fits-all approach. Because we are in uncharted waters, it makes sense to go about this gradually and try different approaches at different locations to see what works. To avoid students with disabilities from being treated as after-thoughts who have to try to fit into a chaotic situation that was not designed with their needs in mind, it can be worthwhile to enable students with disabilities to return to school first, and for teaching staff to ensure their needs are met, before trying to also cope with an onslaught of all other students.

We therefore recommend that:

#13. The provincial plans for return to school should include these features:

  1. a) Rather than having all students across Ontario return to school at once, in a one-size-fits-all strategy, the Ontario Government should lead a strategic return to school process, trying out different approaches to see what works most effectively. For example, opening a few schools first to detect recurring problems and plan to prevent them would assist with opening of other schools across Ontario.
  1. b) The Ontario Government should try having the most vulnerable students, including students with disabilities, return to school first to facilitate their effective accommodation and orientation before all other students return to school.

12. Need for A Rapid Method to Spread the Word to Teachers and Parents About Effective Teaching Strategies for Students with Disabilities During COVID-19

Teachers and parents of students with disabilities are struggling around Ontario to cope with distance learning and the barriers it can create for many students with disabilities. Teachers and parents are creating novel work-arounds to address this.

Yet the Ontario Government has not been effectively canvassing the front lines of teachers and parents to gather these up and share them around the province, so all can benefit without having to re-invent the wheel I n the midst of a traumatic pandemic. We have called on the Ontario Government for the past three months to do this without success. We modelled one way of doing this by our successful May 4, 2020 online virtual town hall on teaching students with disabilities during the COVID-19 crisis (jointly organized with the Ontario Autism Coalition). As far as we have been able to learn, the Ontario Government has neither taken up that idea nor has it shared with school boards the link to our May 4, 2020 virtual town hall so that they can all benefit from it. We have repeatedly asked the Ministry of Education to share that link with school boards.

In the meantime, to fill this gap, several school boards have commendably been trying to do this themselves. They have themselves been compiling good ideas and sharing them within their own board.

This is a huge and wasteful duplication of effort. The Ontario Government should be centrally accumulating and compiling all these resources, as well as researching what other jurisdictions have compiled from their own experience. These should be rapidly made available to front line teachers and parents in a way that is easy to access, not by a blizzard of endless links that few if anyone will have the time to explore.

This effort should have been done weeks ago. it is not too late, since distance learning will remain part of our lives in whole or in part until a vaccine for COVID-19 is created and widely administered.

We therefore recommend that:

#14. The Ministry of Education should immediately put in place an effective proactive team to gather teaching strategies for students with disabilities during distance learning from front line teachers, parents and school boards and make these easily available to the front lines on an ongoing basis. These should be supplemented by strategies that the Ministry researches from other jurisdictions that have innovated creative solutions.

13. Distance Learning Must Be Maintained for Students Who Cannot Return to School

There will be students who cannot return to school when others do. Their disability may make it impossible to accommodate them in school under the restrictions that apply during the COVID-19 pandemic. The school board will have a duty to accommodate them unless the school board can prove that it is impossible to do so without undue hardship. Some students may not be able to return to school because their parents or other family members with whom they live are so medically vulnerable or immune-compromised that the family must take heightened precautions to avoid the risk of contracting COVID-19.

In those cases, even if other students are learning at school, the school board must provide effective and accessible distance learning for those students who must remain at home. This may include home visits from teaching staff.

We therefore recommend that:

#15 The plans for return to school must include measures for ensuring that those who cannot return to school at the same time can secure effective distance learning, including home visits (with social distancing) from teaching staff.

14. Creating Provincial Resources for Parents to Prepare Their Students for Return to School

Some students with disabilities will need extensive preparation at home for their eventual return to school, including learning about social distancing and other new school practices due to COVID-19. Some parents will need a great deal of time to deal with this. Each school board or teacher and family should not have to duplicate these efforts by inventing their own curriculum, social stories or other resources.

We therefore recommend that:

#16. The Ministry of Education should prepare teaching materials for teachers and parents to use, addressing different disability-related learning needs, for preparing students with disabilities for the return to school, to address such changes as social distancing.

15. New Protocols Needed for Safe School Bussing

There were ample problems with bussing of students with disabilities to school before the COVID-19 crisis. In any return to school, heightened safeguards will be needed, including frequent sanitization of busses, ensuring students are seated more than 2 meters from each other and ensuring that the driver has PPE and doesn’t risk spreading COVID-19. It is not realistic to expect that this will all simply happen with private sector bussing companies who employ casual and part time drivers working at low wages.

We therefore recommend that:

#17. The Ministry of Education should create, fund and effectively enforce new standards for safe bussing practices for students with disabilities during any return to school while COVID-19 remains a community threat.



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Major Disability Organizations Unite to Voice Serious Fears About Supposedly “Draft” Ontario Protocol for Rationing Critical Medical Care


A Patient’s Disability Should Never Be Used as a Reason to Deny Medical Care

Accessibility for Ontarians with Disabilities Act Alliance Update United for a Barrier-Free Society for All People with Disabilities
Web: http://www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: http://www.facebook.com/aodaalliance/

April 8, 2020

SUMMARY

In a powerful news release issued by the ARCH Disability Law Centre today, an open letter to the Ford Government was made public that is co-signed by dozens of disability organizations (including the AODA Alliance) and thousands of individuals. This open letter insists that if scarce medical treatments (like ventilators) must be rationed during the COVID-19 crisis, health care providers must never discriminate against a patient with disabilities by denying them needed medical care due to their disability, or due to the health care provider’s beliefs or stereotypes about the quality of life for a patient living with a disability.

The open letter raises serious concerns about a protocol for medical triage emanating from the Ontario Government, copies of which were obtained by some within the disability community. This is triggering real fear within the disability community. The ARCH news release, open letter, and list of organizational signatories are set out below.

In an important article on this topic in today’s Toronto Sun, also set out below, journalist Antonella Artuso reported that the Ford Government did not dispute the existence of the controversial protocol, but Health Minister Christine Elliot claimed it was only a draft. The article includes the following, referring to Health Minister Christine Elliot:

Elliott acknowledged the existence of the document Tuesday but said it still needs to go through final review by government cabinet.

“I know that there have been some concerns that have been expressed by people with certain disabilities, that they would be cut out of treatment if we got to that point,” Elliott said. “I would never allow that to happen. People with disabilities are treated in the same way as everyone else, as they should be.”

This type of document, one that provides guidance on who should get advanced life-saving care, would only come into effect if all else failed, she said.

Four the AODA Alliance’s part, it is hard to believe that such a document would only be a draft if it is not marked as a draft, and if it is already in circulation. It is our experience that at all levels, the Ontario Government is typically preoccupied if not obsessed with such cautions and secrecy around their documents. We would expect this to be especially the case for something as serious and controversial as the protocol for medical triage.

It is good that the Minister said that she would not allow “people with certain disabilities” to be cut out of treatment. The Ford Government must immediately and very publicly retract the protocol, whether or not it is a draft. It must publicly issue a directive that this protocol is not to be followed by health care providers.

The Government must quickly clear up the mixed messages that are no doubt floating around. It’s not just physicians in emergency rooms that need this cleared up. This is similarly vital for nurses and other health care professionals in hospitals and in the community. It’s vital for emergency medical technicians when they arrive at a scene in the community where a emergency patient has called for help. It’s similarly vital for nursing home administrators who can play a role in calling for emergency medical help for their residents.

It is also good that Minister Elliot said that the provincial Cabinet would have to approve any such protocol regarding medical triage. We call on the provincial Cabinet ministers and the Premier to pledge that they will ensure that any such protocol does not discriminate based on disability or permit such discrimination to take place, whether by doctors, nurses, EMTs or other health care providers.

It is vital that the Ford Government now open up the process for making its decisions and developing policy in this area. It cannot remain behind close doors, with the grassroots disability community excluded. We’ve been offering to help the Ontario Government address the urgent needs of people with disabilities during the COVID-19 crisis. It’s time for the Government to take up our offers.

Back on May 15, 2018, when running for office, Doug Ford wrote the AODA Alliance to set out his party’s election pledges on disability accessibility and inclusion. Among other things, he said these words, which now require him and his senior ministers to include us in their efforts during the COVID-19 crisis:

“Your issues are close to the hearts of our Ontario PC Caucus and Candidates, which is why they will play an outstanding role in shaping policy for the Ontario PC Party to assist Ontarians in need.”

Just over a month ago, on February 28, 2020, at a carefully staged media event, the Ford Government pledged that it is leading by example on accessibility for people with disabilities. Now would be a good time and place for the Government to start to do so.

When the immediate crisis passes, there should be an open and independent investigation of how this draft protocol came to be and why the voices of the grassroots disability community have been left out of discussions that so critically affect them.

This medical triage protocol was a top item discussed yesterday when the AODA Alliance and the Ontario Autism Coalition held a grassroots online Virtual Public Forum on what Government needs to do to protect the urgent needs of people with disabilities during the COVID-19 crisis. We urge one and all to watch it and spread the word about it. Over 900 people have already watched it. It remains available at any time to be watched on Youtube, with captioning and American Sign Language interpretation. The April 7, 2020 news release jointly issued by the AODA Alliance and the Ontario Autism Coalition summarizes some key recommendations coming from that virtual public forum.

Our virtual public forum has already secured media coverage including interviews with AODA Alliance Chair David Lepofsky on April 7, 2020 on News Radio 570 in Kitchener, and earlier today on News Radio 1310 in Ottawa.

MORE DETAILS

Toronto Sun April 8, 2020

Originally posted at https://torontosun.com/news/provincial/disabled-to-be-denied-covid-19-care

Disabled to be denied COVID-19 care?
Antonella Artuso

A document that has left people with disabilities “scared” they’ll be denied an intensive care bed or ventilator during the COVID-19 pandemic is just a “draft,” Ontario Health Minister Christine Elliott says.

The Clinical Triage Protocol for Major Surge in COVID Pandemic a copy obtained by the Toronto Sun dated March 28 is not stamped with the word “draft” sets out guidelines for health-care professionals as a “last resort” when allocating life-saving resources during a shortage.

Advocates say the document makes unfair value judgments about the quality of lives lived by those in the disabled community in violation of their human rights, and has left many of them fearful that they won’t be entitled to the same level of care as everybody else.

“A person’s disability should absolutely never be used as a criterion for deciding whether they get critically needed health care,” David Lepofsky, chair of the AODA Alliance, said Tuesday. “And certainly a doctor’s or nurse’s or EMT’s subjective view of the quality of living with a disability compared to the quality of the life of somebody living without a disability should never be a factor in these decisions.”

Advocates for the disabled are planning to release an open letter to the Ontario government Wednesday in protest.

Elliott acknowledged the existence of the document Tuesday but said it still needs to go through final review by government cabinet.

“I know that there have been some concerns that have been expressed by people with certain disabilities, that they would be cut out of treatment if we got to that point,” Elliott said. “I would never allow that to happen. People with disabilities are treated in the same way as everyone else, as they should be.”

This type of document, one that provides guidance on who should get advanced life-saving care, would only come into effect if all else failed, she said.

Robert Lattanzio, executive director of ARCH Disability Law Centre, said the document provides three levels of triage for health-care providers based on demand and resources.

Using the “frailty scale,” the framework doesn’t just look at who would benefit most from the care, but also calls on health professionals to consider factors like the quality of life of those with a disability, he said.

“That is where we cross a line that we cannot cross,” he said.

Lattanzio said he’s not aware that the protocol is currently in place, but he’s hearing from members of the disabled community aware of it and “scared” that they won’t get the care they need if they go to hospital.

“There’s a heightened sense of fear in the midst of everything else that is going on,” Lattanzio said. “All of our lives are turned upside down but for our communities, for people with disabilities, they are in the fight for their lives.”

[email protected]

April 8, 2020 News Release from the ARCH Disability Law Centre For Immediate Release
Open Letter from Major Disability Organizations Calling on the Ontario Government to Ensure Persons are not Deprioritized from Accessing Critical Care Because of their Disability
TORONTO, April 8, 2020 An open letter to the Ontario Government from over 200 disability and community organizations and over 4,800 individuals raises grave concerns about the Clinical Triage Protocol for Major Surge in COVID Pandemic (Ontario Health), dated March 28, 2020, because it threatens to deprioritize access to critical care to some patients due in part to their disability a clear violation of the Ontario Human Rights Code.
The open letter, a link to which is provided below, explains that according to the Triage Protocol, people living with certain disabilities, such as Parkinson Disease, may be ranked as a lower priority when deciding who receives critical care. Similarly, the Triage Protocol indicates that in some circumstances, people who receive supports for daily living, such as those with moderate-to-severe cognitive impairments and the clinically frail elderly, are less likely to receive critical care.

“A person’s disability must not be used as a reason to deprioritize a person’s need for critical care, even during difficult periods of medical care shortages,” said lawyer Robert Lattanzio, Executive Director of the ARCH Disability Law Centre, a co-signatory to the letter. “Doctors, nurses, EMTs or other health care providers must ensure that their decisions are not informed by discriminatory assumptions or stereotypes about the ‘quality of life’ of a person with a disability. Increasingly, people with disabilities are fearful that this is what they are about to face. They desperately need the Government to make it loud and clear that this will not be tolerated.”

“Health care providers need clear, fair and ethically-sound direction in line with our human rights protections on what to do should decisions about scarce medical resources have to be made,” said Lattanzio. “We urge the Government to immediately withdraw this triage protocol, consult with disability communities, and ensure that any revised protocol includes a clear statement reaffirming human rights protections including the right to disability related accommodations and supports, and that disability will not be a factor in determining priority for critical medical treatment.”

Yesterday, this was one of the important issues discussed at a ground-breaking online Virtual Public Forum on what governments must do to meet the urgent needs of people with disabilities during the COVID crisis, available at https://www.youtube.com/watch?v=gJ23it9ULjc

It is important to keep in mind that some people with disabilities bear the disproportionate risk of getting this disease, the greater risk of severe medical consequences from it, and moreover at a higher risk of being denied critical care when needed most.

To view the Open Letter go to archdisabilitylaw.ca
– 30 –
Contact:
Robert Lattanzio, Executive Director
ARCH Disability Law Centre
Toll-free: 1-866-482-2724 extension 2233
Email: [email protected]

April 8, 2020 Open Letter to the Ontario Government on the Medical Triage Protocol

OPEN LETTER: Ontario’s COVID-19 Triage Protocol
April 8, 2020
Hon. Doug Ford, Premier of Ontario
Legislative Building
Queen’s Park
Toronto, ON M7A 1A1
Hon. Christine Elliott, Deputy Premier and Minister of Health of Ontario College Park 5th Floor,
777 Bay Street, Toronto, ON M7A 2J3
Hon. Raymond Sung Joon Cho, Minister of Seniors and Accessibility of Ontario Ministry for Seniors and Accessibility
College Park, 5th Floor
777 Bay Street, Toronto, ON M5G 2C8

Dear Hon. Premier Ford, Hon. Deputy Premier and Minister Elliott, and Hon. Minister Cho: Re: Ontario’s Clinical Triage Protocol
We, the undersigned, share grave concerns regarding Ontario Health’s Clinical Triage Protocol for Major Surge in COVID Pandemic, dated March 28, 2020, which has yet to be released to the public. As disability organizations, we write in particular to underscore the disproportionate and adverse impact that the Triage Protocol will have on people with disabilities, and to make recommendations for reform.

The COVID-19 pandemic is disproportionately impacting persons with disabilities: our communities are more vulnerable to the virus and are being severely impacted by the necessary emergency response measures, like physical distancing, which interferes with the supports they need for daily living or is not altogether possible.

The Triage Protocol must respect the human rights of all persons, including persons with disabilities. Consultation with human rights experts and the marginalized communities of persons who are going to be disproportionately impacted by the Triage Protocol, must be conducted. Even though it is an emergency situation, the COVID-19 pandemic cannot be used as justification for discrimination.

To this end, we make the following specific recommendations:
(1) Persons with disabilities cannot be deprioritized for critical care on the basis of their disability
According to the Triage Protocol, some people will not get critical care because of their disability. For example, the Triage Protocol identifies particular disabilities, such as cognitive disabilities and advanced neurodegenerative diseases including Parkinson Disease, and Amyotrophic Lateral Sclerosis. Persons with these disabilities may in some stages of their disability be deprioritized in determinations about who receives critical care.

It is imperative that decisions about who receives critical care should be made using objective clinical criteria directly associated with mortality risks of COVID-19, and must not be based on stereotypes or assumptions about a person’s disability, and longer term mortality rates that are not directly related to COVID-19. It should also be made clear that by virtue of someone’s disability, they will not be deemed a lower priority and passed over for another patient who does not have a disability.

The Triage Protocol must clearly state that clinical judgment must not be informed by bias, stereotypes, or ableism
The Triage Protocol explicitly states that clinical assessments cannot take into consideration a patient’s socioeconomic privilege or political rank. As the health-care system has a long-entrenched history of ableism, the Triage Protocol must also explicitly state that implicit disability-based bias, stereotypes and ableist assumptions cannot factor into clinical judgment or assessment when allocating critical care resources. It must also make clear that decisions cannot be made on the basis of human-rights protected characteristics and intersecting identities. We understand that clinical judgment is an important part of the Triage Protocol, but there must be necessary safeguards to ensure that particular marginalized groups are not adversely impacted.

Persons with disabilities cannot be deprioritized for critical care based on the supports they receive for daily living
According to the Triage Protocol, persons with disabilities who receive accommodations or supports from others for daily living are in some circumstances less likely to receive critical care. This means that the Triage Protocol has the effect of deeming the lives of persons who require assistance as being less worthy, or assumes that they have a lesser quality of life. These kinds of criteria are discriminatory and devalue the lives of persons with disabilities. The Protocol invites value-based judgments on the basis of disability-related accommodations, which are a basic human right.

The Triage Protocol must clearly ensure that persons with disabilities receive necessary disability-related accommodations
The Triage Protocol does not have a clear statement that persons will receive necessary disability-related accommodations in the implementation of the Triage Protocol. Accommodations, such as interpretation, support or other services to access medical services, are a basic tenet of human rights law. Disability-related accommodations ensure that persons with disabilities have equal opportunity to receive, understand, and benefit from critical care.

We understand and appreciate that health care workers are working hard to care for all Ontarians, and a practical framework is required to help them make very difficult decisions about who gets critical care with some level of efficiency. We therefore support the development of a policy that respects human rights and has a fair procedure of decision making. We ask that any such framework not violate the basic human rights of persons with disabilities. The rationing of scarce resources in the health care system during this health crisis cannot be used as justification for discrimination.

Sincerely,
This letter has been signed by 204 organizations and 4828 individuals, as follows:

Organizations
1. ARCH Disability Law Centre
2. Access Independent Living Services
3. Accessibility for All
4. ACCKWA AIDS Committee of Cambridge, Kitchener, Waterloo & Area 5. Advocacy Centre for the Elderly
6. AIDS ACTION NOW!
7. AIDS Committee of Windsor
8. ALS Society of Canada
9. Alzheimer Society Durham Region
10. Alzheimer Society Lanark Leeds Grenville
11. Alzheimer Society of Niagara Region
12. Alzheimer Society of Perth County
13. Alzheimer Society Timmins-Porcupine
14. Alzheimer Society Waterloo Wellington
15. AODA Alliance
16. Arthritis Society
17. Autism Ontario
18. Balance for Blind Adults
19. BarrierFree Saskatchewan
20. BC Aboriginal Network on Disability Society
21. Brockville and District Association for Community Involvement (BDACI) 22. Bellwoods Centres for Community Living
23. Black Coalition for AIDS Prevention
24. Black Legal Action Centre
25. Bob Rumball Canadian Centre of Excellence for the Deaf
26. Brampton Caledon Community Living
27. Breaking Down Barriers Independent Living Resource Centre 28. Bridges to Belonging
29. Brockville & Area Community Living Association
30. Camp Bowen Society for the Independence of the Blind and Deafblind 31. Canadian Association for Community Living
32. Canadian Autism Spectrum Disorder Alliance
33. Canadian Council on Rehabilitation and Work
34. Canadian Down Syndrome Society
35. Canadian Federation of the Blind of Ontario
36. Canadian Hard of Hearing Association
37. Canadian HIV/AIDS Legal Network
38. Centre for Independent Living in Toronto (CILT)
39. Chatham-Kent Legal Clinic
40. Chinese & Southeast Asian Legal Clinic
41. Christian Horizons
42. Citizen Advocacy Ottawa
43. Citizens With Disabilities – Ontario (CWDO)
44. Community Living Ajax – Pickering and Whitby
45. CNIB Foundation
46. Cochrane Temiskaming Resource Centre
47. Communication Disabilities Access Canada
48. Community Autism Centre Inc.
49. Community Living Ajax Pickering and Whitby
50. Community Living Algoma
51. Community Living Campbellford/ Brighton
52. Community Living Central York
53. Community Living Chatham-Kent
54. Community Living Dundas County
55. Community Living Essex County
56. Community Living Guelph Wellington
57. Community Living Kincardine & District
58. Community Living Kingston & District
59. Community Living North Bay
60. Community Living North Grenville
61. Community Living Ontario
62. Community Living Prince Edward
63. Community Living Quinte West
64. Community Living Toronto
65. Community Living Upper Ottawa Valley
66. Community Living Welland-Pelham
67. Community Living West Nipissing
68. Community living Windsor
69. Community Living York South
70. Community Living-Central Huron
71. Community Resistance Intimacy Project (CRIP)
72. Council of Canadians with Disabilities (CCD)
73. Council of Canadians, Peterborough and Kawarthas chapter 74. DANI
75. Deafblind Community Services
76. DEEN Support Services
77. Disability Alliance BC
78. Disability Justice Network of Ontario (DJNO)
79. DisAbled Women’s Network Canada (DAWN)
80. Dissociative Society of Canada
81. Down Syndrome Association of Peel
82. Down Syndrome Association of Toronto
83. Down Syndrome Caring Parents of Niagara
84. Down Syndrome Niagara
85. Downsview Community Legal Services
86. Durham Association for Family Resources and Support
87. Durham Family Network
88. Easter Seals Ontario
89. Elevate NWO
90. Empower Simcoe
91. Empowered Kids Ontario – Enfants Avenir Ontario
92. ensemble
93. Erich’s Cupboard
94. Ethno Racialized Disability Coalition Ontario (ERDCO)
95. Extend-A-Family
96. Extend-A-Family Waterloo Region
97. Facile Perth
98. Families for a Secure Future
99. Family Alliance Ontario
100. Family Respite Services
101. Family Support Network for Employment
102. Family Support Network (Newmarket/Aurora)
103. Family Support Network (Total Communication Environment) 104. Fetal Alcohol Spectrum Disorder Group of Ottawa
105. Good Things In Life
106. Guelph Independent Living
107. Guide Dog Users of Canada
108. Hamilton & District Injured Workers Group
109. Hamilton Community Legal Clinic
110. Hamilton Family Network
111. Hand Over Hand Community Organization
112. HIV & AIDS Legal Clinic Ontario (HALCO)
113. Hydrocephalus Canada
114. Independent Living Centre of Waterloo Region
115. Inclusive Design Research Centre, OCAD University
116. Income Security Advocacy Centre (ISAC)
117. Independent Living Canada
118. Independent Living Centre London and Area
119. Injured Workers Community Legal Clinic (IWC)
120. Intensive TLC
121. Joyce Scott Non Profit Homes Inc.
122. Kawartha Sexual Assault Centre
123. KMK Law
124. KW AccessAbility
125. KW habilitation
126. Lake Country Community Legal Clinic
127. L’Arche Canada
128. L’Arche Daybreak
129. L’Arche London
130. L’Arche Sudbury
131. Live & Learn Centre
132. London Down Syndrome Association
133. March of Dimes Canada
134. Marsha Forest Centre
135. Mary Centre of the Archdiocese of Toronto
136. Member Family Support Network TCE
137. Middlesex Community Living
138. Millennial Womxn in Policy
139. Montage Support Services
140. MPN Ontario Patient Support Group
141. Muscular Dystrophy Canada
142. National Coalition of People who use Guide and Service Dogs 143. National Educational Association of Disabled Students (NEADS) 144. National Network for Mental Health (NNMH)
145. Network of Women with Disabilities NOW
146. New Vision Advocates
147. No More Silence
148. Older Women’s Network / Living in Place Campaign
149. Ontario Association for Developmental Education
150. Ontario Association of Independent Living Service Providers 151. Ontario Association of the Deaf
152. Ontario Autism Coalition
153. Ontario Disability Coalition
154. Ontario Federation for Cerebral Palsy
155. Ontario Health Coalition
156. Ontario Independent Facilitation Network
157. Options Northwest Personal Support Services
158. Ontario Parents of Visually Impaired Children VIEWS for the Visually Impaired 159. Ottawa Carleton Association for Persons with Developmental Disabilities 160. Ottawa Independent Living Resource Centre
161. P.A.D.D. Parents of Adults who have Developmental Disabilities 162. PACE Independent Living
163. Pacific Training Centre for the Blind
164. Parkdale Community Legal Services
165. Parkdale People’s Economy
166. Participation Lodge Grey-Bruce
167. Peterborough Community Legal Centre
168. Peterborough Health Coalition
169. PHSS-Medical & Complex Care in Community
170. PooranLaw Professional Corporation
171. Prisoners with HIV/AIDS Support Action Network
172. Project 321 Peel Down Syndrome Association
173. Project Autism
174. PWA (Toronto People With AIDS Foundation)
175. Realize
176. RISE: Resource Centre for Independent Living
177. Scleroderma Society of Ontario
178. Shannon Law Office
179. Students for Barrier-free Access
180. Sudbury Community Legal Clinic
181. Tangled Art + Disability
182. The AIDS Committee of Durham Region
183. The AIDS Network
184. The Canadian Arthritis Patient Alliance
185. The FASD E.L.M.O. Network
186. The George Hull Centre for Children and Families
187. The Legal Clinic (Perth, Sharbot Lake, Brockville)
188. The Neighbourhood Group
189. The Organization of Canadian Tamils With Disabilities (OCTD) 190. The Participation House Project, Durham Region
191. Toronto Family Network
192. Toronto Yachad – The Canadian Jewish Council for Disabilities 193. Total Communication Environment
194. Traverse Independence
195. Universities Allied for Essential Medicines (UAEM)
196. Viability Employment Services
197. Vibrant Health Care Alliance
198. Vision Loss Rehabilitation Ontario
199. Waterloo Regional Down Syndrome Society (WRDSS)
200. Windsor-Essex Family Network
201. Workers United Canada Council
202. Working For Change
203. York Region Lifetime Independent Facilitation
204. YWCA Hamilton
The original letter sent to the above noted recipients included a full list of individual signatories.




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Major Disability Organizations Unite to Voice Serious Fears About Supposedly “Draft” Ontario Protocol for Rationing Critical Medical Care – A Patient’s Disability Should Never Be Used as a Reason to Deny Medical Care


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/

Major Disability Organizations Unite to Voice Serious Fears About Supposedly “Draft” Ontario Protocol for Rationing Critical Medical Care – A Patient’s Disability Should Never Be Used as a Reason to Deny Medical Care

April 8, 2020

          SUMMARY

In a powerful news release issued by the ARCH Disability Law Centre today, an open letter to the Ford Government was made public that is co-signed by dozens of disability organizations (including the AODA Alliance) and thousands of individuals. This open letter insists that if scarce medical treatments (like ventilators) must be rationed during the COVID-19 crisis, health care providers must never discriminate against a patient with disabilities by denying them needed medical care due to their disability, or due to the health care provider’s beliefs or stereotypes about the quality of life for a patient living with a disability.

The open letter raises serious concerns about a protocol for medical triage emanating from the Ontario Government, copies of which were obtained by some within the disability community. This is triggering real fear within the disability community. The ARCH news release, open letter, and list of organizational signatories are set out below.

In an important article on this topic in today’s Toronto Sun, also set out below, journalist Antonella Artuso reported that the Ford Government did not dispute the existence of the controversial protocol, but Health Minister Christine Elliot claimed it was only a draft. The article includes the following, referring to Health Minister Christine Elliot:

Elliott acknowledged the existence of the document Tuesday but said it still needs to go through final review by government cabinet.

“I know that there have been some concerns that have been expressed by people with certain disabilities, that they would be cut out of treatment if we got to that point,” Elliott said. “I would never allow that to happen. People with disabilities are treated in the same way as everyone else, as they should be.”

This type of document, one that provides guidance on who should get advanced life-saving care, would only come into effect if all else failed, she said.

Four the AODA Alliance‘s part, it is hard to believe that such a document would only be a draft if it is not marked as a draft, and if it is already in circulation. It is our experience that at all levels, the Ontario Government is typically preoccupied if not obsessed with such cautions and secrecy around their documents. We would expect this to be especially the case for something as serious and controversial as the protocol for medical triage.

It is good that the Minister said that she would not allow “people with certain disabilities” to be cut out of treatment. The Ford Government must immediately and very publicly retract the protocol, whether or not it is a draft. It must publicly issue a directive that this protocol is not to be followed by health care providers.

The Government must quickly clear up the mixed messages that are no doubt floating around. It’s not just physicians in emergency rooms that need this cleared up. This is similarly vital for nurses and other health care professionals in hospitals and in the community. It’s vital for emergency medical technicians when they arrive at a scene in the community where a emergency patient has called for help. It’s similarly vital for nursing home administrators who can play a role in calling for emergency medical help for their residents.

It is also good that Minister Elliot said that the provincial Cabinet would have to approve any such protocol regarding medical triage. We call on the provincial Cabinet ministers and the Premier to pledge that they will ensure that any such protocol does not discriminate based on disability or permit such discrimination to take place, whether by doctors, nurses, EMTs or other health care providers.

It is vital that the Ford Government now open up the process for making its decisions and developing policy in this area. It cannot remain behind close doors, with the grassroots disability community excluded. We’ve been offering to help the Ontario Government address the urgent needs of people with disabilities during the COVID-19 crisis. It’s time for the Government to take up our offers.

Back on May 15, 2018, when running for office, Doug Ford wrote the AODA Alliance to set out his party’s election pledges on disability accessibility and inclusion. Among other things, he said these words, which now require him and his senior ministers to include us in their efforts during the COVID-19 crisis:

“Your issues are close to the hearts of our Ontario PC Caucus and Candidates, which is why they will play an outstanding role in shaping policy for the Ontario PC Party to assist Ontarians in need.”

Just over a month ago, on February 28, 2020, at a carefully staged media event, the Ford Government pledged that it is leading by example on accessibility for people with disabilities. Now would be a good time and place for the Government to start to do so.

When the immediate crisis passes, there should be an open and independent investigation of how this draft protocol came to be and why the voices of the grassroots disability community have been left out of discussions that so critically affect them.

This medical triage protocol was a top item discussed yesterday when the AODA Alliance and the Ontario Autism Coalition held a grassroots online Virtual Public Forum on what Government needs to do to protect the urgent needs of people with disabilities during the COVID-19 crisis. We urge one and all to watch it and spread the word about it. Over 900 people have already watched it. It remains available at any time to be watched on Youtube, with captioning and American Sign Language interpretation. The April 7, 2020 news release jointly issued by the AODA Alliance and the Ontario Autism Coalition summarizes some key recommendations coming from that virtual public forum.

Our virtual public forum has already secured media coverage including interviews with AODA Alliance Chair David Lepofsky on April 7, 2020 on News Radio 570 in Kitchener, and earlier today on News Radio 1310 in Ottawa.

          MORE DETAILS

Toronto Sun April 8, 2020

Originally posted at https://torontosun.com/news/provincial/disabled-to-be-denied-covid-19-care

Disabled to be denied COVID-19 care?

Antonella Artuso

A document that has left people with disabilities “scared” they’ll be denied an intensive care bed or ventilator during the COVID-19 pandemic is just a “draft,” Ontario Health Minister Christine Elliott says.

The Clinical Triage Protocol for Major Surge in COVID Pandemic – a copy obtained by the Toronto Sun dated March 28 is not stamped with the word “draft” – sets out guidelines for health-care professionals as a “last resort” when allocating life-saving resources during a shortage.

Advocates say the document makes unfair value judgments about the quality of lives lived by those in the disabled community in violation of their human rights, and has left many of them fearful that they won’t be entitled to the same level of care as everybody else.

“A person’s disability should absolutely never be used as a criterion for deciding whether they get critically needed health care,” David Lepofsky, chair of the AODA Alliance, said Tuesday. “And certainly a doctor’s or nurse’s or EMT’s subjective view of the quality of living with a disability – compared to the quality of the life of somebody living without a disability – should never be a factor in these decisions.”

Advocates for the disabled are planning to release an open letter to the Ontario government Wednesday in protest.

Elliott acknowledged the existence of the document Tuesday but said it still needs to go through final review by government cabinet.

“I know that there have been some concerns that have been expressed by people with certain disabilities, that they would be cut out of treatment if we got to that point,” Elliott said. “I would never allow that to happen. People with disabilities are treated in the same way as everyone else, as they should be.”

This type of document, one that provides guidance on who should get advanced life-saving care, would only come into effect if all else failed, she said.

Robert Lattanzio, executive director of ARCH Disability Law Centre, said the document provides three levels of triage for health-care providers based on demand and resources.

Using the “frailty scale,” the framework doesn’t just look at who would benefit most from the care, but also calls on health professionals to consider factors like the quality of life of those with a disability, he said.

“That is where we cross a line that we cannot cross,” he said.

Lattanzio said he’s not aware that the protocol is currently in place, but he’s hearing from members of the disabled community aware of it and “scared” that they won’t get the care they need if they go to hospital.

“There’s a heightened sense of fear in the midst of everything else that is going on,” Lattanzio said. “All of our lives are turned upside down but for our communities, for people with disabilities, they are in the fight for their lives.”

[email protected]

April 8, 2020 News Release from the ARCH Disability Law Centre

For Immediate Release

Open Letter from Major Disability Organizations Calling on the Ontario Government to Ensure Persons are not Deprioritized from Accessing Critical Care Because of their Disability

TORONTO, April 8, 2020 – An open letter to the Ontario Government from over 200 disability and community organizations and over 4,800 individuals raises grave concerns about the Clinical Triage Protocol for Major Surge in COVID Pandemic (Ontario Health), dated March 28, 2020, because it threatens to deprioritize access to critical care to some patients due in part to their disability – a clear violation of the Ontario Human Rights Code.

The open letter, a link to which is provided below, explains that according to the Triage Protocol, people living with certain disabilities, such as Parkinson Disease, may be ranked as a lower priority when deciding who receives critical care. Similarly, the Triage Protocol indicates that in some circumstances, people who receive supports for daily living, such as those with moderate-to-severe cognitive impairments and the clinically frail elderly, are less likely to receive critical care.

“A person’s disability must not be used as a reason to deprioritize a person’s need for critical care, even during difficult periods of medical care shortages,” said lawyer Robert Lattanzio, Executive Director of the ARCH Disability Law Centre, a co-signatory to the letter. “Doctors, nurses, EMTs or other health care providers must ensure that their decisions are not informed by discriminatory assumptions or stereotypes about the ‘quality of life’ of a person with a disability. Increasingly, people with disabilities are fearful that this is what they are about to face. They desperately need the Government to make it loud and clear that this will not be tolerated.”

“Health care providers need clear, fair and ethically-sound direction in line with our human rights protections on what to do should decisions about scarce medical resources have to be made,” said Lattanzio. “We urge the Government to immediately withdraw this triage protocol, consult with disability communities, and ensure that any revised protocol includes a clear statement reaffirming human rights protections including the right to disability related accommodations and supports, and that disability will not be a factor in determining priority for critical medical treatment.”

Yesterday, this was one of the important issues discussed at a ground-breaking online Virtual Public Forum on what governments must do to meet the urgent needs of people with disabilities during the COVID crisis, available at https://www.youtube.com/watch?v=gJ23it9ULjc

It is important to keep in mind that some people with disabilities bear the disproportionate risk of getting this disease, the greater risk of severe medical consequences from it, and moreover at a higher risk of being denied critical care when needed most.

To view the Open Letter go to archdisabilitylaw.ca

Contact:

Robert Lattanzio, Executive Director

ARCH Disability Law Centre

Toll-free: 1-866-482-2724 extension 2233

Email: [email protected]

April 8, 2020 Open Letter to the Ontario Government on the Medical Triage Protocol

OPEN LETTER: Ontario’s COVID-19 Triage Protocol

April 8, 2020

Hon. Doug Ford, Premier of Ontario

Legislative Building

Queen’s Park

Toronto, ON M7A 1A1

Hon. Christine Elliott, Deputy Premier and Minister of Health of Ontario

College Park 5th Floor,

777 Bay Street, Toronto, ON M7A 2J3

Hon. Raymond Sung Joon Cho, Minister of Seniors and Accessibility of Ontario

Ministry for Seniors and Accessibility

College Park, 5th Floor

777 Bay Street, Toronto, ON M5G 2C8

Dear Hon. Premier Ford, Hon. Deputy Premier and Minister Elliott, and Hon. Minister Cho:

Re:       Ontario’s Clinical Triage Protocol

We, the undersigned, share grave concerns regarding Ontario Health’s Clinical Triage Protocol for Major Surge in COVID Pandemic, dated March 28, 2020, which has yet to be released to the public. As disability organizations, we write in particular to underscore the disproportionate and adverse impact that the Triage Protocol will have on people with disabilities, and to make recommendations for reform.

The COVID-19 pandemic is disproportionately impacting persons with disabilities: our communities are more vulnerable to the virus and are being severely impacted by the necessary emergency response measures, like physical distancing, which interferes with the supports they need for daily living or is not altogether possible.

The Triage Protocol must respect the human rights of all persons, including persons with disabilities. Consultation with human rights experts and the marginalized communities of persons who are going to be disproportionately impacted by the Triage Protocol, must be conducted. Even though it is an emergency situation, the COVID-19 pandemic cannot be used as justification for discrimination.

To this end, we make the following specific recommendations:

  • Persons with disabilities cannot be deprioritized for critical care on the basis of their disability

According to the Triage Protocol, some people will not get critical care because of their disability. For example, the Triage Protocol identifies particular disabilities, such as cognitive disabilities and advanced neurodegenerative diseases including Parkinson Disease, and Amyotrophic Lateral Sclerosis. Persons with these disabilities may in some stages of their disability be deprioritized in determinations about who receives critical care.

It is imperative that decisions about who receives critical care should be made using objective clinical criteria directly associated with mortality risks of COVID-19, and must not be based on stereotypes or assumptions about a person’s disability, and longer term mortality rates that are not directly related to COVID-19. It should also be made clear that by virtue of someone’s disability, they will not be deemed a lower priority and passed over for another patient who does not have a disability.

 

The Triage Protocol must clearly state that clinical judgment must not be informed by bias, stereotypes, or ableism

The Triage Protocol explicitly states that clinical assessments cannot take into consideration a patient’s socioeconomic privilege or political rank. As the health-care system has a long-entrenched history of ableism, the Triage Protocol must also explicitly state that implicit disability-based bias, stereotypes and ableist assumptions cannot factor into clinical judgment or assessment when allocating critical care resources. It must also make clear that decisions cannot be made on the basis of human-rights protected characteristics and intersecting identities. We understand that clinical judgment is an important part of the Triage Protocol, but there must be necessary safeguards to ensure that particular marginalized groups are not adversely impacted.

 

Persons with disabilities cannot be deprioritized for critical care based on the supports they receive for daily living

According to the Triage Protocol, persons with disabilities who receive accommodations or supports from others for daily living are in some circumstances less likely to receive critical care. This means that the Triage Protocol has the effect of deeming the lives of persons who require assistance as being less worthy, or assumes that they have a lesser quality of life. These kinds of criteria are discriminatory and devalue the lives of persons with disabilities. The Protocol invites value-based judgments on the basis of disability-related accommodations, which are a basic human right.

 

The Triage Protocol must clearly ensure that persons with disabilities receive necessary disability-related accommodations

The Triage Protocol does not have a clear statement that persons will receive necessary disability-related accommodations in the implementation of the Triage Protocol. Accommodations, such as interpretation, support or other services to access medical services, are a basic tenet of human rights law. Disability-related accommodations ensure that persons with disabilities have equal opportunity to receive, understand, and benefit from critical care.

We understand and appreciate that health care workers are working hard to care for all Ontarians, and a practical framework is required to help them make very difficult decisions about who gets critical care with some level of efficiency. We therefore support the development of a policy that respects human rights and has a fair procedure of decision making. We ask that any such framework not violate the basic human rights of persons with disabilities. The rationing of scarce resources in the health care system during this health crisis cannot be used as justification for discrimination.

Sincerely,

This letter has been signed by 204 organizations and 4828 individuals, as follows:

 

Organizations

  1. ARCH Disability Law Centre
  2. Access Independent Living Services
  3. Accessibility for All
  4. ACCKWA – AIDS Committee of Cambridge, Kitchener, Waterloo & Area
  5. Advocacy Centre for the Elderly
  6. AIDS ACTION NOW!
  7. AIDS Committee of Windsor
  8. ALS Society of Canada
  9. Alzheimer Society Durham Region
  10. Alzheimer Society Lanark Leeds Grenville
  11. Alzheimer Society of Niagara Region
  12. Alzheimer Society of Perth County
  13. Alzheimer Society Timmins-Porcupine
  14. Alzheimer Society Waterloo Wellington
  15. AODA Alliance
  16. Arthritis Society
  17. Autism Ontario
  18. Balance for Blind Adults
  19. BarrierFree Saskatchewan
  20. BC Aboriginal Network on Disability Society
  21. Brockville and District Association for Community Involvement (BDACI)
  22. Bellwoods Centres for Community Living
  23. Black Coalition for AIDS Prevention
  24. Black Legal Action Centre
  25. Bob Rumball Canadian Centre of Excellence for the Deaf
  26. Brampton Caledon Community Living
  27. Breaking Down Barriers Independent Living Resource Centre
  28. Bridges to Belonging
  29. Brockville & Area Community Living Association
  30. Camp Bowen Society for the Independence of the Blind and Deafblind
  31. Canadian Association for Community Living
  32. Canadian Autism Spectrum Disorder Alliance
  33. Canadian Council on Rehabilitation and Work
  34. Canadian Down Syndrome Society
  35. Canadian Federation of the Blind of Ontario
  36. Canadian Hard of Hearing Association
  37. Canadian HIV/AIDS Legal Network
  38. Centre for Independent Living in Toronto (CILT)
  39. Chatham-Kent Legal Clinic
  40. Chinese & Southeast Asian Legal Clinic
  41. Christian Horizons
  42. Citizen Advocacy Ottawa
  43. Citizens With Disabilities – Ontario (CWDO)
  44. Community Living Ajax – Pickering and Whitby
  45. CNIB Foundation
  46. Cochrane Temiskaming Resource Centre
  47. Communication Disabilities Access Canada
  48. Community Autism Centre Inc.
  49. Community Living Ajax Pickering and Whitby
  50. Community Living Algoma
  51. Community Living Campbellford/ Brighton
  52. Community Living Central York
  53. Community Living Chatham-Kent
  54. Community Living Dundas County
  55. Community Living Essex County
  56. Community Living Guelph Wellington
  57. Community Living Kincardine & District
  58. Community Living Kingston & District
  59. Community Living North Bay
  60. Community Living North Grenville
  61. Community Living Ontario
  62. Community Living Prince Edward
  63. Community Living Quinte West
  64. Community Living Toronto
  65. Community Living Upper Ottawa Valley
  66. Community Living Welland-Pelham
  67. Community Living West Nipissing
  68. Community living Windsor
  69. Community Living York South
  70. Community Living-Central Huron
  71. Community Resistance Intimacy Project (CRIP)
  72. Council of Canadians with Disabilities (CCD)
  73. Council of Canadians, Peterborough and Kawarthas chapter
  74. DANI
  75. Deafblind Community Services
  76. DEEN Support Services
  77. Disability Alliance BC
  78. Disability Justice Network of Ontario (DJNO)
  79. DisAbled Women’s Network Canada (DAWN)
  80. Dissociative Society of Canada
  81. Down Syndrome Association of Peel
  82. Down Syndrome Association of Toronto
  83. Down Syndrome Caring Parents of Niagara
  84. Down Syndrome Niagara
  85. Downsview Community Legal Services
  86. Durham Association for Family Resources and Support
  87. Durham Family Network
  88. Easter Seals Ontario
  89. Elevate NWO
  90. Empower Simcoe
  91. Empowered Kids Ontario – Enfants Avenir Ontario
  92. ensemble
  93. Erich’s Cupboard
  94. Ethno Racialized Disability Coalition Ontario (ERDCO)
  95. Extend-A-Family
  96. Extend-A-Family Waterloo Region
  97. Facile Perth
  98. Families for a Secure Future
  99. Family Alliance Ontario
  100. Family Respite Services
  101. Family Support Network for Employment
  102. Family Support Network (Newmarket/Aurora)
  103. Family Support Network (Total Communication Environment)
  104. Fetal Alcohol Spectrum Disorder Group of Ottawa
  105. Good Things In Life
  106. Guelph Independent Living
  107. Guide Dog Users of Canada
  108. Hamilton & District Injured Workers Group
  109. Hamilton Community Legal Clinic
  110. Hamilton Family Network
  111. Hand Over Hand Community Organization
  112. HIV & AIDS Legal Clinic Ontario (HALCO)
  113. Hydrocephalus Canada
  114. Independent Living Centre of Waterloo Region
  115. Inclusive Design Research Centre, OCAD University
  116. Income Security Advocacy Centre (ISAC)
  117. Independent Living Canada
  118. Independent Living Centre London and Area
  119. Injured Workers Community Legal Clinic (IWC)
  120. Intensive TLC
  121. Joyce Scott Non Profit Homes Inc.
  122. Kawartha Sexual Assault Centre
  123. KMK Law
  124. KW AccessAbility
  125. KW habilitation
  126. Lake Country Community Legal Clinic
  127. L’Arche Canada
  128. L’Arche Daybreak
  129. L’Arche London
  130. L’Arche Sudbury
  131. Live & Learn Centre
  132. London Down Syndrome Association
  133. March of Dimes Canada
  134. Marsha Forest Centre
  135. Mary Centre of the Archdiocese of Toronto
  136. Member Family Support Network TCE
  137. Middlesex Community Living
  138. Millennial Womxn in Policy
  139. Montage Support Services
  140. MPN Ontario Patient Support Group
  141. Muscular Dystrophy Canada
  142. National Coalition of People who use Guide and Service Dogs
  143. National Educational Association of Disabled Students (NEADS)
  144. National Network for Mental Health (NNMH)
  145. Network of Women with Disabilities NOW
  146. New Vision Advocates
  147. No More Silence
  148. Older Women’s Network / Living in Place Campaign
  149. Ontario Association for Developmental Education
  150. Ontario Association of Independent Living Service Providers
  151. Ontario Association of the Deaf
  152. Ontario Autism Coalition
  153. Ontario Disability Coalition
  154. Ontario Federation for Cerebral Palsy
  155. Ontario Health Coalition
  156. Ontario Independent Facilitation Network
  157. Options Northwest Personal Support Services
  158. Ontario Parents of Visually Impaired Children – VIEWS for the Visually Impaired
  159. Ottawa Carleton Association for Persons with Developmental Disabilities
  160. Ottawa Independent Living Resource Centre
  161. A.D.D. Parents of Adults who have Developmental Disabilities
  162. PACE Independent Living
  163. Pacific Training Centre for the Blind
  164. Parkdale Community Legal Services
  165. Parkdale People’s Economy
  166. Participation Lodge Grey-Bruce
  167. Peterborough Community Legal Centre
  168. Peterborough Health Coalition
  169. PHSS-Medical & Complex Care in Community
  170. PooranLaw Professional Corporation
  171. Prisoners with HIV/AIDS Support Action Network
  172. Project 321 Peel Down Syndrome Association
  173. Project Autism
  174. PWA (Toronto People With AIDS Foundation)
  175. Realize
  176. RISE: Resource Centre for Independent Living
  177. Scleroderma Society of Ontario
  178. Shannon Law Office
  179. Students for Barrier-free Access
  180. Sudbury Community Legal Clinic
  181. Tangled Art + Disability
  182. The AIDS Committee of Durham Region
  183. The AIDS Network
  184. The Canadian Arthritis Patient Alliance
  185. The FASD E.L.M.O. Network
  186. The George Hull Centre for Children and Families
  187. The Legal Clinic (Perth, Sharbot Lake, Brockville)
  188. The Neighbourhood Group
  189. The Organization of Canadian Tamils With Disabilities (OCTD)
  190. The Participation House Project, Durham Region
  191. Toronto Family Network
  192. Toronto Yachad – The Canadian Jewish Council for Disabilities
  193. Total Communication Environment
  194. Traverse Independence
  195. Universities Allied for Essential Medicines (UAEM)
  196. Viability Employment Services
  197. Vibrant Health Care Alliance
  198. Vision Loss Rehabilitation Ontario
  199. Waterloo Regional Down Syndrome Society (WRDSS)
  200. Windsor-Essex Family Network
  201. Workers United Canada Council
  202. Working For Change
  203. York Region Lifetime Independent Facilitation
  204. YWCA Hamilton

The original letter sent to the above noted recipients included a full list of individual signatories.



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What Barriers Do Students with Disabilities Face in Post-Secondary Education in Ontario? Send Us Feedback on Our Draft Framework for a Post-Secondary Education Accessibility Standard


Accessibility for Ontarians with Disabilities Act Alliance Update United for a Barrier-Free Society for All People with Disabilities
http://Web: www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: http://www.facebook.com/aodaalliance/

March 11, 2020

SUMMARY

Well, were at it once again! We want and need your feedback! This time, its all about barriers impeding students with disabilities in post-secondary education in Ontario.

Two years ago, the Ontario Government appointed an advisory Standards Development Committee to prepare recommendations on what should be included in an accessibility standard to be enacted under the Accessibility for Ontarians with Disabilities Act, to tear down the barriers that impede students with disabilities in post-secondary education in Ontario. That includes such things as colleges and universities in Ontario.

We want to present ideas to that Standards Development Committee on what it should recommend. We are preparing a Framework for what the Post-Secondary Education Accessibility Standard should include. Below we set out a draft of that Framework, showing our work to date.

This draft Framework is about 38 pages long. The first 22 pages list recommendations on 16 different topics. After that, there is a 16 page appendix with specific proposals for accessibility of the built environment in post-secondary education organizations. If you dont have time to read it all, wed welcome your feedback on any parts of it that you have time to review.

Please look it over and send us your comments by April 3, 2020. What do you like in it? What are we missing? What should we change?

Please email us your thoughts by April 1, 2020. Write us at [email protected] The more specific you can be, the better!

Please dont use track changes to give us feedback, as it can present accessibility problems. Instead, send us an email with your comments. You can mention the number of the recommendation on which you are commenting, or cut and paste the passage on which you are commenting.

Once we get your feedback, we will finalize this Framework, make it public, and send it to the Post-Secondary Education Standards Development Committee.

This is the third such Framework weve prepared in the past 8 or 9 months. Last fall we prepared a detailed Framework on what the promised accessibility standard should include that will cover education in Ontario schools between kindergarten and Grade 12. We have submitted it to the K-12 Education Standards Development Committee.

Last month, we made public our Framework of what should be included in the promised Health Care Accessibility Standard. We have submitted that to the Health Care Standards Development Committee.

These Frameworks are our latest effort to try to provide constructive and leading-edge suggestions on how the Ontario Government could show strong new leadership on accessibility for over 2.6 million Ontarians with disabilities. We hope and trust that those Standards Development Committees found our proposals helpful. We thank everyone who has taken the time to give us feedback up to now as we worked on these important briefs.

To learn about our decade-long campaign to get the Ontario Government to take effective action under the AODA to address accessibility barriers that impede students with disabilities in Ontario’s education system, visit our websites Education page. To learn about our decade-long campaign for similar action under the AODA to address the disability barriers that impede patients with disabilities in Ontarios health care system, take a look at our websites Health Care page.

An inexcusable 405 days have now gone by since the Ford Government received the final report on the implementation and enforcement of the Accessibility for Ontarians with Disabilities Act that was prepared by former Lieutenant Governor David Onley. We are still waiting for the Ford Government to come up with a comprehensive and effective plan of new measures to implement the Onley Reports recommendations, needed to substantially strengthen the AODAs implementation and enforcement. To date, all the Government has offered Ontarians with disabilities is thin gruel.

MORE DETAILS

Accessibility for Ontarians with Disabilities Act Alliance
United for a Barrier-Free Society for All People with Disabilities www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance

Draft Only
A Framework for the Post-Secondary Education Accessibility Standard

March 11, 2020

Prepared by the Accessibility for Ontarians with Disabilities Act Alliance

Note: This is only a draft. It is still a work in progress. Feedback on it is welcome. By April 3, 2020, please send feedback to [email protected] Please do not use track changes to provide feedback.

Introduction — What is This Proposed Framework?

Students with disabilities face too many barriers at all levels of Ontario’s post-secondary education system. To address this, the Ontario Government has agreed to create an Education Accessibility Standard under the Accessibility for Ontarians with Disabilities Act (AODA). In 2018, the Ontario Government appointed two committees to make recommendations on what the Education Accessibility Standard should include: The K-12 Education Standards Development Committee was appointed for making recommendations on what that accessibility standard should include to address barriers in Ontario’s publicly-funded schools from Kindergarten to Grade 12. The Post-Secondary Education Standards Development Committee was appointed to make recommendations for what that accessibility standard should include to address barriers in Ontario’s post-secondary education institutions, e.g. colleges and universities.

Under the AODA, an accessibility standard is an enforceable regulation. It has the force of law. It spells out the disability barriers that are to be removed or prevented in a sector of society. It identifies the policies, practices or other measures an organization must implement to remove or prevent those barriers, and the timelines required for these actions.

In this Framework, the AODA Alliance outlines the key ingredients and aims for the promised Education Accessibility Standard in the area of post-secondary education. On October 10, 2019, the AODA Alliance made public a Framework for what the Education Accessibility Standard should include to remove and prevent barriers in Ontarios publicly-funded schools from kindergarten to Grade 12. This new Framework builds on and expands upon ideas in that earlier document, and adds additional ideas, all tailored to apply to the post-secondary education context.

Where this Framework states that a post-secondary education organization should or similar wording, this means by this that the Education Accessibility Standard should include a provision that requires the post-secondary education organization to take the step we describe.

To be effective, the Education Accessibility Standard must do much more than require organizations to have a policy on accessibility and to train its employees on that policy. Organizations want and need to know specifically what they must do to comply.

Under the AODA, a Standards Development Committees job is to recommend the contents of an AODA accessibility standard. It should recommend the specific measures, practices and policies that an accessibility standard should require an organization to implement. If a Standards Development Committee chooses to also recommend some non-regulatory measures, that is beyond the Committees core mandate. It should not detract or distract from fulfilling that core mandate. For example, the 2018 final recommendations of the Transportation Standards Development Committee largely focused on recommendations of other measures, outside the revision of the 2011 Transportation Accessibility Standard that that Committee was assigned to review. A recommended practice that are not enshrined in an accessibility standard as a regulation, are not binding on an obligated organization. They cannot be enforced.

It is especially important for the post-secondary education sector to become accessible to students with disabilities. A good post-secondary education is very important for getting a good job, or indeed getting a job at all. This is even more important for people with disabilities. People with disabilities chronically face a substantially higher unemployment rate than the public does as a whole. Barriers in the post-secondary education system can only make this situation worse. A strong and effective post-secondary Education Accessibility Standard is therefore an important measure for increasing employment opportunities for people with disabilities.

1. What Should the Long-Term Objectives of the Post-Secondary Education Accessibility Standard Be?

#1 The purpose of the Education Accessibility Standard should be to ensure that by 2025, post-secondary education in Ontario will be fully accessible and barrier-free for students with disabilities:

A) By removing and preventingaccessibility barriers impeding students with disabilities from fully participating in, being fully included in, and fully benefitting from all aspects of post-secondary education in Ontario, and

B) By providing a prompt, accessible, fair, effective and user-friendly process for students with disabilities to learn about and seek programs, services, supports, accommodations and
placements tailored to the individualstrengths and needs of each student with disabilities.

c) Eliminating or substantially reducing the need for students with disabilities to have to fight against post-secondary education accessibility barriers, one at a time, and the need for post-secondary education organizations to have to re-invent the accessibility wheel one education program at a time.

2. A Vision of An Accessible Post-Secondary Education System

The Post-Secondary Education Accessibility Standard should begin by setting out a vision of what an accessible post-secondary education system should include. It should include the following:

#2.1 The post-secondary education system will be designed and operated from top to bottom for all of its students, including students with all kinds of disabilities, as disability is defined in the Ontario Human Rights Code, the AODA and/or the Canadian Charter of Rights and Freedoms.

#2.2 The post-secondary education system will no longer be designed and operated from the starting point of aiming to serve the fictional “average” student or students who have no disabilities. Instead, it will be designed and operated to serve all students, including students with disabilities.

#2.3 The built environment in post-secondary education organizations such as colleges and universities, and the furniture and equipment on those premises (such as gym equipment) will all be fully accessible to people with disabilities and will be designed based on the principle of universal design. Where education programs or trips take place outside the post-secondary education organization premises, these will be held at locations that are disability-accessible, unless it is impossible to do so without undue hardship.

#2.4 Courses taught to students, including the curriculum and lesson plans, as well as informal learning activities, will fully incorporate principles of Universal Design in Learning (UDL), and where needed, differential instruction, so that they are inclusive for students with disabilities.

#2.5 Instructional materials used in post-secondary education organizations will be readily and promptly available in formats that are fully accessible to students with disabilities (such as those with print disabilities) who need to use them and will be available in accessible formats when needed, at no extra charge to the student.

#2.6 All digital technology and content used in Ontario’s post-secondary education organizations such as hardware, software and online learning, used in class or from home, will be fully accessible and will fully embody the principle of universal design. Professors and other instructors working with students with disabilities will be properly trained to use the accessibility features of that hardware, software and online learning technology.

#2.7 Inclusion and Universal Design in Learning will extend beyond formal classroom learning to other educational activities, such as experiential learning opportunities.

#2.8 Students with disabilities will have prompt access to the up-to-date adaptive technology and specialized supports they need, and training on how to use it, to best enable them to fully take part in and benefit from post-secondary education related programming. Students with disabilities will have the unobstructed right to bring a qualified service animal with them to post-secondary education programs and activities.

#2.9 Professors and other instructional staff will be fully trained to serve all students, and not just students who have no disabilities. They will be fully trained in such things as Universal Design in Learning and differential instruction.

#2.10 Tests and other forms of evaluation at post-secondary education organizations will be designed based on principles of universal design and Universal Design in Learning, so that they will be barrier-free for students with disabilities and will provide a fair and accurate assessment of their progress.

#2.11 Students with disabilities will encounter a pro-actively welcoming environment at post-secondary education organizations to facilitate their full participation, and a welcoming environment in which they can seek and receive accommodations for their disabilities where needed.

#2.12 Application processes and forms, admission criteria, admission tests or other admission screening to get into any post-secondary education program will be barrier-free for students with disabilities.

#2.13 Students with disabilities will have prompt, effective and easy access to user-friendly information in multiple languages about the post-secondary educational opportunities, options, programs, services, supports and accommodations available for them and their disability, and about the process for them to seek these.

#2.14 Where a student with a disability believes that a post-secondary education organization is not effectively meeting the student’s disability-related needs, (or if the student believes that the post-secondary education organization is not providing an educational program, service, support or accommodation which it had agreed to provide, the student will have access to a prompt, fair, open and arms-length review process, including an offer of a voluntary Alternative Resolution Process if needed. It will be conducted by someone with expertise in the education of students with disabilities who was not involved in the original decision or activity, and who does not oversee the work of those involved in the student’s direct education.

#2.15 There will be no bureaucratic, procedural or policy barriers that will impede the effective placement and accommodation of individual students with disabilities in post-secondary education organizations.

#2.16 Major new Government strategies or initiatives in Ontario’s post-secondary education system, whether adopted by the Ontario Government or otherwise, will be proactively designed from the start to fully include the needs of students with disabilities.

#2.17 Those officials who are responsible in the Ontario Government and within post-secondary education organizations for leading, overseeing and operating Ontario’s post-secondary education system will have strong and specific requirements to address disability accessibility and inclusion in their mandates and will be accountable for their work on this.

3. General Provisions that the Post-Secondary Education Accessibility Standard Should Include

#3.1 The Post-Secondary accessibility standard should cover and apply to disability barriers in all post-secondary education programs in Ontario, and not only to those offered in or by a college or university. Whether or not the terms of reference for the Post-Secondary Standards Development Committee only focus on post-secondary education offered in a college or university, the same barriers and solutions almost always apply to post-secondary education, whether it is offered by a college or university or by some other post-secondary education organization.

For example, for students with disabilities who are studying law, they can encounter the same disability barriers at an Ontario law school, situated in a university, or when they undertake the Bar Admissions Course, which the Law Society of Ontario offers. To train to be a lawyer in Ontario, a student must get a law degree from a law school and then pass the Law Society of Ontarios Bar course and examinations. Accordingly, the Post-Secondary Standards Development Committee should make recommendations regarding any post-secondary programs, whether or not they are offered in a college or university.

#3.2 Where this accessibility standard refers to “students with disabilities “, this should include any student who has any kind of disability, including, for example, any kind of physical, mental, sensory, learning, intellectual, mental health, communication, neurological, neurobehavioural or other kind of disability within the meaning of the Ontario Human Rights Code, the Accessibility for Ontarians with Disabilities Act or the Canadian Charter of Rights and Freedoms.

#3.3 Each post-secondary education organization should be required to establish a permanent committee of its governing board to be called the “Accessibility Committee”. This Accessibility Committee should have responsibility and authority to oversee the organizations compliance with the Accessibility for Ontarians with Disabilities Act and with the requirements of the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms in so far as they guarantee the right of students with disabilities to fully participate in and fully benefit from the education programs and opportunities that the organization provides.

#3.4 Each post-secondary education organization should be required to establish in each faculty or program, a faculty or program Accessibility Committee. It should include representatives from the facultys or programs instructors, management, staff and students with disabilities. Its mandate should be to identify barriers in the school and its programs and to make recommendations for accessibility improvements to be shared with the faculty, program and post-secondary education organizations senior management and governing board.

#3.5 Each post-secondary education organization should be required to establish or designate the position of Chief Accessibility/Inclusion Officer, reporting to the CEO, with a mandate and responsibility to ensure proper leadership on the organizations accessibility and inclusion obligations under the Ontario Human Rights Code, the Canadian Charter of Rights and Freedoms and the Accessibility for Ontarians with Disabilities Act, including the requirements set by this accessibility standard. This responsibility may be assigned to an existing senior management official.

#3.6 Each post-secondary education organization should set up and maintain a network of teaching and other staff with disabilities, and a network of students with disabilities, to get input on accessibility issues at the organization.

#3.7 Beyond the specific measures on removing and preventing barriers set out in the Post-Secondary Education Accessibility /Standard and in other AODA accessibility standards, each post-secondary education organization should be required to systematically review its educational programming, services, facilities, premises and equipment to identify recurring accessibility barriers within that organization that can impede the full and effective participation and inclusion of students with disabilities. A comprehensive plan for removing and preventing these accessibility barriers should be developed, implemented and made public with clear time lines, clear assignment of responsibilities for action, monitoring for progress, and reporting to the organizations governing board and senior management. It should include actions on barriers identified by the organizations faculty or program Accessibility Committees established under this standard. This plan should aim at all accessibility barriers that can impede students with disabilities from full inclusion in the education and other programs and activities at that organization, whether or not they are specifically identified in the Education Accessibility Standard or in any other specific accessibility standards enacted under the AODA.

#3.8 Each post-secondary education organization should have an explicit duty to create a welcoming environment for students with disabilities, to seek accommodations for their disabilities.

#3.9 To further ensure the effective accommodation of students with disabilities and the entrenchment of accessibility at the front lines, while creating and developing expertise in this area, each post-secondary education organization Shall implement the following:

a) in a small post-secondary education organization, such as one that offers only one program, one senior employee within the organization who reports to the organizations chief executive officer, dean or director, should be designated as that organizations Disability Accessibility and Accommodation Coordinator/Champion. Their responsibility is to serve as the one-stop-shopping point person for students with disabilities seeking accommodations, and being the employee to lead efforts at the organization towards incorporating accessibility into plans and decisions from the top down.

b) In a large post-secondary education organization, such as a college or university that has several faculties or programs, each faculty or program should designate a comparable Disability Accessibility and Accommodation Coordinator/Champion with similar responsibilities within that faculty or program.

c) A larger post-secondary education organization that has more than one Disability Accessibility and Accommodation Coordinator/Champion should network these individuals so they can pool expertise and resources.

d) The Council of Ontario Universities and comparable associations of other categories of post-secondary education organizations should establish networks of Disability Accessibility and Accommodation Coordinators/Champions to pool their expertise and resources.

e) Where a post-secondary education organization has an existing support/service centre for students with disabilities it may help serve these roles, but in the case of a larger post-secondary education organization, there should be a Disability Accessibility and Accommodation Coordinator/Champion designated in each faculty or program.

#3.10 Each post-secondary education organization should develop and implement human resources policies targeted at full accessibility and inclusion, such as making knowledge and experience on implementing inclusion an important hiring and promotions criterion especially for senior management.

4. The Right of Students with Disabilities to Know About Disability-Related Programs, Services, and Supports at Post-Secondary Education Organizations, and How to Access Them

Barrier: Students with disabilities can at times find it difficult to get easily accessed and accessible information from post-secondary education organizations and from the Ontario Government on education options, services and supports available for students with disabilities in post-secondary education organizations and how to access them.

#4.1 Each post-secondary education organization should provide the public, including students with disabilities, with easily-located, timely and effective information, in accessible formats, on the available services, programs and supports for students with disabilities and how to access them. Each post-secondary education organization should ensure that students with disabilities are informed, as early as possible, in a readily-accessible and understandable way, about important information such as:

a) That the post-secondary education organization recognizes that it has a duty to ensure that a student with a disability has the right to full participation in and full inclusion in all the post-secondary education organizations programming, and has the right to be accommodated in connection with those programs under the Ontario Human Rights Code and Canadian Charter of Rights and Freedoms. This applies to students with any and every kind of disability.

b) About the menu of options, placements, programs, services, supports and accommodations for students with disabilities available at the post-secondary education organization.

c) About which persons and which office to approach at the post-secondary education organization to get this information, to request placements, programs, supports, services or accommodations for students with disabilities, or to raise concerns about whether the post-secondary education organization is effectively meeting the students education needs.

d) The processes and procedures at the post-secondary education organization for students with disabilities to request disability-related services, supports or accommodations.

#4.2 Each post-secondary education organization should develop, implement and make public an action plan to substantially improve its provision of the important information, described above, to students with disabilities including any who are applying for admission to the post-secondary education organization:

a) This plans objective should be to ensure that all students with disabilities get the information they need to ensure that students of all abilities can fully participate in and benefit from the educational and other opportunities available at the post-secondary education organization.

b) Each post-secondary education organization should ensure that all of this important information is fully and readily accessible in a prompt and timely way to all students with disabilities and applicants for admission, in accessible formats and in jargon-free plain language. in a diverse range of languages. It should be easy to find this information. Among other things, this information should be posted on the post-secondary education organizations website, in a prominent place that is easy to find, with a link to it prominently on the post-secondary education organizations home page. A post-secondary education organization should not simply rely on its website to share this information.

c) Each post-secondary education organization should create a user-friendly package of information to be provided to applicants or prospective applicants for admission to any program at the post-secondary education organization. It should emphasize the need to alert the post-secondary education organization as early as possible to any disability accommodation needs.

5. Ensuring that Students Have a Fair and Effective Process for Raising Concerns About a Post-Secondary Education Organizations Accommodation of the Disability-Related Needs of Students with Disabilities

Barrier: The need for consistent and effective processes within a post-secondary education organization to ensure an easily-accessed and fair procedure to enable students with disabilities to seek and receive needed disability supports and accommodations, and for raising disability-related concerns.

#5.1 Each post-secondary education organization should establish and maintain an effective, fair and user-friendly process for students with disabilities to request and effectively take part in the development and implementation of plans for meeting and accommodating their disability-related needs.

#5.2 As part of this process, students with disabilities should be invited to take part in a joint in-person or virtual meeting to plan for their disability-related supports and accommodations. The student should be invited to bring to the table any supports and professionals that can assist them.

#5.3 If the student had an Individual Education Plan (IEP) from an Ontario school, or a finding by an Ontario school boards Identification and Placement Review Committee (IPRC) that identified them as having a disability (exceptionality), then the post-secondary education organization should treat that as sufficient proof that the student has a disability, without requiring further proof, unless the post-secondary education organization has independent proof showing that the student no longer has that disability. In that case, the post-secondary education organization shall provide the student with that proof and shall provide the student with an opportunity to demonstrate that they have a disability-related accommodation need. If the student had a specific disability-related accommodation while in school, the post-secondary education organization shall treat that as strong proof that they still have the same accommodation need at the post-secondary education organization, unless the post-secondary education organization has convincing proof that this need no longer exists or that an alternative and equally effective accommodation should be preferred.

#5.4 If a post-secondary education organization decides not to provide a requested disability accommodation, service, or support for a student that the student requested, or to meet a disability-related need that the student identified, the post-secondary education organization should promptly provide written reasons for that refusal.

#5.5 If students with disabilities disagree with any aspect of a post-secondary education organizations decision on a request for accommodation, or believe that the post-secondary education organization has not provided supports or accommodations to which it had agreed, the organization should make available a respectful, non-adversarial internal review process for hearing, mediating and deciding on the students concerns. The Post-Secondary Education Accessibility Standard should set out the specifics of this review process. This review process should include the following:

a) It should be very prompt. Arrangements for a student’s accommodations should be finalized as quickly as possible, so that the students needs are promptly met.

b) No proposed services, supports or accommodations that the post-secondary education organization is prepared to offer should be withheld from a student pending a review. The student should not feel pressured not to seek this review, lest they be placed in a position of educational disadvantage during the review process.

c) The review process should be fair. The post-secondary education organization should let the student know all of its issues or concerns with the students request or concerns, and give the student a fair chance to voice their concerns.

d) The review should be by a person or persons who are independent and impartial. They should have expertise in the education of students with disabilities. They should not have taken part in any of the earlier discussions or decisions at that post-secondary education organization regarding the services, supports or accommodations for that child.

e) At the review, every effort should be made to mediate and resolve any disagreements between the student and the post-secondary education organization. If the matter cannot be resolved by agreement, there should be an option for a qualified person who is outside the post-secondary education organization to be appointed at no charge to the student, to consider the review, along prompt timelines.

f) At the review, written reasons should be given for the decision, especially if any of the students requests or concerns are not accepted.

6. Expediting the Early Identification and Accommodation of Students with Disabilities’ Needs

Barrier: Students with disabilities can face delays and administrative/bureaucratic impediments to ensuring that they get all needed disability-related supports and accommodations. This comes in no small part from the fact that post-secondary education organizations are often large organizations with administrative responsibilities distributed over a number of departments and individuals. The effective accommodation of students is far easier to achieve when requests for accommodation are presented and considered as early as possible.

#6.1 The Post-Secondary Education Accessibility Standard should require specific measures to tear down administrative, bureaucratic and other barriers to reduce delays for identifying, seeking and securing needed disability supports and accommodations. For example:

a) post-secondary education organizations should be required to notify all students who apply for admission to any program or who seek information about programs to which they might apply, about the availability of disability-related supports and accommodation and the process for seeking them.

b) The post-secondary education organizations interactive voice response system for receiving incoming phone calls should announce to all callers the organizations commitment to accommodate students with disabilities and the number to press to get introductory information about how to seek such.

c) Programming handouts and broadcast email communications to incoming students should include similar general information.

d) the post-secondary education organizations broadcast email announcements and other communications to the student population should include summary information to this effect with relevant links.

e) Classroom instructors should make announcements in their first week of classes to this effect.

7. Ensuring Digital Accessibility

Barrier: Post-secondary education organizations using classroom technology, such as hardware, software, online learning systems, online courses and internal or external websites that lack digital accessibility; post-secondary education organizations policies and practices that can be obstacles to using adaptive technology designed for people with disabilities; Insufficient staff and instructor training and familiarity with creating accessible documents, with the use of accessibility features of mainstream technology, and with disability-specific adaptive technology.

#7.1 Each post-secondary education organization should ensure that:

a) Educational and information equipment and technology, including hardware, software, and tablet/mobile apps deployed in educational settings should be designed and configured based on universal design principles, to ensure that students with disabilities can fully use them.

b) A post-secondary education organizations Learning Management Systems (LMS) should be accessible to staff and students with disabilities, including those who use adaptive technology. They should have all accessibility features turned on and available to ensure that information posted through them will be accessible to students with disabilities, including those using adaptive technology such as screen readers or voice recognition tools. Each post-secondary education organization should ensure that no instructor or other staff is able to turn off any feature of the LMS that is accessible in favour of one that is not.

c) Each post-secondary education organizations internal and external websites and intranet content, including internet content available to students for learning purposes, including all online learning programs, should be fully accessible, with all new information posted on them to be fully accessible.

d) Electronic documents created at the post-secondary education organization for use in education and other programming and activities should be created in accessible formats unless there is a compelling and unavoidable reason making it impossible to do so. PDF format should be avoided. If a PDF document is created, an alternate version of the content should be simultaneously provided and posted in an accessible Microsoft Word or HTML format.

e) Software used to produce a post-secondary education organizations key documents for use by students should be designed to ensure that they produce these documents in accessible formats.

f) Textbooks and learning software should be procured only if they include full information technology accessibility. Any textbook used in any learning environment must be accessible to instructors and students with disabilities at the time of procurement. Here again, PDF should not be used unless an accessible alternative format such as MS Word is also simultaneously available. For example, if a textbook is available in EPUB format, the textbooks must meet the international standard for that file format. For EPUB it is the W3C Digital Publishing Guidelines currently under review. If a textbook is available in print, the publisher should be required to provide the digital version of the textbook in an accessible format at the same time the print version is delivered to the school/Board.

#7.2 Each post-secondary education organization should establish, implement, publicize and enforce information technology procurement accessibility requirements, to ensure that no technology is purchased unless it ensures full digital accessibility. Digital and information technology accessibility should be included in all Requests for Proposal (RFP) or other tenders for sale of products and services to a post-secondary education organization. It should be a condition of any such procurement that the vender will promptly remediate any accessibility shortcomings at its own expense.

#7.3 Each post-secondary education organization shall ensure that its instructional staff are fully trained in the creation of accessible electronic documents and online content for use by students, and shall periodically and randomly spot-check such documents to assist in ensuring that instructional staff are effectively trained and up-to-date in this area.

#7.4 Each post-secondary education organization shall review its policies and practices to identify, remove and prevent any barriers to the accessibility of its online and digital content that students might use as part of their educational activities.

#7.5 Each post-secondary education organization shall ensure that its information technology support and help staff includes specialists in access technology, and that students with disabilities get prompt access to IT support when needed.

8. Ensuring Universal Design in Learning and Differentiated Instruction Are Used in All Teaching Activities, Both Online and in Classroom Learning

Barrier: Too often, the curricula and lesson plans used in post-secondary education organizations were not designed and delivered based on principles of accessibility, Universal Design in Learning (UDL) and differentiated instruction (DI). Universal design in learning takes the principles of universal design (designing buildings and products so all can use them) and transfers them to the teaching and learning realm. It focuses on ways to ensure that an education program, course or other learning activity is designed to meet the learning needs of all learners, not just those with no disabilities. To provide the starkest example, a drama teacher who has a class play the game Charades is not using UDL principles if their class includes a blind student, for who that activity would be entirely inaccessible.

It may be easier to entrench UDL and differentiated instruction in the K-12 school system. To teach in our publicly-funded schools, a teacher must first complete recognized programs in a teachers college. If those teachers colleges were to make UDL and differentiated instructions core competencys that they taught all of their students, Ontario could end up with schools staffed with teachers that are equipped to teach using these principles. Existing teachers could and should be trained in UDL and differentiated instruction during their PD days.

In contrast, to get a job as an instructor or professor at an Ontario post-secondary education organization, a person does not need to have successfully completed any prior course or training on how to teach. That makes it much more challenging to embed UDL and differentiated instruction principles in the teaching activities at Ontarios post-secondary education organizations.

Principles of UDL and differentiated instruction can be effectively deployed in a manner that respects the academic freedom of those who teach in post-secondary education organizations. Those such as tenured university professors remain free to choose what ideas they wish to convey. UDL and differentiated instruction aim to ensure that all students can effectively learn that content to ultimately serve the goal of academic freedom.

The intent/rationale of the following recommendations is to entrench universal design in learning and differentiated instruction in the curricula and teaching at post-secondary education organizations.

#8.1 Each post-secondary education organization should adopt and publicize a policy committing to the goals and deployment of universal design in learning (UDL) and differentiated instruction (DI) in its education programs, including in the design and delivery of its curricula.

#8.2 Each post-secondary education organization should develop and implement a plan to ensure that all teachers and teaching staff understand, and effectively and consistently use, principles of Universal Design in Learning and differentiated instruction when preparing and delivering courses and other educational programming, to effectively address the spectrum of different learning needs and styles of their students. For example:

a) Each post-secondary education organization should develop, implement and monitor a comprehensive plan to train its instructional staff on using UDL and DI principles when preparing and delivering courses and course content in order to effectively meet their students spectrum of different learning needs and styles.

b) Each post-secondary education organization should include knowledge of UDL and differentiated instruction principles as an important criterion when recruiting or promoting instructional staff.

c) Each post-secondary education organization should ensure that teachers are provided with appropriate resources and support to successfully implement their UDL and DI training. Each post-secondary education organization should monitor how effectively UDL and differentiated instruction are incorporated into their education programs on the front lines.

d) Each post-secondary education organization should provide teaching coaches with expertise in UDL and DI to support instructional staff.

#8.3 The Ontario Government should create templates or models for the foregoing training so that each post-secondary education organization does not have to reinvent the wheel in this context.

9. Removing Attitudinal Barriers Against Students with Disabilities

Barrier: Stereotypes, lack of knowledge and other attitudes among some staff at post-secondary education organizations and among some other students, that do not recognize the right and benefits of students with disabilities to get a full and equal education.

#9.1 To help reduce or eliminate attitudinal barriers that can impede students with disabilities each post-secondary education organization should:

a) Develop and implement a multi-year strategy to publicize the organizations commitment to and the benefits of inclusion and full participation of students with disabilities.

b) Post around the post-secondary education organization announcements of the post-secondary education organizations commitment to inclusion of students with disabilities, and the benefits this brings to all students.

c) Provide specific training to all front-line staff (not limited to instructional staff) on the importance of inclusion.

d) Implement human resources policies and practices to expand school board staff knowledge and skills regarding inclusion.

10. Ensuring Accessibility of Instructional Materials that Students with Disabilities Use

Barrier: Instructional materials, such as textbooks and other instructional materials and teaching resources that are not provided at the same time in an accessible format for students with disabilities. This is not limited to digital materials, referred to earlier in this Framework.

Section 15 of the Integrated Accessibility Standards Regulation, enacted in June 2011, and in force for school boards since 2013 or 2015 (depending on their size) requires education organizations to provide instructional materials on request in an accessible format, and to make this part of their procurement of such resources. However, this provision has not been effective and sufficient to effectively ensure that students with disabilities face no barriers in this context. Therefore, much stronger measures are needed.

#10.1 To ensure that instructional materials are fully accessible on a timely basis to students with disabilities such as vision loss and those with learning disabilities that affect reading, each post-secondary education organization should:

a) Promptly survey students with disabilities who need accessible instructional materials, and their instructional staff, to get their front-line experiences on whether they get timely access to accessible instructional materials, and to get specifics on where this has been most lacking.

b) Establish a dedicated resource within the post-secondary education organization, or shared among post-secondary education organizations, to convert instructional materials to an accessible format, where needed, on a timely basis. A student should not be required to show proof that they own a hard copy of an item to be able to get it in an accessible format.

c) Review its procurement practices to ensure that any new instructional materials that are acquired are fully accessible or conversion-ready and monitor to ensure that this is always done in practice. A condition of procurement should be a requirement that the supplier or vendor must remediate any inaccessible materials at its own expense.

#10.2 The Education Accessibility Standard should require the Ontario Government to implement, monitor and publicly report on province-wide strategies to ensure the procurement of and use of accessible instructional materials across post-secondary education organizations.

11. Ensuring Barrier-Free Post-Secondary Program Admission Requirements

Barrier: Admission requirements to a post-secondary program that unintentionally or inadvertently impede access to the program for otherwise-qualified students with disabilities.

The intention/rationale of these recommendations is to ensure that students with disabilities can have their eligibility for admission to a post-secondary program fairly and accurately assessed.

#11.1 Every post-secondary education organization shall review its admission criteria for gaining admission to any of its post-secondary education programs, to identify any barriers that would impede otherwise-qualified students with disabilities from admission, and shall adjust those criteria to either:

a) Remove the admission criteria that constitute a barrier to admission, or

b) Provide an alternative method for assessing students with disabilities for admission to the program.

12. Ensuring Student Testing/Assessment is Free of Disability Barriers

Barrier: Tests or other performance assessments of students that are not designed in a way that ensures that students with disabilities are fairly and accurately assessed.

Throughout the post-secondary education system, students take tests, submit papers, and undertake other assessments of their academic performance. There have been no mandatory provincial requirements of which we are aware to ensure that the ways students’ performance is tested or assessed are barrier-free for students with disabilities, and to ensure a fair and accurate assessment of their performance.

#12.1 The Post-Secondary Education Accessibility Standard should set requirements for proper approaches to ensure tests and other methods of performance evaluation provide a fair, accurate and barrier-free assessment of students with disabilities, and on when and how to provide an alternative evaluation method.

#12.2 To ensure that a school board fairly and accurately assesses the performance of students with disabilities, each post-secondary education organization should:

a) Have a policy that commits to ensure that testing and other assessments of students’ performance and learning are designed to be barrier-free for students with disabilities.

b) Give its instructional staff training resources on how to ensure a test or other assessment method is a fair, accurate and barrier-free assessment for students with disabilities in their class, and where needed, how to provide an alternative evaluation method.

c) Monitor implementation of these.

13. Ensuring Students with Disabilities Have the Technology and Other Supports They Need for Effective Learning

Barrier: Policy and bureaucratic impediments to students with disabilities getting the adaptive technology and other supports they need for learning at a post-secondary education organization.

There are inconsistent practices around Ontario for making available to students with disabilities the adaptive technology and support services they need, and the training required to be able to effectively use that equipment.

#13.1 The Post-Secondary Education Accessibility Standard should require that procedural, bureaucratic and other barriers to the acquisition, training and use of needed adaptive equipment and technology at school should be eliminated. It should require the establishment of a prompt, standardized and consistent provincial system for the procurement and deployment of accessible technology to post-secondary students with disabilities that ensures access to the most appropriate and up-to-date technology that is available on the market.

#13.2 The Post-Secondary Education Accessibility Standard should provide that each post-secondary education organization should ensure that students with disabilities are able to bring a trained service animal to their premises as a disability accommodation.

14. Removing Barriers to Participation in Experiential Learning

Barrier: Experiential learning programs that do not ensure that accessible and inclusive experiential learning placements are made available to students with disabilities, and insufficient supports to help organizations, providing experiential learning placements, to facilitate the placement of students with disabilities.

#14.1 To ensure that students with disabilities can fully participate in a post-secondary education organizations experiential learning programs, each such organization should:

a) Review its experiential learning programs to identify and remove any accessibility barriers.

b) Put in place a process to affirmatively reach out to potential placement organizations in order to ensure that there will be a range of accessible placement opportunities in which students with disabilities can participate.

c) Ensure that its partner organizations that accept its students for experiential learning placements are effectively informed of their duty to accommodate the learning needs of students with disabilities.

d) Create and share supports and advice for placement organizations who need assistance to ensure that students with disabilities can fully participate in their experiential learning placements.

e) Monitor placement organizations to ensure they have someone in place to ensure that students with disabilities are effectively accommodated, and to ensure that effective accommodation was provided during each placement of a student with a disability who needed accommodation.

f) Survey students with disabilities and experiential learning placement organizations at the end of any experiential learning placements to see if their disability-related needs were effectively accommodated.

#14.2 The Ontario Government should provide templates for these policies and measures. It should also prepare and make available training videos for post-secondary education organizations and organizations offering experiential learning programs to guide them on accommodating students with disabilities in experiential learning placements.

15. The Need to Harness the Experience and Expertise of People with Disabilities Working in Post-Secondary Education Organizations to Expedite the Removal and Prevention of Barriers Facing Students with Disabilities

Barrier: People with disabilities working in post-secondary education organizations too often face accessibility barriers in the workplace that also hurt students with disabilities.

The intent/rationale of the following recommendations is to ensure that the experience and expertise of people with disabilities working in post-secondary education organizations is effectively harnessed to help root out the accessibility barriers that impede students with disabilities. This is because workplace disability barriers and education service disability barriers often are the same or substantially overlap.

#15-1. Each post-secondary education organization should be required to establish a committee of those employees and volunteers with disabilities who wish to voluntarily join it, to give the organizations senior management feedback on the barriers in the organization that could impede employees or students with disabilities.

16. Ensuring a Fully Accessible Built Environment at Post-Secondary Education Organizations

The intent/rationale of these recommendations is to ensure that as soon as possible, and no later than January 1, 2025, the built environment in the post-secondary education system and the equipment on those premises (such as gym equipment) would all be fully accessible to people with disabilities and would be designed based on the principle of universal design. Where post-secondary education programs or trips take place outside the post-secondary education organization, these will be held at locations that are disability-accessible. The intent/rationale is also to ensure that no public money is used to create new barriers or perpetuate existing barriers in the post-secondary education system.

There can be costs associated with these measures. The Government will need to determine how much it is prepared to spend, and which of these requirements it would thereby adopt. A Standards Development Committee cannot and should not pre-decide that for the Government.

There is a far greater cost of not imposing these requirements. If the built environment at post-secondary education organizations remains inaccessible, or new post-secondary facilities are built with new barriers, there will be later retrofit costs and litigation costs in response to human rights cases.

Providing a barrier-free built environment in post-secondary education organizations benefits everyone. It ensures that all students of all ages and abilities can come to learn there. It enables people with disabilities to be employed in all jobs throughout the post-secondary education organization. It enables the premises of the post-secondary education organization, a public facility, to be used for other important public uses, such as being rented for conferences.

These recommendations do not include specific technical requirements, such as the precise width of doorways or other paths of travel. These recommendations set out the barriers to be addressed and the specific measures to address them. If the Government of Ontario adopts these, it would have to then proceed to set technical requirements where possible. Barriers:

1. Too often, the built environment at post-secondary education organizations has physical barriers that can partially or totally impede some students with disabilities from being able to enter or independently move around.

2. The Ontario Building Code and existing accessibility standards do not set out all the modern and sufficient accessibility requirements for the built environment in Ontario. The Government of Ontario has no accessibility standard for the built environment in post-secondary education organizations. The Government has not agreed to develop a Built Environment Accessibility Standard to substantially strengthen the general accessibility provisions for society as a whole in the Ontario Building Code.

Accordingly, it is left to each post-secondary education organization to come up with its own designs to address accessibility in the built environment at its premises. This is highly inefficient and wasteful.

The AODA Alliance has illustrated this in two widely-viewed online videos that focus on the built environment at two post-secondary education organizations, chosen because they are typical, not worse than others:

a) the new Culinary Arts Centre at Centennial College: https://www.youtube.com/watch?v=Dgfrum7e-_0&t=87s

b) The new Student Learning Centre at Ryerson University: https://youtu.be/4oe4xiKknt0

3. The Ontario Government does not ensure that public money is never used to create or perpetuate disability barriers in the built environment.

Recommendations

Examples of these requirements are set out in the Appendix to this Framework, below.

#16.1 The Post-Secondary Education Accessibility Standard should set out specific requirements for accessibility in the built environment at post-secondary education organizations and other locations where post-secondary education programs are to be offered. These should meet the accessibility requirements of the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms and should meet the needs of all disabilities and not only people with mobility disabilities. These should include:

a) Specific requirements to be included in a new facility to be built.

b) Requirements to be included in a renovation of or addition to an existing post-secondary facility, and

c) Retrofit requirements for an existing post-secondary facility, even if it is not slated for a major renovation or addition, to the extent that they are readily achievable and important to ensure the facilitys accessibility.

#16.2 Each post-secondary education organization should develop a plan to ensure that the built environment of its educational facilities becomes fully accessible to people with disabilities as soon as reasonably possible, and in any event, no later than January 1, 2025. As part of this:

a) As a first step, each post-secondary education organization should develop a plan for making as many of its facilities disability-accessible within its current financial context. Accessibility does not only include the needs of people with mobility disabilities. It includes the needs of people with other disabilities such as people with vision and/or hearing loss, autism, intellectual or developmental disabilities, learning disabilities or mental health disorders.

b) Each post-secondary education organization should identify which of its existing facilities can be more easily made accessible, and which facilities would require substantially more extensive action to be made physically accessible. An interim plan should be developed to show what progress towards full physical accessibility can be made by first addressing facilities that would require less money to be made physically more accessible, and the most high-impact facilities.

#16.3 The post-secondary education organizations review of its built environment shall include a thorough review of the campuss overall layout. Where navigation around the campus, or from building to building, lacks the needed and appropriate cues for people with vision loss or other disabilities, proper way-finding, including tactile walking surface indicators, will be installed to facilitate the ease of safe navigation around the campus

#16.4 When a post-secondary education organization seeks to retain or hire design professionals, such as architects, interior designers or landscape architects, for the design of a new facility or an existing facilitys retrofit or renovation, or for any other infrastructure project, the post-secondary education organization should include in any Request for Proposal (RFP) a mandatory requirement that the design professional must have sufficient demonstrated expertise in accessibility design, and not simply knowledge about compliance with the Ontario Building Code or the AODA. This includes the accessibility needs of people with all kinds of disabilities, and not just those with mobility impairments.

#16.5 When a post-secondary education organization is planning to construct a new facility, or to expand or renovate an existing facility or other infrastructure, a suitably qualified accessibility consultant should be directly retained by the post-secondary education organization (and not by a private architecture firm) to advise on the project from the outset, with their unedited advice being transmitted directly to the post-secondary education organization and not only to the private design professionals who are retained to design the project. Completing the 8 day training course on accessibility offered by the Rick Hansen Foundation should not be treated as either necessary or sufficient for this purpose, as that course is substantially inadequate and has significant problems.

#16.6 The post-secondary education organization should have design specifications or plans for any new construction or major renovations of any of its facilities reviewed by its boards Accessibility Committee and by representatives of its students and employees with disabilities. If the post-secondary education organization rejects any of their recommendations regarding the projects accessibility it shall provide written reasons for its decision to do so.

#16.7 Where possible, a post-secondary education organization should not renovate an existing facility that lacks disability accessibility, unless the organization has a plan to also make that facility accessible. For example, a post-secondary education organization should not spend public money to renovate the second storey of a facility which lacks accessibility to the second storey, if the organization does not have a plan to make that second storey disability-accessible. Very pressing health and safety concerns should be the only reason for any exception to this.

#16.8 Each post-secondary education organization should only hold off-site educational events at venues whose built environment is accessible, unless to do so would be impossible without undue hardship.

#16.9 To ensure that gym, sports, athletic equipment and other like equipment and facilities are accessible for students with disabilities, the Post-Secondary Education Accessibility Standard should set out specific technical accessibility requirements for new or existing outdoor or indoor gym,, sports, athletic and other like equipment, drawing on accessibility standards and best practices in other jurisdictions, if sufficient, so that each post-secondary education organization does not have to re-invent the accessibility wheel.

#16.10 Each post-secondary education organization should:

a) Take an inventory of the accessibility of its existing indoor and outdoor gym, sports, athletic and like equipment and spaces, and make this public, including posting this information online.

b) Adopt a plan to remediate the accessibility of existing gym, sports, athletic or other like equipment or spaces, in consultation with students with disabilities.

c) Ensure that a qualified accessibility expert is engaged to ensure that the purchase of new equipment or remediation of existing equipment or spaces is properly conducted, with their advice being given directly to the post-secondary education organization.

#16.11 The Ontario Government should be required to revise its funding formula or criteria for construction of facilities at a post-secondary education organization to ensure that it requires and does not obstruct the inclusion of all needed accessibility features in that construction project.

Appendix 1 Specific Accessible Design Requirements for the Built Environment Proposed For the Post-Secondary Education Accessibility Standard

The following design features should be required by the Post-Secondary Education Accessibility Standard and in any new construction or renovation at a post-secondary education organization. Where an existing post-secondary facility is undergoing no renovation, any of the following measures which are readily achievable should be required. To fill in the specifics, the Ontario Government should enact technical requirements for the following, as binding enforceable rules, not as voluntary guidelines:

Usable Accessible Design for Outdoor or Exterior Site Elements

1. Access to the site for pedestrians
Clear, intuitive connection to the accessible entrance
a. A tactile raised line map shall be provided at the main entry points adjacent to the accessible path of travel but with enough space to ensure users do not block the path for others
b. Path of travel from each sidewalk connects to an accessible entrance with few to no joints to avoid bumps. The primary paths shall be wide enough to allow two-way traffic with a clear width that allows two people using wheelchairs or guide dogs to pass each other. For secondary paths where a single path is used, passing spaces shall be provided at regular intervals and at all decision points. The height difference from the sidewalk to the entrance will not require a ramp or stairs. The path will provide drainage slopes only and ensure no puddles form on the path. Paths will be heated during winter months using heat from the school or other renewable energy sources.
c. Bike parking shall be adjacent to the entry path. Riders shall be required to dismount and not ride on the pedestrian routes. Bike parking shall provide horizontal storage with enough space to ensure users and parked bikes do not block the path for others. The ground surface below the bikes shall be colour contrasted and textured to be distinct from the pedestrian path.
d. Rest areas and benches with clear floor space for at least two assistive mobility devices or strollers or a mix of both shall be provided. Benches shall be colour contrasted, have back and arm rests and provide transfer seating options at both ends of the bench. These shall be provided every 30m along the path placed adjoining. The bench and space for assistive devices are not to block the path. If the path to the main entrance is less than 30m at least one rest area shall be provided along the route. If the drop-off area is in a different location than the pedestrian route from the sidewalk, an interior rest area shall be provided with clear sightlines to the drop-off area. If the drop-off area is more than 20m from the closest accessible entrance an exterior accessible heated shelter shall be provided for those awaiting pick-up. The ground surface below the rest areas shall be colour contrasted and textured to be distinct from the pedestrian path it abuts
e. Tactile directional indicators shall be provided where large open paved areas happen along the route, or where walking paths are not readily navigable by persons with vision loss, due to a lack of reliable shorelines and landmarks. f. Accessible pedestrian directional signage at decision points
g. Lighting levels shall be bright and even enough to avoid shadows and ensure its easy to see the features and to keep people safe. h. Accessible duress stations (Emergency safety zones in public spaces)
i. Heated walkways shall be used where possible to ensure the path is always clear of snow and ice

1. Access to the site for vehicles
a. Clear, intuitive connection to the drop-off and accessible parking
b. Passenger drop-off shall include space for driveway, layby, access aisle (painted with non-slip paint), and a drop curb (to provide a smooth transition) for the full length of the drop off. This edge shall be identified and protected with high colour contrasted tactile attention indicators and bollards to stop cars, so people with vision loss or those not paying attention get a warning before walking into the car area. Sidewalk slopes shall provide drainage in all directions for the full length of the dropped curb
c. Overhead protection shall be provided by a canopy that allows for a clearance for raised vans or buses and shall provide as much overhead protection as possible for people who may need more time to load or off-load
d. Heated walkways from the drop-off and parking shall be used to ensure the path is always clear of snow and ice
e. A tactile walking directional indicator path shall lead from the drop-off area to the closest accessible entrance to the building (typically the main entrance)
f. A parking surface will only be steep enough to provide drainage in all directions. The drainage will be designed to prevent puddles from forming at the parking or along the pedestrian route from the parking
g. Parking design should include potential expansion plans for future growth and/or to address increased need for accessible parking
h. Parking access aisles shall connect to the sidewalk with a curb cut that leads to the closest accessible entrance to the building (so that no one needs to travel along the driveway behind parked cars or in the path of car traffic)
i. Lighting levels shall be bright and even enough to avoid shadows and to ensure its easy to see obstacles and to keep people safe.
j. If there is more than one parking lot, each site shall have a distinctive colour and shape symbol associated with it that will be used on all directional signage especially along pedestrian routes.

3. Parking
a. The provision of parking spaces near the entrance to a facility is important to accommodate persons with a varying range of abilities as well as persons with limited mobility. Medical conditions, such as anemia, arthritis or heart conditions, using crutches or the physical act of pushing a wheelchair, all can make it difficult to travel long distances. Minimizing travel distances is particularly important outdoors, where weather conditions and ground surfaces can make travel difficult and hazardous.
b. The sizes of accessible parking stalls are important. A person using a mobility aid such as a wheelchair requires a wider parking space to accommodate the manoeuvring of the wheelchair beside the car or van. A van may also require additional space to deploy a lift or ramp out the side or back door. An individual would require space for the deployment of the lift itself as well as additional space to manoeuvre on/off the lift.
c. Heights of passage along the driving routes to accessible parking is a factor. Accessible vans may have a raised roof resulting in the need for additional overhead clearance. Alternatively, the floor of the van may be lowered, resulting in lower capacity to travel over for speed bumps and pavement slope transitions.
d. Wherever possible, parking signs shall be located away from pedestrian routes, because they can constitute an overhead and/or protruding hazard. All parking signage shall be placed at the end of the parking space in a bollard barricade to stop cars, trucks or vans from parking over and blocking the sidewalk.

4. A Buildings exterior doors
a. Level areas on both sides of a buildings exterior door shall allow the clear floor space for a large scooter or mobility device or several strollers to be at the door. Exterior surface slope shall only provide drainage away from the building.
b. 100% of a buildings exterior doors will be accessible with level thresholds, colour contrast, accessible door hardware and in-door windows or side windows (where security allows) so those approaching the door can see if someone is on the other side of the door
c. Main entry doors at the front of the building and the door closest to the parking lot (if not the same) to be obvious, prominent and will have automatic sliders with overhead sensors. Placing power door operator buttons correctly is difficult and often creates barriers especially within the vestibule
d. Accessible security access for after hours or if used all day with 2-way video for those who are deaf and/or scrolling voice to text messaging
e. All exit doors shall be accessible with a level threshold and clear floor space on either side of the door. The exterior shall include a paved accessible path leading away from the building

Accessible Design for Interior Building Elements

1. Entrances
a. All entrances used by staff and/or the public shall be accessible and comply with this section. In a retrofit situation where it is technically infeasible to make all staff and public entrances accessible, at least 50% of all staff and public entrances shall be accessible and comply with this section. In a retrofit situation where it is technically infeasible to make all public entrances accessible, the primary entrances used by staff and the public shall be accessible. 2. Door
a. Doors shall be sufficiently wide enough to accommodate stretchers, wheelchairs or assistive scooters, pushing strollers, or making a delivery
b. Threshold at the doors base shall be level to allow a trip free and wheel friendly passage. c. Heavy doors and those with auto closers shall provide automatic door openers. d. Room entrances shall have doors.
e. Direction of door swing shall be chosen to enhance the usability and limit the hazard to others of the door opening.
f. Sliding doors can be easier for some individuals to operate, and can also require less wheelchair manoeuvring space. g. Doors that require two hands to operate will not be used. h. Revolving doors are not accessible.
i. Full glass doors are not to be used as they represent a hazard.
j. Colour-contrasting will be provided on door frames, door handles as well as the door edges.
k. Door handles and locks will be operable by using a closed fist, and not require fine finger control, tight grasping, pinching, or twisting of the wrist to operate

3. Gates, Turnstiles and Openings
a. Gates and turnstiles should be designed to accommodate the full range of users that may pass through them. Single-bar gates designed to be at a convenient waist height for ambulatory persons are at neck and face height for children and chest height for persons who use wheelchairs or scooters.
b. Revolving turnstiles should not be used as they are a physical impossibility for a person in a wheelchair to negotiate. They are also difficult for persons using canes or crutches, or persons with poor balance.
c. All controlled entry points will provide an accessible width to allow passage of wheelchairs, other mobility devices, strollers, walkers or delivery carts.

4. Windows, Glazed Screens and Sidelights
a. Broad expanses of glass should not be used for walls, beside doors and as doors can be difficult to detect. This may be a particular concern to persons with vision loss/no vision. It is also possible for anyone to walk into a clear sheet of glazing especially if they are distracted or in a hurry.
b. Window sill heights and operating controls for opening windows or closing blinds should be accessible…located on a path of travel, with clear floor space, within reach of a shorter or seated user, colour contrasted and not require punching or twisting to operate.

5. Interior Layout
a. The main office where visitors and others need to report to upon entering the building shall always be located on the same level as the entrance, as close to the entrance as possible. If the path of travel to the office crosses a large open area, a tactile directional indicator path shall lead from the main entrance(s) to the office ID signage next to the office door.
b. As much as possible, classrooms and or public destinations shall be on the ground floor. Where this is not possible, at least 2 elevators should be provided to access all other levels. Where the building is long and spread out, travel distance to elevators should be considered to reduce extra time needed for students and staff or others who use the elevators instead of the stairs. If feature stairs (staircases included in whole or in part for design aesthetics) are included, elevators shall be co-located and just as prominent as the stairs
c. Corridors should meet at 90 degree angles. Floor layouts from floor to floor should be consistent and predictable so the room number line up and are the same with the floors above and below along with the washrooms
d. Multi-stall washrooms shall always place the womens washroom on the right and the mens washroom on the left. No labyrinth entrances shall be used. Universal washrooms shall be co-located immediately adjacent to the stall washrooms, in a location that is consistent and predictable throughout the building

6. Facilities
a. The entry doors to each type of facility within a building should be accessible, colour contrasted, obvious and prominent and designed as part of the wayfinding system including accessible signage that is co-located with power door openers controls.
b. Tactile attention indicator tile will be placed on the floor in front of the accessible ID signage at each room or facility type. Where a room or facility entrance is placed off of a large interior open area

7. Elevators

a. Elevator Doors will provide a clear width to allow a stretcher and larger mobility devices to get in and out b. Doors will have sensors so doors will auto open if the doorway is blocked
c. Elevators will be installed in pairs so that when one is out of service for repair or maintenance, there is an alternative available.
d. Elevators will be sized at allow at least two mobility device users and two non-mobility devices users to be in the elevator at the same time. This should also allow for a wide stretcher in case of emergency.
e. Assistive listening will be available in each elevator to help make the audible announcements heard by those using hearing aids
f. Emergency button on the elevators control panel will also provide 2-way communication with video and scrolling text and a keyboard for people who are deaf or who have other communication disabilities
g. Inside the elevators will be additional horizontal buttons on the side wall in case there is not enough room for a person using a mobility aid to push the typical vertical buttons along the wall beside the door. If there are only two floors the elevator will only provide the door open, close and emergency call buttons and the elevator will automatically move to the floor it is not on.
h. The words spoken in the elevators voice announcement of the floor will be the same as the braille and print floor markings, so the button shows 1 as a number, 1 in braille and the voice says first floor not G for Ground with M in braille and voice says first floor.)
i. Ensure the star symbol for each elevator matches ground level appropriate to the elevator. The star symbol indicates the floor the elevator will return to in an emergency. This means users in the elevator will open closest to the available accessible exit. If the entrance on the north side is on the second floor, the star symbol in that elevator will be next to the button that says 2. If the entrance on the south side of the building is on the 1st floor, the star symbol will be next to the button that says 1.
j. The voice on the elevator shall be set at a volume that is audible above typical noise levels while the elevator is in use, so that people on the elevator can easily hear the audible floor announcements.
k. Lighting levels inside the elevator will match the lighting at the elevator lobbies. Lighting will be measured at the ground level
l. Elevators will provide colour contrast between the floor and the walls inside the cab and between the frame of the door or the doors with the wall surrounding in the elevator lobbies. Vinyl peel and stick sheets or paint will be used to cover the shiny metal which creates glare. Vinyl sheets will be plain to ensure the door looks like a door, and not like advertising
m. In a retrofit situation where adding 2 elevators is not technically possible without undue hardship, platform lifts may be considered. Elevators that are used by all facility users are preferred to platform lifts which tend to segregate persons with disabilities and which limit space at entrance and stair locations. Furthermore, independent access is often compromised by such platform lifts,, because platform lifts are often require a key to operate. Whenever possible, integrated elevator access should be incorporated to avoid the use of lifts.

8. Ramps
a. A properly designed ramp can provide wait-free access for those using wheelchairs or scooters, pushing strollers or moving packages on a trolley or those who are using sign language to communicate and dont want to stop talking as they climb stairs.
b. A ramps textured surfaces, edge protection and handrails all provide important safety features.
c. On outdoor ramps, heated surfaces shall be provided to address the safety concerns associated with snow and ice.
d. Ramps shall only be used where the height difference between levels is no more than 1m (4ft). Longer ramps take up too much space and are too tiring for many users. Where a height difference is more than 1m in height, elevators will be provided instead.
e. Landings will be sized to allow a large mobility device or scooter to make a 360 degree turn and/or for two people with mobility assistive devices or guide dogs to pass
f. Slopes inside the building will be no higher than is permitted for exterior ramps in the AODA Design of Public Spaces Standard, to ensure usability without making the ramp too long.
g. Curved ramps will not be used, because the cross slope at the turn is hard to navigate and a tipping hazard for many people.
h. Colour and texture contrast will be provided to differentiate the full slope from any level landings. Tactile attention domes shall not be used at ramps, because they are meant only for stairs and for drop-off edges like at stages

9. Stairs
a. Stairs that are comfortable for many adults may be challenging for children, shorter persons seniors or persons of short stature.
b. The leading edge of each step (aka nosing) shall not present tripping hazards, particularly to persons with prosthetic devices or those using canes and will have a bright colour contrast to the rest of the horizontal step surface.
c. Each stair in a staircase will use the same height and depth, to avoid creating tripping hazards
d. The rise between stairs will always be smooth, so that shoes will not catch on an abrupt edge causing a tripping hazard. These spaces will always be closed as open stairs create a tripping hazard.
e. The top of all stair entry points will have a tactile attention indicator surface, to ensure the drop-off is identified for those who are blind or distracted.
f. Handrails will aid all users navigating stairways safely. Handrails will be provided on both sides of all stairs, and will be provided at both the traditional height as well as a second lower rail for children or people who are shorter. These will be in a high colour contrasting colour and round in shape, without sharp edges or interruptions. Rails shall always be at a right angle to the stairs, and shall never be itched at an angle.
g. g) Spiral, curved or irregular staircases shall never be created, as they are a serious tripping hazard.

10. Washroom Facilities
a. Washroom facilities will accommodate the range of people that will use the space. Although many persons with disabilities use toilet facilities independently, some may require assistance. Where the individual providing assistance is of the opposite gender then typical gender-specific washrooms are awkward, and so an individual washroom is required.
b. Parents and caregivers with small children and strollers also benefit from a large, individual washroom with toilet and change facilities contained within the same space.
c. Circumstances such as wet surfaces and the act of transferring between toilet and wheelchair or scooter can make toilet facilities accident-prone areas. An individual falling in a washroom with a door that swings inward could prevent his or her own rescuers from opening the door. Due to the risk of accidents, emergency call buttons are vital in all washrooms.
d. The appropriate design of all features will ensure the usability and safety of all toilet facilities.
e. The identification of washrooms will include pictograms for children or people who cannot read. All signage will include braille that translates the text on the print sign, and not only the room number.
f. There are three types of washrooms. Single use accessible washrooms, single use universal washrooms, and multi-use stalled washrooms. The number and types of washrooms used in a facility will be determined by the number of users. There will always at least be one universal washroom.
g. All washrooms will have doors with power door opening buttons. No door washrooms will be hard to identify for people who have vision loss.
i. In stall washrooms with urinals, all urinals will be accessible with lower rim heights. Universal washrooms will have an upper rim at the same height as typical non-accessible urinals to avoid the mess taller users can make. All urinals will provide vertical grab bars which are colour contrasted to the walls. Where dividers between urinals are used, the dividers will be colour contrasted to the walls as well.
h. Stall washrooms accessible sized stalls At least 2 accessible stalls shall be provided in each washroom to avoid long wait times. Facilities with accessible education programs that include a large percentage of people with mobility disabilities should have all stalls sized to accommodate a turn circle and the transfer space beside the toilet.
i. All washrooms near rooms that will be used for public events shall include a baby change table that is accessible to all users, not placed inside a stall. It shall be colour contrasted with the surroundings and usable for those in a seated mobility device and or of shorter stature.
ii. At least one universal washroom will include an adult sized change table, with the washroom located near appropriate facilities in the facility and any public event spaces. These are important for some adults with disabilities and for children with disabilities who are too large for the baby change tables. This helps prevent anyone from needing to be changed lying on a bathroom floor.
iii. Where shower stalls are provided, these shall include accessible sized stalls.
iv. Portable Toilets at Special Events shall all be accessible. At least one will include an adult sized change table. i. Washroom Stalls:
i. Manoeuvrability of a wheelchair or scooter is the principal consideration in the design of an accessible stall. The increased size of the stall is required to ensure there is sufficient space to facilitate proper placement of a wheelchair or scooter to accommodate a person transferring transfer onto the toilet from their mobility device. There may also be instances where an individual requires assistance. Thus, the stall will have to accommodate a second person. Stall Door swings are normally outward for safety reasons and space considerations. However, this makes it difficult to close the door once inside. A handle mounted part way along the door makes it easier for someone inside the stall to close the door behind them. Minimum requirements for non-accessible toilet stalls are included to ensure that persons who do not use wheelchairs or scooters can be adequately accommodated within any toilet stall. Universal features include accessible hardware and a minimum stall width to accommodate persons of large stature or parents with small children.

j. Toilets:
i. Automatic flush controls are preferred. If flushing mechanisms are not automated, flushing controls shall be on the transfer side of the toilet, with colour contrasted and lever style handles.

k. Sinks:
i. Each accessible sink shall be on an accessible path of travel that other people, using other sinks or features (like hand-dryers), are not positioned to block. Automated sink controls are preferred. While faucets with remote-eye technology may initially confuse some individuals, their ease of use is notable. Individuals with hand strength or dexterity difficulties can use lever-style handles. For an individual in a wheelchair and younger children, a lower counter height and clearance for knees under the counter are required. The insulating of hot water pipes shall be assured to protect the legs of an individual using a wheelchair. This is particularly important when a disability impairs sensation such that the individual would not sense that their legs were being burned. The combination of shallow sinks and higher water pressures can cause unacceptable splashing at lavatories.
ii. Powered hand-dryers shall make minimum noise, to avoid being a barrier to people with vision loss or those with sensory integration issues for whom loud blasting sound can make a bathroom unusable. l. Urinals:
i. Each urinal needs to be on an accessible path of travel with clear floor space in front of each accessible urinal to provide the manoeuvring space for a mobility device. Grab bars shall be provided to assist individuals rising from a seated position and others to steady themselves. Floor-mounted urinals accommodate children and persons of short stature as well as enabling easier access to drain personal care devices. Flush controls, where used, will be automatic preferred. Strong colour contrasts shall be provided between the urinal, the wall and the floor to assist persons with vision loss/no vision. m. Showers
i. Where showers are provided, roll-in or curbless shower stalls shall be provided to eliminate the hazard of stepping over a threshold and are essential for persons with disabilities who use wheelchairs or other mobility devices in the shower. Grab bars and non-slip materials shall be included as safety measures that will support any individual. Hand-held shower heads or a water-resistant folding bench shall be included to assist people with disabilities. These are also convenient for others. Equipment that has contrasting colour from the shower stall shall be included to assist individuals with vision loss/no vision.

11. Drinking Fountains
a. Drinking fountain height should accommodate shorter persons, and that of a person using a wheelchair or scooter. Potentially conflicting with this, the height should strive to attempt to accommodate individuals who have difficulty bending and who would require a higher fountain. Where feasible, this may require more than one fountain, at different heights. The operating system shall account for limited hand strength or dexterity. Fountains will be recessed, to avoid protruding into the path of travel. Angled recessed alcove designs allow more flexibility and require less precision by a person using a wheelchair or scooter. Providing accessible signage with a tactile attention indicator tile will help those who with vision loss to find the fountain.

12. Performance Stages
a. Elevated platforms, such as stage areas, speaker podiums, etc., shall be accessible to all. A clear accessible route will be provided along the same path of access for those who are not using mobility assistive devices as those who do. Lifts will not be used to access stage or raised platforms, unless the facility is retrofitting an existing stage and it is not technically possible to provide access by other means.
b. The stage shall include safety features to assist persons with vision loss or those momentarily blinded by stage lights from falling off the edge of a raised stage, such as a colour contrasted raised lip along the edge of the stage.
c. Lecterns shall be accessible with an adjustable height surface, knee space and accessible audio visual (AV) and information technology (IT) equipment. Lecterns shall have a microphone that is connected to an assistive listening system, such as a hearing loop. The office and/or presentation area will have assistive listening units available for those who may request them, for example people who are hard of hearing but not yet wearing hearing aids.
d. Lighting shall be adjustable to allow for a minimum of lighting in the public seating area and back stage to allow those who need to move or leave with sufficient lighting at floor level to be safe

13. Offices, Work Areas, and Meeting Rooms
a. Offices providing services or programs to the public will be accessible to all, regardless of mobility or functional needs. Offices and related support areas shall be accessible to staff and visitors with disabilities.
b. All people, but particularly those with hearing loss/persons who are hard-of-hearing, will benefit from having a quiet acoustic environment – background noise from mechanical equipment such as fans, shall be designed to be minimal. Telephone equipment that supports the needs of individuals with hearing and vision loss shall be available.
c. The provision of assistive speaking devices is important for the range of individuals who may have difficulty with low vocal volume thus affecting production of normal audible levels of sound. Where offices and work areas and small meeting rooms do not have assistive listening, such as hearing loops permanently installed, portable assistive hearing loops shall be available at the office
d. Tables and workstations shall provide the knee space requirements of an individual in a mobility assistive device. Adjustable height tables allow for a full range of user needs. Circulation areas shall accommodate the spatial needs of mobility equipment as large as scooters to ensure all areas and facilities in the space can be reached with appropriate manoeuvring and turning spaces.
e. Natural coloured task lighting, such as that provided through halogen bulbs, shall be used wherever possible to facilitate use by all, especially persons with low vision.
f. In locations where reflective glare may be problematic, such as large expanses of glass with reflective flooring, blinds that can be louvered upwards shall be provided. Controls for blinds shall be accessible to all and usable with a closed fist without pinching or twisting

14. Outdoor Athletic and Recreational Facilities
a. Areas for outdoor recreation, leisure and active sport participation shall be designed to be available to people of a spectrum of abilities.
b. Outdoor spaces will allow persons with a disability to be active participants, as well as spectators, volunteers and members of staff. Spaces will be accessible including boardwalks, trails and footbridges, pathways, parks, parkettes and playgrounds, parks, parkettes and playgrounds, grandstand and other viewing areas, and playing fields
c. Assistive listening will be provided where game or other announcements will be made for all areas including the change room, player, coach and public areas.
d. Noise cancelling headphones shall be available to those with sensory disabilities.
e. Outdoor exercise equipment will include options for those with a variety of disabilities including those with temporary disabilities undergoing rehabilitation.
f. Seating and like facilities shall be inclusive and allow for all members of a disabled sports team to sit together in an integrated way that does not segregate anyone.
g. Seating and facilities will be inclusive and allow for all members of a sports team of people with disabilities to sit together in an integrated way that does not segregate anyone.

15. Arenas, Halls and Other Indoor Recreational Facilities
a. Areas for recreation, leisure and active sport participation will be accessible to all members of the community.
b. Assistive listening will be provided where game or other announcements will be made for all areas including the change room, player, coach and public areas.
c. Noise cancelling headphones will be available to those with sensory disabilities.
d. Access will be provided throughout outdoor facilities including: playing fields and other sports facilities, all activity areas, outdoor trails, swimming areas, play spaces, lockers, dressing/change rooms and showers.
e. Interior access will be provided to halls, arenas, and other sports facilities, including access to the site, all activity spaces, gymnasia, fitness facilities, lockers, dressing/change rooms and showers.
f. Spaces will allow people with disabilities to be active participants, as well as spectators, volunteers and members of staff.
g. Indoor exercise equipment will include options for those with a variety of disabilities including those with temporary disabilities who are undergoing rehabilitation.
h. Seating and facilities will be inclusive and allow for all members of a sports team of people with disabilities to sit together in an integrated way that does not segregate or stigmatize anyone.

16. Swimming Pools
a. Primary considerations for accommodating persons who have mobility impairments include accessible change facilities and a means of access into the water. Ramped access into the water is preferred over lift access, as it promotes integration (everyone will use the ramp) and independence.
b. Persons with low vision benefit from colour and textural surfaces that are detectable and safe for both bare feet or those wearing water shoes. These surfaces will be provided along primary routes of travel leading to access points such as pool access ladders and ramps.
c. Tactile surface markings and other barriers will be provided at potentially dangerous locations, such as the edge of the pool, at steps into the pool and at railings.

17. Cafeterias
a. Cafeteria serving lines and seating area designs shall reflect the lower sight lines, reduced reach, knee-space and manoeuvring requirements of a person using a wheelchair or scooter. Patrons using mobility devices may not be able to hold a tray or food items while supporting themselves on canes or while manoeuvring a wheelchair.
b. If tray slides are provided, they will be designed to move trays with minimal effort. c. Food signage will be accessible.
d. All areas where food is ordered and picked up will be designed to meet accessible service counter requirements
e. Self-serve food will be within the reach of people who are shorter or using seated mobility assistive devices
f. Where trays are provided, a tray cart that can be attached to seated assistive mobility devices or a staff assistant solution that is readily available shall be available on demand, because carrying trays and pushing a chair or operating a motorized assistive device can be difficult or impossible

18. Libraries
a. All service counters shall provide accessibility features
b. Study carrels will accommodate the knee-space and armrest requirements of a person using a mobility device.
c. Computer catalogues, carrels and workstations will be provided at a range of heights, to accommodate persons who are standing or sitting, as well as people of different ages and sizes.
d. Workstations shall be equipped with assistive technology such as large displays, screen readers, to increase the accessibility of a library.
e. Book drop-off slots shall be at different heights for standing and seated use with accessible signage, to enhance usability.

19. Teaching Spaces and Classrooms
a. Students, instructors and staff with disabilities will have accessibility to teaching and classroom facilities, including teaching computer labs.
b. All teaching spaces and classrooms will provide power door operators and assistive listening systems such as hearing loops
c. Additional considerations may be necessary for spaces and/or features specifically designated for use by students with disabilities, such as accessibility standard accommodations for complex personal care needs.
d. Students instructors and staff with disabilities will be accommodated in all teaching spaces throughout the facility.
e. This accessibility will include the ability to enter and move freely throughout the space, as well as to use the various built-in elements within (i.e. blackboards and/or whiteboards, switches, computer stations, sinks, etc.).
f. Individuals with disabilities frequently use learning aids and other assistive devices that require a power supply. Additional electrical outlets shall be provided throughout teaching spaces to -accommodate the use of such equipment.
g. Except where it is impossible, fixtures, fittings, furniture and equipment will be specified for teaching spaces, which is usable by students, faculty, teaching assistants and staff with disabilities.
h. Providing only one size of seating does not reflect the diversity of body types of our society. Offering seats with an increased width and weight capacity is helpful for persons of large stature. Seating with increased legroom will better suit individuals that are taller. Removable armrests can be helpful for persons of larger stature as well as individuals using wheelchairs that prefer to transfer to the seat.

20. Laboratories
a. In addition to the requirements for classrooms, additional accessibility considerations may be necessary for spaces and/or features in laboratories.

21. Waiting and Queuing Areas
a. Queuing areas for information, tickets or services will permit persons who use wheelchairs, scooters and other mobility devices as well as for persons with a varying range of user ability to easily move through the line safely. All lines shall be accessible.
b. Waiting and queuing areas will provide space for mobility devices, such as wheelchairs and scooters. Queuing lines that turn corners or double back on themselves will provide adequate space to manoeuvre mobility devices. Handrails with high colour contrast will be provided along queuing lines, because they are a useful support for individuals and guidance for those with vision loss. Benches in waiting areas shall be provided for individuals who may have difficulty with standing for extended periods.
c. Assistive listening systems will be provided, such as hearing loops, will be provided along with accessible signage indicating this service is available.

22. Information, Reception and Service Counters
a. All information, reception and service counters will be accessible to the full range of visitors. Where adjustable height furniture is not used, a choice of fixed counter heights will provide a range of options for a variety of persons. Lowered sections will serve children, persons of short stature and persons using mobility devices such as a wheelchair or scooter. The choice of heights will also extend to any speaking ports and writing surfaces.
b. Counters will provide knee space under the counter to accommodate a person using a wheelchair or a scooter.
c. The provision of assistive speaking and listening devices is important for the range of individuals who may have difficulty with low vocal volume thus affecting production of normal audible levels of sound. The space where people are speaking will have appropriate acoustic treatment to ensure the best possible conditions for communication. Both the public and staff sides of the counter will have good lighting for the faces to help facilitate lip reading.
d. Colour contrast will be provided to delineate the public service counters and speaking ports for people with low vision.

23. Lockers
a. Lockers will be accessible with colour contrast and accessible signage
b. In change rooms an accessible bench will be provided in close proximity to lockers.
c. Lockers at lower heights serve the reach of short people or a person using a wheelchair or scooter.
d. The locker operating mechanisms will be at an appropriate height and operable by individuals with restrictions in hand dexterity (i.e. operable with a closed fist).

24. Storage, Shelving and Display Units
a. The heights of storage, shelving and display units will address a full range of vantage points including the lower sightlines of short people or a person using a wheelchair or scooter. The lower heights also serve the lower reach of these individuals.
b. Displays and storage along a path of travel that are too low can be problematic for individuals that have difficulty bending down or who are blind. If these protrude too much into the path of travel, each will protect people with the use of a trip free cane detectable guard.
c. Appropriate lighting and colour contrast is particularly important for persons with vision loss.
d. Signage provided will be accessible with braille, text, colour contrast and tactile features

25. Public Address Systems
a. Public address systems will be designed to best accommodate all users, especially those that may be hard of hearing. They will be easy to hear above the ambient background noise of the environment with no distortion or feedback. Background noise or music will be minimized.
b. Technology for visual equivalents of information being broadcast will be available for individuals with hearing loss/persons who are hard-of-hearing who may not hear an audible public address system.
c. Classrooms, library, hallways, and other areas will have assistive listening equipment that is tied into the general public address system.

26. Emergency Exits, Fire Evacuation and Areas of Rescue Assistance
a. In order to be accessible to all individuals, emergency exits will include the same accessibility features as other doors. The doors and routes will be marked in a way that is accessible to all individuals, including those who may have difficulty with literacy, such as persons speaking a different language.
b. Persons with vision loss/no vision will be provided a means to quickly locate exits audio or talking signs could assist.
c. In the event of fire when elevators cannot be used, areas of rescue assistance shall be provided especially for anyone who has difficulty traversing sets of stairs. Areas of rescue assistance will be provided on all floors above or below the ground floor. Exit stairs will provide an area of rescue assistance on the landing with at least two spaces for people with mobility assistive devices sized to ensure those spaces do not block the exit route for those using the stairs. The number of spaces necessary should be sized by the number of people on each floor. Each area of refuge will provide a 2-way communication system with both video and audio to allow those using the space to communicate that they are waiting there and to communicate with fire safety services and or security. All signage associated with the area of rescue assistance will be accessible and include braille for all controls and information.

27. Space and Reach Requirements
a. The dimensions and manoeuvring characteristics of wheelchairs, scooters and other mobility devices will allow for a full array of equipment that is used by individuals to access and use facilities, as well as the diverse range of user ability.

28. Ground and Floor Surfaces
a. Irregular surfaces, such as cobblestones or pea-gravel finished concrete, shall be avoided because they are difficult for both walking and pushing a wheelchair. Slippery surfaces are to be avoided because they are hazardous to all individuals and especially hazardous for seniors and others who may not be sure-footed.
b. Glare from polished floor surfaces is to be avoided because it can be uncomfortable for all users and can be a particular obstacle to persons with vision loss by obscuring important orientation and safety features. Pronounced colour contrast between walls and floor finishes are helpful for persons with vision loss, as are changes in colour/texture where a change in level or function occurs. c. Patterned floors should be avoided, as they can create visual confusion.
d. Thick pile carpeting is to be avoided as it makes pushing a wheelchair very difficult. Small and uneven changes in floor level represent a further barrier to using a wheelchair and present a tripping hazard to ambulatory persons.
e. Openings in any ground or floor surface such as grates or grilles are to be avoided because they can catch canes or wheelchair wheels. ?
29. Universal Design Practices Beyond Typical Accessibility Requirements
a. Areas of refuge should be provided even when a building has a sprinkler system. b. No hangout steps* should ever be included in the building or facility.
c. Hangout steps are a socializing area that is sometimes used for presentations. It looks similar to bleachers. Each seating level is further away from the front and higher up but here people sit on the floor rather than on seats. Each seating level is about as deep as four stairs and about 3 stairs high. There is typically a regular staircase provided on one side that leads from the front or stage area to the back at the top. The stairs allow ambulatory people access to all levels of the seating areas, but the only seating spaces for those who use mobility assistive devices are at the front or at the top at the back but these are not integrated in any way with the other seating options.
d. There should never be stramps. A stramp is a stair case that someone has built a ramp running back and forth across it. These create accessibility problems rather than solving them.
e. Rest areas should be differentiated from walking surfaces or paths by texture- and colour-contrast f. Keypads angled to be usable from both a standing and a seated position g. Finishes
i. No floor-to-ceiling mirrors
ii. Colour luminance contrast between:
iii. Floor to wall
iv. Door or door frame to wall
v. Door hardware to door
vi. Controls to wall surfaces

h. Furniture Arrange seating in square arrangement so all participants can see each other for those who are lip reading or using sign language




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What Barriers Do Students with Disabilities Face in Post-Secondary Education in Ontario? Send Us Feedback on Our Draft Framework for a Post-Secondary Education Accessibility Standard


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/

What Barriers Do Students with Disabilities Face in Post-Secondary Education in Ontario? Send Us Feedback on Our Draft Framework for a Post-Secondary Education Accessibility Standard

March 11, 2020

          SUMMARY

Well, we’re at it once again! We want and need your feedback! This time, it’s all about barriers impeding students with disabilities in post-secondary education in Ontario.

Two years ago, the Ontario Government appointed an advisory Standards Development Committee to prepare recommendations on what should be included in an accessibility standard to be enacted under the Accessibility for Ontarians with Disabilities Act, to tear down the barriers that impede students with disabilities in post-secondary education in Ontario. That includes such things as colleges and universities in Ontario.

We want to present ideas to that Standards Development Committee on what it should recommend. We are preparing a Framework for what the Post-Secondary Education Accessibility Standard should include. Below we set out a draft of that Framework, showing our work to date.

This draft Framework is about 38 pages long. The first 22 pages list recommendations on 16 different topics. After that, there is a 16 page appendix with specific proposals for accessibility of the built environment in post-secondary education organizations. If you don’t have time to read it all, we’d welcome your feedback on any parts of it that you have time to review.

Please look it over and send us your comments by April 3, 2020. What do you like in it? What are we missing? What should we change?

Please email us your thoughts by April 1, 2020. Write us at [email protected] The more specific you can be, the better!

Please don’t use “track changes” to give us feedback, as it can present accessibility problems. Instead, send us an email with your comments. You can mention the number of the recommendation on which you are commenting, or cut and paste the passage on which you are commenting.

Once we get your feedback, we will finalize this Framework, make it public, and send it to the Post-Secondary Education Standards Development Committee.

This is the third such Framework we’ve prepared in the past 8 or 9 months. Last fall we prepared a detailed Framework on what the promised accessibility standard should include that will cover education in Ontario schools between kindergarten and Grade 12. We have submitted it to the K-12 Education Standards Development Committee.

Last month, we made public our Framework of what should be included in the promised Health Care Accessibility Standard. We have submitted that to the Health Care Standards Development Committee.

These Frameworks are our latest effort to try to provide constructive and leading-edge suggestions on how the Ontario Government could show strong new leadership on accessibility for over 2.6 million Ontarians with disabilities. We hope and trust that those Standards Development Committees found our proposals helpful. We thank everyone who has taken the time to give us feedback up to now as we worked on these important briefs.

To learn about our decade-long campaign to get the Ontario Government to take effective action under the AODA to address accessibility barriers that impede students with disabilities in Ontario’s education system, visit our website’s Education page. To learn about our decade-long campaign for similar action under the AODA to address the disability barriers that impede patients with disabilities in Ontario’s health care system, take a look at our website’s Health Care page.

An inexcusable 405 days have now gone by since the Ford Government received the final report on the implementation and enforcement of the Accessibility for Ontarians with Disabilities Act that was prepared by former Lieutenant Governor David Onley. We are still waiting for the Ford Government to come up with a comprehensive and effective plan of new measures to implement the Onley Report’s recommendations, needed to substantially strengthen the AODA’s implementation and enforcement. To date, all the Government has offered Ontarians with disabilities is thin gruel.

          MORE DETAILS

Accessibility for Ontarians with Disabilities Act Alliance

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

www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance

Draft Only

A Framework for the Post-Secondary Education Accessibility Standard

March 11, 2020

Prepared by the Accessibility for Ontarians with Disabilities Act Alliance

Note: This is only a draft. It is still a work in progress. Feedback on it is welcome. By April 3, 2020, please send feedback to [email protected] Please do not use “track changes” to provide feedback.

Introduction — What is This Proposed Framework?

Students with disabilities face too many barriers at all levels of Ontario’s post-secondary education system. To address this, the Ontario Government has agreed to create an Education Accessibility Standard under the Accessibility for Ontarians with Disabilities Act (AODA). In 2018, the Ontario Government appointed two committees to make recommendations on what the Education Accessibility Standard should include: The K-12 Education Standards Development Committee was appointed for making recommendations on what that accessibility standard should include to address barriers in Ontario’s publicly-funded schools from Kindergarten to Grade 12. The Post-Secondary Education Standards Development Committee was appointed to make recommendations for what that accessibility standard should include to address barriers in Ontario’s post-secondary education institutions, e.g. colleges and universities.

Under the AODA, an accessibility standard is an enforceable regulation. It has the force of law. It spells out the disability barriers that are to be removed or prevented in a sector of society. It identifies the policies, practices or other measures an organization must implement to remove or prevent those barriers, and the timelines required for these actions.

In this Framework, the AODA Alliance outlines the key ingredients and aims for the promised Education Accessibility Standard in the area of post-secondary education. On October 10, 2019, the AODA Alliance made public a Framework for what the Education Accessibility Standard should include to remove and prevent barriers in Ontario’s publicly-funded schools from kindergarten to Grade 12. This new Framework builds on and expands upon ideas in that earlier document, and adds additional ideas, all tailored to apply to the post-secondary education context.

Where this Framework states that “a post-secondary education organization should …” or similar wording, this means by this that the Education Accessibility Standard should include a provision that requires the post-secondary education organization to take the step we describe.

To be effective, the Education Accessibility Standard must do much more than require organizations to have a policy on accessibility and to train its employees on that policy. Organizations want and need to know specifically what they must do to comply.

Under the AODA, a Standards Development Committee’s job is to recommend the contents of an AODA accessibility standard. It should recommend the specific measures, practices and policies that an accessibility standard should require an organization to implement. If a Standards Development Committee chooses to also recommend some non-regulatory measures, that is beyond the Committee’s core mandate. It should not detract or distract from fulfilling that core mandate. For example, the 2018 final recommendations of the Transportation Standards Development Committee largely focused on recommendations of other measures, outside the revision of the 2011 Transportation Accessibility Standard that that Committee was assigned to review. A recommended practice that are not enshrined in an accessibility standard as a regulation, are not binding on an obligated organization. They cannot be enforced.

It is especially important for the post-secondary education sector to become accessible to students with disabilities. A good post-secondary education is very important for getting a good job, or indeed getting a job at all. This is even more important for people with disabilities. People with disabilities chronically face a substantially higher unemployment rate than the public does as a whole. Barriers in the post-secondary education system can only make this situation worse. A strong and effective post-secondary Education Accessibility Standard is therefore an important measure for increasing employment opportunities for people with disabilities.

1. What Should the Long-Term Objectives of the Post-Secondary Education Accessibility Standard Be?

#1 The purpose of the Education Accessibility Standard should be to ensure that by 2025, post-secondary education in Ontario will be fully accessible and barrier-free for students with disabilities:

  1. A) By removing and preventing accessibility barriers impeding students with disabilities from fully participating in, being fully included in, and fully benefitting from all aspects

of post-secondary education in Ontario, and

  1. B) By providing a prompt, accessible, fair, effective and user-friendly process for students with disabilities to learn about and seek programs, services, supports, accommodations and

placements tailored to the individual strengths and needs of each student with disabilities.”

  1. c) Eliminating or substantially reducing the need for students with disabilities to have to fight against post-secondary education accessibility barriers, one at a time, and the need for post-secondary education organizations to have to re-invent the accessibility wheel one education program at a time.

2. A Vision of An Accessible Post-Secondary Education System

The Post-Secondary Education Accessibility Standard should begin by setting out a vision of what an accessible post-secondary education system should include. It should include the following:

#2.1 The post-secondary education system will be designed and operated from top to bottom for all of its students, including students with all kinds of disabilities, as “disability” is defined in the Ontario Human Rights Code, the AODA and/or the Canadian Charter of Rights and Freedoms.

#2.2 The post-secondary education system will no longer be designed and operated from the starting point of aiming to serve the fictional “average” student or students who have no disabilities. Instead, it will be designed and operated to serve all students, including students with disabilities.

#2.3 The built environment in post-secondary education organizations such as colleges and universities, and the furniture and equipment on those premises (such as gym equipment) will all be fully accessible to people with disabilities and will be designed based on the principle of universal design. Where education programs or trips take place outside the post-secondary education organization premises, these will be held at locations that are disability-accessible, unless it is impossible to do so without undue hardship.

#2.4 Courses taught to students, including the curriculum and lesson plans, as well as informal learning activities, will fully incorporate principles of Universal Design in Learning (UDL), and where needed, differential instruction, so that they are inclusive for students with disabilities.

#2.5 Instructional materials used in post-secondary education organizations will be readily and promptly available in formats that are fully accessible to students with disabilities (such as those with print disabilities) who need to use them and will be available in accessible formats when needed, at no extra charge to the student.

#2.6 All digital technology and content used in Ontario’s post-secondary education organizations such as hardware, software and online learning, used in class or from home, will be fully accessible and will fully embody the principle of universal design. Professors and other instructors working with students with disabilities will be properly trained to use the accessibility features of that hardware, software and online learning technology.

#2.7 Inclusion and Universal Design in Learning will extend beyond formal classroom learning to other educational activities, such as experiential learning opportunities.

#2.8 Students with disabilities will have prompt access to the up-to-date adaptive technology and specialized supports they need, and training on how to use it, to best enable them to fully take part in and benefit from post-secondary education related programming. Students with disabilities will have the unobstructed right to bring a qualified service animal with them to post-secondary education programs and activities.

#2.9 Professors and other instructional staff will be fully trained to serve all students, and not just students who have no disabilities. They will be fully trained in such things as Universal Design in Learning and differential instruction.

#2.10 Tests and other forms of evaluation at post-secondary education organizations will be designed based on principles of universal design and Universal Design in Learning, so that they will be barrier-free for students with disabilities and will provide a fair and accurate assessment of their progress.

#2.11 Students with disabilities will encounter a pro-actively welcoming environment at post-secondary education organizations to facilitate their full participation, and a welcoming environment in which they can seek and receive accommodations for their disabilities where needed.

#2.12 Application processes and forms, admission criteria, admission tests or other admission screening to get into any post-secondary education program will be barrier-free for students with disabilities.

#2.13 Students with disabilities will have prompt, effective and easy access to user-friendly information in multiple languages about the post-secondary educational opportunities, options, programs, services, supports and accommodations available for them and their disability, and about the process for them to seek these.

#2.14 Where a student with a disability believes that a post-secondary education organization is not effectively meeting the student’s disability-related needs, (or if the student believes that the post-secondary education organization is not providing an educational program, service, support or accommodation which it had agreed to provide, the student will have access to a prompt, fair, open and arms-length review process, including an offer of a voluntary Alternative Resolution Process if needed. It will be conducted by someone with expertise in the education of students with disabilities who was not involved in the original decision or activity, and who does not oversee the work of those involved in the student’s direct education.

#2.15 There will be no bureaucratic, procedural or policy barriers that will impede the effective placement and accommodation of individual students with disabilities in post-secondary education organizations.

#2.16 Major new Government strategies or initiatives in Ontario’s post-secondary education system, whether adopted by the Ontario Government or otherwise, will be proactively designed from the start to fully include the needs of students with disabilities.

#2.17 Those officials who are responsible in the Ontario Government and within post-secondary education organizations for leading, overseeing and operating Ontario’s post-secondary education system will have strong and specific requirements to address disability accessibility and inclusion in their mandates and will be accountable for their work on this.

3. General Provisions that the Post-Secondary Education Accessibility Standard Should Include

#3.1 The Post-Secondary accessibility standard should cover and apply to disability barriers in all post-secondary education programs in Ontario, and not only to those offered in or by a college or university. Whether or not the terms of reference for the Post-Secondary Standards Development Committee only focus on post-secondary education offered in a college or university, the same barriers and solutions almost always apply to post-secondary education, whether it is offered by a college or university or by some other post-secondary education organization.

For example, for students with disabilities who are studying law, they can encounter the same disability barriers at an Ontario law school, situated in a university, or when they undertake the Bar Admissions Course, which the Law Society of Ontario offers. To train to be a lawyer in Ontario, a student must get a law degree from a law school and then pass the Law Society of Ontario’s Bar course and examinations. Accordingly, the Post-Secondary Standards Development Committee should make recommendations regarding any post-secondary programs, whether or not they are offered in a college or university.

#3.2 Where this accessibility standard refers to “students with disabilities “, this should include any student who has any kind of disability, including, for example, any kind of physical, mental, sensory, learning, intellectual, mental health, communication, neurological, neurobehavioural or other kind of disability within the meaning of the Ontario Human Rights Code, the Accessibility for Ontarians with Disabilities Act or the Canadian Charter of Rights and Freedoms.

#3.3 Each post-secondary education organization should be required to establish a permanent committee of its governing board to be called the “Accessibility Committee”. This Accessibility Committee should have responsibility and authority to oversee the organization’s compliance with the Accessibility for Ontarians with Disabilities Act and with the requirements of the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms in so far as they guarantee the right of students with disabilities to fully participate in and fully benefit from the education programs and opportunities that the organization provides.

#3.4 Each post-secondary education organization should be required to establish in each faculty or program, a faculty or program Accessibility Committee. It should include representatives from the faculty’s or program’s instructors, management, staff and students with disabilities. Its mandate should be to identify barriers in the school and its programs and to make recommendations for accessibility improvements to be shared with the faculty, program and post-secondary education organization’s senior management and governing board.

#3.5 Each post-secondary education organization should be required to establish or designate the position of Chief Accessibility/Inclusion Officer, reporting to the CEO, with a mandate and responsibility to ensure proper leadership on the organization’s accessibility and inclusion obligations under the Ontario Human Rights Code, the Canadian Charter of Rights and Freedoms and the Accessibility for Ontarians with Disabilities Act, including the requirements set by this accessibility standard. This responsibility may be assigned to an existing senior management official.

#3.6 Each post-secondary education organization should set up and maintain a network of teaching and other staff with disabilities, and a network of students with disabilities, to get input on accessibility issues at the organization.

#3.7 Beyond the specific measures on removing and preventing barriers set out in the Post-Secondary Education Accessibility /Standard and in other AODA accessibility standards, each post-secondary education organization should be required to systematically review its educational programming, services, facilities, premises and equipment to identify recurring accessibility barriers within that organization that can impede the full and effective participation and inclusion of students with disabilities. A comprehensive plan for removing and preventing these accessibility barriers should be developed, implemented and made public with clear time lines, clear assignment of responsibilities for action, monitoring for progress, and reporting to the organization’s governing board and senior management. It should include actions on barriers identified by the organization’s faculty or program Accessibility Committees established under this standard. This plan should aim at all accessibility barriers that can impede students with disabilities from full inclusion in the education and other programs and activities at that organization, whether or not they are specifically identified in the Education Accessibility Standard or in any other specific accessibility standards enacted under the AODA.

#3.8 Each post-secondary education organization should have an explicit duty to create a welcoming environment for students with disabilities, to seek accommodations for their disabilities.

#3.9 To further ensure the effective accommodation of students with disabilities and the entrenchment of accessibility at the front lines, while creating and developing expertise in this area, each post-secondary education organization

Shall implement the following:

  1. a) in a small post-secondary education organization, such as one that offers only one program, one senior employee within the organization who reports to the organization’s chief executive officer, dean or director, should be designated as that organization’s Disability Accessibility and Accommodation Coordinator/Champion. Their responsibility is to serve as the one-stop-shopping point person for students with disabilities seeking accommodations, and being the employee to lead efforts at the organization towards incorporating accessibility into plans and decisions from the top down.
  1. b) In a large post-secondary education organization, such as a college or university that has several faculties or programs, each faculty or program should designate a comparable Disability Accessibility and Accommodation Coordinator/Champion with similar responsibilities within that faculty or program.
  1. c) A larger post-secondary education organization that has more than one Disability Accessibility and Accommodation Coordinator/Champion should network these individuals so they can pool expertise and resources.
  1. d) The Council of Ontario Universities and comparable associations of other categories of post-secondary education organizations should establish networks of Disability Accessibility and Accommodation Coordinators/Champions to pool their expertise and resources.
  1. e) Where a post-secondary education organization has an existing support/service centre for students with disabilities it may help serve these roles, but in the case of a larger post-secondary education organization, there should be a Disability Accessibility and Accommodation Coordinator/Champion designated in each faculty or program.

#3.10 Each post-secondary education organization should develop and implement human resources policies targeted at full accessibility and inclusion, such as making knowledge and experience on implementing inclusion an important hiring and promotions criterion especially for senior management.

4. The Right of Students with Disabilities to Know About Disability-Related Programs, Services, and Supports at Post-Secondary Education Organizations, and How to Access Them

Barrier: Students with disabilities can at times find it difficult to get easily accessed and accessible information from post-secondary education organizations and from the Ontario Government on education options, services and supports available for students with disabilities in post-secondary education organizations and how to access them.

#4.1 Each post-secondary education organization should provide the public, including students with disabilities, with easily-located, timely and effective information, in accessible formats, on the available services, programs and supports for students with disabilities and how to access them. Each post-secondary education organization should ensure that students with disabilities are informed, as early as possible, in a readily-accessible and understandable way, about important information such as:

  1. a) That the post-secondary education organization recognizes that it has a duty to ensure that a student with a disability has the right to full participation in and full inclusion in all the post-secondary education organization’s programming, and has the right to be accommodated in connection with those programs under the Ontario Human Rights Code and Canadian Charter of Rights and Freedoms. This applies to students with any and every kind of disability.
  1. b) About the menu of options, placements, programs, services, supports and accommodations for students with disabilities available at the post-secondary education organization.
  1. c) About which persons and which office to approach at the post-secondary education organization to get this information, to request placements, programs, supports, services or accommodations for students with disabilities, or to raise concerns about whether the post-secondary education organization is effectively meeting the student’s education needs.
  1. d) The processes and procedures at the post-secondary education organization for students with disabilities to request disability-related services, supports or accommodations.

#4.2 Each post-secondary education organization should develop, implement and make public an action plan to substantially improve its provision of the important information, described above, to students with disabilities including any who are applying for admission to the post-secondary education organization:

  1. a) This plan’s objective should be to ensure that all students with disabilities get the information they need to ensure that students of all abilities can fully participate in and benefit from the educational and other opportunities available at the post-secondary education organization.
  1. b) Each post-secondary education organization should ensure that all of this important information is fully and readily accessible in a prompt and timely way to all students with disabilities and applicants for admission, in accessible formats and in jargon-free plain language. in a diverse range of languages. It should be easy to find this information. Among other things, this information should be posted on the post-secondary education organization’s website, in a prominent place that is easy to find, with a link to it prominently on the post-secondary education organization’s home page. A post-secondary education organization should not simply rely on its website to share this information.
  1. c) Each post-secondary education organization should create a user-friendly package of information to be provided to applicants or prospective applicants for admission to any program at the post-secondary education organization. It should emphasize the need to alert the post-secondary education organization as early as possible to any disability accommodation needs.

5. Ensuring that Students Have a Fair and Effective Process for Raising Concerns About a Post-Secondary Education Organization’s Accommodation of the Disability-Related Needs of Students with Disabilities

Barrier: The need for consistent and effective processes within a post-secondary education organization to ensure an easily-accessed and fair procedure to enable students with disabilities to seek and receive needed disability supports and accommodations, and for raising disability-related concerns.

#5.1 Each post-secondary education organization should establish and maintain an effective, fair and user-friendly process for students with disabilities to request and effectively take part in the development and implementation of plans for meeting and accommodating their disability-related needs.

#5.2 As part of this process, students with disabilities should be invited to take part in a joint in-person or virtual meeting to plan for their disability-related supports and accommodations. The student should be invited to bring to the table any supports and professionals that can assist them.

#5.3 If the student had an Individual Education Plan (IEP) from an Ontario school, or a finding by an Ontario school board’s Identification and Placement Review Committee (IPRC) that identified them as having a disability (exceptionality), then the post-secondary education organization should treat that as sufficient proof that the student has a disability, without requiring further proof, unless the post-secondary education organization has independent proof showing that the student no longer has that disability. In that case, the post-secondary education organization shall provide the student with that proof and shall provide the student with an opportunity to demonstrate that they have a disability-related accommodation need. If the student had a specific disability-related accommodation while in school, the post-secondary education organization shall treat that as strong proof that they still have the same accommodation need at the post-secondary education organization, unless the post-secondary education organization has convincing proof that this need no longer exists or that an alternative and equally effective accommodation should be preferred.

#5.4 If a post-secondary education organization decides not to provide a requested disability accommodation, service, or support for a student that the student requested, or to meet a disability-related need that the student identified, the post-secondary education organization should promptly provide written reasons for that refusal.

#5.5 If students with disabilities disagree with any aspect of a post-secondary education organization’s decision on a request for accommodation, or believe that the post-secondary education organization has not provided supports or accommodations to which it had agreed, the organization should make available a respectful, non-adversarial internal review process for hearing, mediating and deciding on the student’s concerns. The Post-Secondary Education Accessibility Standard should set out the specifics of this review process. This review process should include the following:

  1. a) It should be very prompt. Arrangements for a student’s accommodations should be finalized as quickly as possible, so that the student’s needs are promptly met.
  1. b) No proposed services, supports or accommodations that the post-secondary education organization is prepared to offer should be withheld from a student pending a review. The student should not feel pressured not to seek this review, lest they be placed in a position of educational disadvantage during the review process.
  1. c) The review process should be fair. The post-secondary education organization should let the student know all of its issues or concerns with the student’s request or concerns, and give the student a fair chance to voice their concerns.
  1. d) The review should be by a person or persons who are independent and impartial. They should have expertise in the education of students with disabilities. They should not have taken part in any of the earlier discussions or decisions at that post-secondary education organization regarding the services, supports or accommodations for that child.
  1. e) At the review, every effort should be made to mediate and resolve any disagreements between the student and the post-secondary education organization. If the matter cannot be resolved by agreement, there should be an option for a qualified person who is outside the post-secondary education organization to be appointed at no charge to the student, to consider the review, along prompt timelines.
  1. f) At the review, written reasons should be given for the decision, especially if any of the student’s requests or concerns are not accepted.

6. Expediting the Early Identification and Accommodation of Students with Disabilities’ Needs

Barrier: Students with disabilities can face delays and administrative/bureaucratic impediments to ensuring that they get all needed disability-related supports and accommodations. This comes in no small part from the fact that post-secondary education organizations are often large organizations with administrative responsibilities distributed over a number of departments and individuals. The effective accommodation of students is far easier to achieve when requests for accommodation are presented and considered as early as possible.

#6.1 The Post-Secondary Education Accessibility Standard should require specific measures to tear down administrative, bureaucratic and other barriers to reduce delays for identifying, seeking and securing needed disability supports and accommodations. For example:

  1. a) post-secondary education organizations should be required to notify all students who apply for admission to any program or who seek information about programs to which they might apply, about the availability of disability-related supports and accommodation and the process for seeking them.
  1. b) The post-secondary education organization’s interactive voice response system for receiving incoming phone calls should announce to all callers the organization’s commitment to accommodate students with disabilities and the number to press to get introductory information about how to seek such.
  1. c) Programming handouts and broadcast email communications to incoming students should include similar general information.
  1. d) the post-secondary education organization’s broadcast email announcements and other communications to the student population should include summary information to this effect with relevant links.
  1. e) Classroom instructors should make announcements in their first week of classes to this effect.

7. Ensuring Digital Accessibility

Barrier: Post-secondary education organizations using classroom technology, such as hardware, software, online learning systems, online courses and internal or external websites that lack digital accessibility; post-secondary education organizations’ policies and practices that can be obstacles to using adaptive technology designed for people with disabilities; Insufficient staff and instructor training and familiarity with creating accessible documents, with the use of accessibility features of mainstream technology, and with disability-specific adaptive technology.

#7.1 Each post-secondary education organization should ensure that:

  1. a) Educational and information equipment and technology, including hardware, software, and tablet/mobile apps deployed in educational settings should be designed and configured based on universal design principles, to ensure that students with disabilities can fully use them.
  1. b) A post-secondary education organization’s Learning Management Systems (LMS) should be accessible to staff and students with disabilities, including those who use adaptive technology. They should have all accessibility features turned on and available to ensure that information posted through them will be accessible to students with disabilities, including those using adaptive technology such as screen readers or voice recognition tools. Each post-secondary education organization should ensure that no instructor or other staff is able to turn off any feature of the LMS that is accessible in favour of one that is not.
  1. c) Each post-secondary education organization’s internal and external websites and intranet content, including internet content available to students for learning purposes, including all online learning programs, should be fully accessible, with all new information posted on them to be fully accessible.
  1. d) Electronic documents created at the post-secondary education organization for use in education and other programming and activities should be created in accessible formats unless there is a compelling and unavoidable reason making it impossible to do so. PDF format should be avoided. If a PDF document is created, an alternate version of the content should be simultaneously provided and posted in an accessible Microsoft Word or HTML format.
  1. e) Software used to produce a post-secondary education organization’s key documents for use by students should be designed to ensure that they produce these documents in accessible formats.
  1. f) Textbooks and learning software should be procured only if they include full information technology accessibility. Any textbook used in any learning environment must be accessible to instructors and students with disabilities at the time of procurement. Here again, PDF should not be used unless an accessible alternative format such as MS Word is also simultaneously available. For example, if a textbook is available in EPUB format, the textbooks must meet the international standard for that file format. For EPUB it is the W3C Digital Publishing Guidelines currently under review. If a textbook is available in print, the publisher should be required to provide the digital version of the textbook in an accessible format at the same time the print version is delivered to the school/Board.

#7.2 Each post-secondary education organization should establish, implement, publicize and enforce information technology procurement accessibility requirements, to ensure that no technology is purchased unless it ensures full digital accessibility. Digital and information technology accessibility should be included in all Requests for Proposal (RFP) or other tenders for sale of products and services to a post-secondary education organization. It should be a condition of any such procurement that the vender will promptly remediate any accessibility shortcomings at its own expense.

#7.3 Each post-secondary education organization shall ensure that its instructional staff are fully trained in the creation of accessible electronic documents and online content for use by students, and shall periodically and randomly spot-check such documents to assist in ensuring that instructional staff are effectively trained and up-to-date in this area.

#7.4 Each post-secondary education organization shall review its policies and practices to identify, remove and prevent any barriers to the accessibility of its online and digital content that students might use as part of their educational activities.

#7.5 Each post-secondary education organization shall ensure that its information technology support and help staff includes specialists in access technology, and that students with disabilities get prompt access to IT support when needed.

8. Ensuring Universal Design in Learning and Differentiated Instruction Are Used in All Teaching Activities, Both Online and in Classroom Learning

Barrier: Too often, the curricula and lesson plans used in post-secondary education organizations were not designed and delivered based on principles of accessibility, Universal Design in Learning (UDL) and differentiated instruction (DI). Universal design in learning takes the principles of universal design (designing buildings and products so all can use them) and transfers them to the teaching and learning realm. It focuses on ways to ensure that an education program, course or other learning activity is designed to meet the learning needs of all learners, not just those with no disabilities. To provide the starkest example, a drama teacher who has a class play the game “Charades” is not using UDL principles if their class includes a blind student, for who that activity would be entirely inaccessible.

It may be easier to entrench UDL and differentiated instruction in the K-12 school system. To teach in our publicly-funded schools, a teacher must first complete recognized programs in a teacher’s college. If those teacher’s colleges were to make UDL and differentiated instructions core competency’s that they taught all of their students, Ontario could end up with schools staffed with teachers that are equipped to teach using these principles. Existing teachers could and should be trained in UDL and differentiated instruction during their PD days.

In contrast, to get a job as an instructor or professor at an Ontario post-secondary education organization, a person does not need to have successfully completed any prior course or training on how to teach. That makes it much more challenging to embed UDL and differentiated instruction principles in the teaching activities at Ontario’s post-secondary education organizations.

Principles of UDL and differentiated instruction can be effectively deployed in a manner that respects the academic freedom of those who teach in post-secondary education organizations. Those such as tenured university professors remain free to choose what ideas they wish to convey. UDL and differentiated instruction aim to ensure that all students can effectively learn that content to ultimately serve the goal of academic freedom.

The intent/rationale of the following recommendations is to entrench universal design in learning and differentiated instruction in the curricula and teaching at post-secondary education organizations.

#8.1 Each post-secondary education organization should adopt and publicize a policy committing to the goals and deployment of universal design in learning (UDL) and differentiated instruction (DI) in its education programs, including in the design and delivery of its curricula.

#8.2 Each post-secondary education organization should develop and implement a plan to ensure that all teachers and teaching staff understand, and effectively and consistently use, principles of Universal Design in Learning and differentiated instruction when preparing and delivering courses and other educational programming, to effectively address the spectrum of different learning needs and styles of their students. For example:

  1. a) Each post-secondary education organization should develop, implement and monitor a comprehensive plan to train its instructional staff on using UDL and DI principles when preparing and delivering courses and course content in order to effectively meet their students’ spectrum of different learning needs and styles.
  1. b) Each post-secondary education organization should include knowledge of UDL and differentiated instruction principles as an important criterion when recruiting or promoting instructional staff.
  1. c) Each post-secondary education organization should ensure that teachers are provided with appropriate resources and support to successfully implement their UDL and DI training. Each post-secondary education organization should monitor how effectively UDL and differentiated instruction are incorporated into their education programs on the front lines.
  1. d) Each post-secondary education organization should provide teaching coaches with expertise in UDL and DI to support instructional staff.

#8.3 The Ontario Government should create templates or models for the foregoing training so that each post-secondary education organization does not have to reinvent the wheel in this context.

9. Removing Attitudinal Barriers Against Students with Disabilities

Barrier: Stereotypes, lack of knowledge and other attitudes among some staff at post-secondary education organizations and among some other students, that do not recognize the right and benefits of students with disabilities to get a full and equal education.

#9.1 To help reduce or eliminate attitudinal barriers that can impede students with disabilities each post-secondary education organization should:

  1. a) Develop and implement a multi-year strategy to publicize the organization’s commitment to and the benefits of inclusion and full participation of students with disabilities.
  1. b) Post around the post-secondary education organization announcements of the post-secondary education organization’s commitment to inclusion of students with disabilities, and the benefits this brings to all students.
  1. c) Provide specific training to all front-line staff (not limited to instructional staff) on the importance of inclusion.
  1. d) Implement human resources policies and practices to expand school board staff knowledge and skills regarding inclusion.

10. Ensuring Accessibility of Instructional Materials that Students with Disabilities Use

Barrier: Instructional materials, such as textbooks and other instructional materials and teaching resources that are not provided at the same time in an accessible format for students with disabilities. This is not limited to digital materials, referred to earlier in this Framework.

Section 15 of the Integrated Accessibility Standards Regulation, enacted in June 2011, and in force for school boards since 2013 or 2015 (depending on their size) requires education organizations to provide instructional materials on request in an accessible format, and to make this part of their procurement of such resources. However, this provision has not been effective and sufficient to effectively ensure that students with disabilities face no barriers in this context. Therefore, much stronger measures are needed.

#10.1 To ensure that instructional materials are fully accessible on a timely basis to students with disabilities such as vision loss and those with learning disabilities that affect reading, each post-secondary education organization should:

  1. a) Promptly survey students with disabilities who need accessible instructional materials, and their instructional staff, to get their front-line experiences on whether they get timely access to accessible instructional materials, and to get specifics on where this has been most lacking.
  1. b) Establish a dedicated resource within the post-secondary education organization, or shared among post-secondary education organizations, to convert instructional materials to an accessible format, where needed, on a timely basis. A student should not be required to show proof that they own a hard copy of an item to be able to get it in an accessible format.
  1. c) Review its procurement practices to ensure that any new instructional materials that are acquired are fully accessible or conversion-ready and monitor to ensure that this is always done in practice. A condition of procurement should be a requirement that the supplier or vendor must remediate any inaccessible materials at its own expense.

#10.2 The Education Accessibility Standard should require the Ontario Government to implement, monitor and publicly report on province-wide strategies to ensure the procurement of and use of accessible instructional materials across post-secondary education organizations.

11. Ensuring Barrier-Free Post-Secondary Program Admission Requirements

Barrier: Admission requirements to a post-secondary program that unintentionally or inadvertently impede access to the program for otherwise-qualified students with disabilities.

The intention/rationale of these recommendations is to ensure that students with disabilities can have their eligibility for admission to a post-secondary program fairly and accurately assessed.

#11.1 Every post-secondary education organization shall review its admission criteria for gaining admission to any of its post-secondary education programs, to identify any barriers that would impede otherwise-qualified students with disabilities from admission, and shall adjust those criteria to either:

  1. a) Remove the admission criteria that constitute a barrier to admission, or
  1. b) Provide an alternative method for assessing students with disabilities for admission to the program.

12. Ensuring Student Testing/Assessment is Free of Disability Barriers

Barrier: Tests or other performance assessments of students that are not designed in a way that ensures that students with disabilities are fairly and accurately assessed.

Throughout the post-secondary education system, students take tests, submit papers, and undertake other assessments of their academic performance. There have been no mandatory provincial requirements of which we are aware to ensure that the ways students’ performance is tested or assessed are barrier-free for students with disabilities, and to ensure a fair and accurate assessment of their performance.

#12.1 The Post-Secondary Education Accessibility Standard should set requirements for proper approaches to ensure tests and other methods of performance evaluation provide a fair, accurate and barrier-free assessment of students with disabilities, and on when and how to provide an alternative evaluation method.

#12.2 To ensure that a school board fairly and accurately assesses the performance of students with disabilities, each post-secondary education organization should:

  1. a) Have a policy that commits to ensure that testing and other assessments of students’ performance and learning are designed to be barrier-free for students with disabilities.
  1. b) Give its instructional staff training resources on how to ensure a test or other assessment method is a fair, accurate and barrier-free assessment for students with disabilities in their class, and where needed, how to provide an alternative evaluation method.
  1. c) Monitor implementation of these.

13. Ensuring Students with Disabilities Have the Technology and Other Supports They Need for Effective Learning

Barrier: Policy and bureaucratic impediments to students with disabilities getting the adaptive technology and other supports they need for learning at a post-secondary education organization.

There are inconsistent practices around Ontario for making available to students with disabilities the adaptive technology and support services they need, and the training required to be able to effectively use that equipment.

#13.1 The Post-Secondary Education Accessibility Standard should require that procedural, bureaucratic and other barriers to the acquisition, training and use of needed adaptive equipment and technology at school should be eliminated. It should require the establishment of a prompt, standardized and consistent provincial system for the procurement and deployment of accessible technology to post-secondary students with disabilities that ensures access to the most appropriate and up-to-date technology that is available on the market.

#13.2 The Post-Secondary Education Accessibility Standard should provide that each post-secondary education organization should ensure that students with disabilities are able to bring a trained service animal to their premises as a disability accommodation.

14. Removing Barriers to Participation in Experiential Learning

Barrier: Experiential learning programs that do not ensure that accessible and inclusive experiential learning placements are made available to students with disabilities, and insufficient supports to help organizations, providing experiential learning placements, to facilitate the placement of students with disabilities.

#14.1 To ensure that students with disabilities can fully participate in a post-secondary education organization’s experiential learning programs, each such organization should:

  1. a) Review its experiential learning programs to identify and remove any accessibility barriers.
  1. b) Put in place a process to affirmatively reach out to potential placement organizations in order to ensure that there will be a range of accessible placement opportunities in which students with disabilities can participate.
  1. c) Ensure that its partner organizations that accept its students for experiential learning placements are effectively informed of their duty to accommodate the learning needs of students with disabilities.
  1. d) Create and share supports and advice for placement organizations who need assistance to ensure that students with disabilities can fully participate in their experiential learning placements.
  1. e) Monitor placement organizations to ensure they have someone in place to ensure that students with disabilities are effectively accommodated, and to ensure that effective accommodation was provided during each placement of a student with a disability who needed accommodation.
  1. f) Survey students with disabilities and experiential learning placement organizations at the end of any experiential learning placements to see if their disability-related needs were effectively accommodated.

#14.2 The Ontario Government should provide templates for these policies and measures. It should also prepare and make available training videos for post-secondary education organizations and organizations offering experiential learning programs to guide them on accommodating students with disabilities in experiential learning placements.

 

15. The Need to Harness the Experience and Expertise of People with Disabilities Working in Post-Secondary Education Organizations to Expedite the Removal and Prevention of Barriers Facing Students with Disabilities

Barrier: People with disabilities working in post-secondary education organizations too often face accessibility barriers in the workplace that also hurt students with disabilities.

The intent/rationale of the following recommendations is to ensure that the experience and expertise of people with disabilities working in post-secondary education organizations is effectively harnessed to help root out the accessibility barriers that impede students with disabilities. This is because workplace disability barriers and education service disability barriers often are the same or substantially overlap.

#15-1. Each post-secondary education organization should be required to establish a committee of those employees and volunteers with disabilities who wish to voluntarily join it, to give the organization’s senior management feedback on the barriers in the organization that could impede employees or students with disabilities.

16. Ensuring a Fully Accessible Built Environment at Post-Secondary Education Organizations

The intent/rationale of these recommendations is to ensure that as soon as possible, and no later than January 1, 2025, the built environment in the post-secondary education system and the equipment on those premises (such as gym equipment) would all be fully accessible to people with disabilities and would be designed based on the principle of universal design. Where post-secondary education programs or trips take place outside the post-secondary education organization, these will be held at locations that are disability-accessible. The intent/rationale is also to ensure that no public money is used to create new barriers or perpetuate existing barriers in the post-secondary education system.

There can be costs associated with these measures. The Government will need to determine how much it is prepared to spend, and which of these requirements it would thereby adopt. A Standards Development Committee cannot and should not pre-decide that for the Government.

There is a far greater cost of not imposing these requirements. If the built environment at post-secondary education organizations remains inaccessible, or new post-secondary facilities are built with new barriers, there will be later retrofit costs and litigation costs in response to human rights cases.

Providing a barrier-free built environment in post-secondary education organizations benefits everyone. It ensures that all students of all ages and abilities can come to learn there. It enables people with disabilities to be employed in all jobs throughout the post-secondary education organization. It enables the premises of the post-secondary education organization, a public facility, to be used for other important public uses, such as being rented for conferences.

These recommendations do not include specific technical requirements, such as the precise width of doorways or other paths of travel. These recommendations set out the barriers to be addressed and the specific measures to address them. If the Government of Ontario adopts these, it would have to then proceed to set technical requirements where possible.

Barriers:

  1. Too often, the built environment at post-secondary education organizations has physical barriers that can partially or totally impede some students with disabilities from being able to enter or independently move around.
  1. The Ontario Building Code and existing accessibility standards do not set out all the modern and sufficient accessibility requirements for the built environment in Ontario. The Government of Ontario has no accessibility standard for the built environment in post-secondary education organizations. The Government has not agreed to develop a Built Environment Accessibility Standard to substantially strengthen the general accessibility provisions for society as a whole in the Ontario Building Code.

Accordingly, it is left to each post-secondary education organization to come up with its own designs to address accessibility in the built environment at its premises. This is highly inefficient and wasteful.

The AODA Alliance has illustrated this in two widely-viewed online videos that focus on the built environment at two post-secondary education organizations, chosen because they are typical, not worse than others:

  1. a) the new Culinary Arts Centre at Centennial College: https://www.youtube.com/watch?v=Dgfrum7e-_0&t=87s
  1. b) The new Student Learning Centre at Ryerson University: https://youtu.be/4oe4xiKknt0
  1. The Ontario Government does not ensure that public money is never used to create or perpetuate disability barriers in the built environment.

Recommendations

Examples of these requirements are set out in the Appendix to this Framework, below.

#16.1 The Post-Secondary Education Accessibility Standard should set out specific requirements for accessibility in the built environment at post-secondary education organizations and other locations where post-secondary education programs are to be offered. These should meet the accessibility requirements of the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms and should meet the needs of all disabilities and not only people with mobility disabilities. These should include:

  1. a) Specific requirements to be included in a new facility to be built.
  1. b) Requirements to be included in a renovation of or addition to an existing post-secondary facility, and
  1. c) Retrofit requirements for an existing post-secondary facility, even if it is not slated for a major renovation or addition, to the extent that they are readily achievable and important to ensure the facility’s accessibility.

#16.2 Each post-secondary education organization should develop a plan to ensure that the built environment of its educational facilities becomes fully accessible to people with disabilities as soon as reasonably possible, and in any event, no later than January 1, 2025. As part of this:

  1. a) As a first step, each post-secondary education organization should develop a plan for making as many of its facilities disability-accessible within its current financial context. Accessibility does not only include the needs of people with mobility disabilities. It includes the needs of people with other disabilities such as people with vision and/or hearing loss, autism, intellectual or developmental disabilities, learning disabilities or mental health disorders.
  1. b) Each post-secondary education organization should identify which of its existing facilities can be more easily made accessible, and which facilities would require substantially more extensive action to be made physically accessible. An interim plan should be developed to show what progress towards full physical accessibility can be made by first addressing facilities that would require less money to be made physically more accessible, and the most high-impact facilities.

#16.3 The post-secondary education organization’s review of its built environment shall include a thorough review of the campus’s overall layout. Where navigation around the campus, or from building to building, lacks the needed and appropriate cues for people with vision loss or other disabilities, proper way-finding, including tactile walking surface indicators, will be installed to facilitate the ease of safe navigation around the campus

#16.4 When a post-secondary education organization seeks to retain or hire design professionals, such as architects, interior designers or landscape architects, for the design of a new facility or an existing facility’s retrofit or renovation, or for any other infrastructure project, the post-secondary education organization should include in any Request for Proposal (RFP) a mandatory requirement that the design professional must have sufficient demonstrated expertise in accessibility design, and not simply knowledge about compliance with the Ontario Building Code or the AODA. This includes the accessibility needs of people with all kinds of disabilities, and not just those with mobility impairments.

#16.5 When a post-secondary education organization is planning to construct a new facility, or to expand or renovate an existing facility or other infrastructure, a suitably qualified accessibility consultant should be directly retained by the post-secondary education organization (and not by a private architecture firm) to advise on the project from the outset, with their unedited advice being transmitted directly to the post-secondary education organization and not only to the private design professionals who are retained to design the project. Completing the 8 day training course on accessibility offered by the Rick Hansen Foundation should not be treated as either necessary or sufficient for this purpose, as that course is substantially inadequate and has significant problems.

#16.6 The post-secondary education organization should have design specifications or plans for any new construction or major renovations of any of its facilities reviewed by its board’s Accessibility Committee and by representatives of its students and employees with disabilities. If the post-secondary education organization rejects any of their recommendations regarding the project’s accessibility it shall provide written reasons for its decision to do so.

#16.7 Where possible, a post-secondary education organization should not renovate an existing facility that lacks disability accessibility, unless the organization has a plan to also make that facility accessible. For example, a post-secondary education organization should not spend public money to renovate the second storey of a facility which lacks accessibility to the second storey, if the organization does not have a plan to make that second storey disability-accessible. Very pressing health and safety concerns should be the only reason for any exception to this.

#16.8 Each post-secondary education organization should only hold off-site educational events at venues whose built environment is accessible, unless to do so would be impossible without undue hardship.

#16.9 To ensure that gym, sports, athletic equipment and other like equipment and facilities are accessible for students with disabilities, the Post-Secondary Education Accessibility Standard should set out specific technical accessibility requirements for new or existing outdoor or indoor gym,, sports, athletic and other like equipment, drawing on accessibility standards and best practices in other jurisdictions, if sufficient, so that each post-secondary education organization does not have to re-invent the accessibility wheel.

#16.10 Each post-secondary education organization should:

  1. a) Take an inventory of the accessibility of its existing indoor and outdoor gym, sports, athletic and like equipment and spaces, and make this public, including posting this information online.
  1. b) Adopt a plan to remediate the accessibility of existing gym, sports, athletic or other like equipment or spaces, in consultation with students with disabilities.
  1. c) Ensure that a qualified accessibility expert is engaged to ensure that the purchase of new equipment or remediation of existing equipment or spaces is properly conducted, with their advice being given directly to the post-secondary education organization.

#16.11 The Ontario Government should be required to revise its funding formula or criteria for construction of facilities at a post-secondary education organization to ensure that it requires and does not obstruct the inclusion of all needed accessibility features in that construction project.

Appendix 1 – Specific Accessible Design Requirements for the Built Environment Proposed For the Post-Secondary Education Accessibility Standard

The following design features should be required by the Post-Secondary Education Accessibility Standard and in any new construction or renovation at a post-secondary education organization. Where an existing post-secondary facility is undergoing no renovation, any of the following measures which are readily achievable should be required. To fill in the specifics, the Ontario Government should enact technical requirements for the following, as binding enforceable rules, not as voluntary guidelines:

Usable Accessible Design for Outdoor or Exterior Site Elements

  1. Access to the site for pedestrians

Clear, intuitive connection to the accessible entrance

  1. A tactile raised line map shall be provided at the main entry points adjacent to the accessible path of travel but with enough space to ensure users do not block the path for others
  2. Path of travel from each sidewalk connects to an accessible entrance with few to no joints to avoid bumps. The primary paths shall be wide enough to allow two-way traffic with a clear width that allows two people using wheelchairs or guide dogs to pass each other. For secondary paths where a single path is used, passing spaces shall be provided at regular intervals and at all decision points. The height difference from the sidewalk to the entrance will not require a ramp or stairs. The path will provide drainage slopes only and ensure no puddles form on the path. Paths will be heated during winter months using heat from the school or other renewable energy sources.
  3. Bike parking shall be adjacent to the entry path. Riders shall be required to dismount and not ride on the pedestrian routes. Bike parking shall provide horizontal storage with enough space to ensure users and parked bikes do not block the path for others. The ground surface below the bikes shall be colour contrasted and textured to be distinct from the pedestrian path.
  4. Rest areas and benches with clear floor space for at least two assistive mobility devices or strollers or a mix of both shall be provided. Benches shall be colour contrasted, have back and arm rests and provide transfer seating options at both ends of the bench. These shall be provided every 30m along the path placed adjoining. The bench and space for assistive devices are not to block the path. If the path to the main entrance is less than 30m at least one rest area shall be provided along the route. If the drop-off area is in a different location than the pedestrian route from the sidewalk, an interior rest area shall be provided with clear sightlines to the drop-off area. If the drop-off area is more than 20m from the closest accessible entrance an exterior accessible heated shelter shall be provided for those awaiting pick-up. The ground surface below the rest areas shall be colour contrasted and textured to be distinct from the pedestrian path it abuts
  5. Tactile directional indicators shall be provided where large open paved areas happen along the route, or where walking paths are not readily navigable by persons with vision loss, due to a lack of reliable shorelines and landmarks.
  6. Accessible pedestrian directional signage at decision points
  7. Lighting levels shall be bright and even enough to avoid shadows and ensure it’s easy to see the features and to keep people safe.
  8. Accessible duress stations (Emergency safety zones in public spaces)
  9. Heated walkways shall be used where possible to ensure the path is always clear of snow and ice
  1. Access to the site for vehicles
  2. Clear, intuitive connection to the drop-off and accessible parking
  3. Passenger drop-off shall include space for driveway, layby, access aisle (painted with non-slip paint), and a drop curb (to provide a smooth transition) for the full length of the drop off. This edge shall be identified and protected with high colour contrasted tactile attention indicators and bollards to stop cars, so people with vision loss or those not paying attention get a warning before walking into the car area. Sidewalk slopes shall provide drainage in all directions for the full length of the dropped curb
  4. Overhead protection shall be provided by a canopy that allows for a clearance for raised vans or buses and shall provide as much overhead protection as possible for people who may need more time to load or off-load
  5. Heated walkways from the drop-off and parking shall be used to ensure the path is always clear of snow and ice
  6. A tactile walking directional indicator path shall lead from the drop-off area to the closest accessible entrance to the building (typically the main entrance)
  7. A parking surface will only be steep enough to provide drainage in all directions. The drainage will be designed to prevent puddles from forming at the parking or along the pedestrian route from the parking
  8. Parking design should include potential expansion plans for future growth and/or to address increased need for accessible parking
  9. Parking access aisles shall connect to the sidewalk with a curb cut that leads to the closest accessible entrance to the building (so that no one needs to travel along the driveway behind parked cars or in the path of car traffic)
  10. Lighting levels shall be bright and even enough to avoid shadows and to ensure it’s easy to see obstacles and to keep people safe.
  11. If there is more than one parking lot, each site shall have a distinctive colour and shape symbol associated with it that will be used on all directional signage especially along pedestrian routes.
  1. Parking
  2. The provision of parking spaces near the entrance to a facility is important to accommodate persons with a varying range of abilities as well as persons with limited mobility. Medical conditions, such as anemia, arthritis or heart conditions, using crutches or the physical act of pushing a wheelchair, all can make it difficult to travel long distances. Minimizing travel distances is particularly important outdoors, where weather conditions and ground surfaces can make travel difficult and hazardous.
  3. The sizes of accessible parking stalls are important. A person using a mobility aid such as a wheelchair requires a wider parking space to accommodate the manoeuvring of the wheelchair beside the car or van. A van may also require additional space to deploy a lift or ramp out the side or back door. An individual would require space for the deployment of the lift itself as well as additional space to manoeuvre on/off the lift.
  4. Heights of passage along the driving routes to accessible parking is a factor. Accessible vans may have a raised roof resulting in the need for additional overhead clearance. Alternatively, the floor of the van may be lowered, resulting in lower capacity to travel over for speed bumps and pavement slope transitions.
  5. Wherever possible, parking signs shall be located away from pedestrian routes, because they can constitute an overhead and/or protruding hazard. All parking signage shall be placed at the end of the parking space in a bollard barricade to stop cars, trucks or vans from parking over and blocking the sidewalk.
  1. A Building’s exterior doors
  2. Level areas on both sides of a building’s exterior door shall allow the clear floor space for a large scooter or mobility device or several strollers to be at the door. Exterior surface slope shall only provide drainage away from the building.
  3. 100% of a building’s exterior doors will be accessible with level thresholds, colour contrast, accessible door hardware and in-door windows or side windows (where security allows) so those approaching the door can see if someone is on the other side of the door
  4. Main entry doors at the front of the building and the door closest to the parking lot (if not the same) to be obvious, prominent and will have automatic sliders with overhead sensors. Placing power door operator buttons correctly is difficult and often creates barriers especially within the vestibule
  5. Accessible security access for after hours or if used all day with 2-way video for those who are deaf and/or scrolling voice to text messaging
  6. All exit doors shall be accessible with a level threshold and clear floor space on either side of the door. The exterior shall include a paved accessible path leading away from the building

Accessible Design for Interior Building Elements

  1. Entrances
  2. All entrances used by staff and/or the public shall be accessible and comply with this section. In a retrofit situation where it is technically infeasible to make all staff and public entrances accessible, at least 50% of all staff and public entrances shall be accessible and comply with this section. In a retrofit situation where it is technically infeasible to make all public entrances accessible, the primary entrances used by staff and the public shall be accessible.
  3. Door
  4. Doors shall be sufficiently wide enough to accommodate stretchers, wheelchairs or assistive scooters, pushing strollers, or making a delivery
  5. Threshold at the door’s base shall be level to allow a trip free and wheel friendly passage.
  6. Heavy doors and those with auto closers shall provide automatic door openers.
  7. Room entrances shall have doors.
  8. Direction of door swing shall be chosen to enhance the usability and limit the hazard to others of the door opening.
  9. Sliding doors can be easier for some individuals to operate, and can also require less wheelchair manoeuvring space.
  10. Doors that require two hands to operate will not be used.
  11. Revolving doors are not accessible.
  12. Full glass doors are not to be used as they represent a hazard.
  13. Colour-contrasting will be provided on door frames, door handles as well as the door edges.
  14. Door handles and locks will be operable by using a closed fist, and not require fine finger control, tight grasping, pinching, or twisting of the wrist to operate
  1. Gates, Turnstiles and Openings
  2. Gates and turnstiles should be designed to accommodate the full range of users that may pass through them. Single-bar gates designed to be at a convenient waist height for ambulatory persons are at neck and face height for children and chest height for persons who use wheelchairs or scooters.
  3. Revolving turnstiles should not be used as they are a physical impossibility for a person in a wheelchair to negotiate. They are also difficult for persons using canes or crutches, or persons with poor balance.
  4. All controlled entry points will provide an accessible width to allow passage of wheelchairs, other mobility devices, strollers, walkers or delivery carts.
  1. Windows, Glazed Screens and Sidelights
  2. Broad expanses of glass should not be used for walls, beside doors and as doors can be difficult to detect. This may be a particular concern to persons with vision loss/no vision. It is also possible for anyone to walk into a clear sheet of glazing especially if they are distracted or in a hurry.
  3. Window sill heights and operating controls for opening windows or closing blinds should be accessible…located on a path of travel, with clear floor space, within reach of a shorter or seated user, colour contrasted and not require punching or twisting to operate.
  1. Interior Layout
  2. The main office where visitors and others need to report to upon entering the building shall always be located on the same level as the entrance, as close to the entrance as possible. If the path of travel to the office crosses a large open area, a tactile directional indicator path shall lead from the main entrance(s) to the office ID signage next to the office door.
  3. As much as possible, classrooms and or public destinations shall be on the ground floor. Where this is not possible, at least 2 elevators should be provided to access all other levels. Where the building is long and spread out, travel distance to elevators should be considered to reduce extra time needed for students and staff or others who use the elevators instead of the stairs. If feature stairs (staircases included in whole or in part for design aesthetics) are included, elevators shall be co-located and just as prominent as the stairs
  4. Corridors should meet at 90 degree angles. Floor layouts from floor to floor should be consistent and predictable so the room number line up and are the same with the floors above and below along with the washrooms
  5. Multi-stall washrooms shall always place the women’s washroom on the right and the men’s washroom on the left. No labyrinth entrances shall be used. Universal washrooms shall be co-located immediately adjacent to the stall washrooms, in a location that is consistent and predictable throughout the building
  1. Facilities
  2. The entry doors to each type of facility within a building should be accessible, colour contrasted, obvious and prominent and designed as part of the wayfinding system including accessible signage that is co-located with power door openers controls.
  3. Tactile attention indicator tile will be placed on the floor in front of the accessible ID signage at each room or facility type. Where a room or facility entrance is placed off of a large interior open area
  1. Elevators
  1. Elevator Doors will provide a clear width to allow a stretcher and larger mobility devices to get in and out
  2. Doors will have sensors so doors will auto open if the doorway is blocked
  3. Elevators will be installed in pairs so that when one is out of service for repair or maintenance, there is an alternative available.
  4. Elevators will be sized at allow at least two mobility device users and two non-mobility devices users to be in the elevator at the same time. This should also allow for a wide stretcher in case of emergency.
  5. Assistive listening will be available in each elevator to help make the audible announcements heard by those using hearing aids
  6. Emergency button on the elevator’s control panel will also provide 2-way communication with video and scrolling text and a keyboard for people who are deaf or who have other communication disabilities
  7. Inside the elevators will be additional horizontal buttons on the side wall in case there is not enough room for a person using a mobility aid to push the typical vertical buttons along the wall beside the door. If there are only two floors the elevator will only provide the door open, close and emergency call buttons and the elevator will automatically move to the floor it is not on.
  8. The words spoken in the elevator’s voice announcement of the floor will be the same as the braille and print floor markings, so the button shows 1 as a number, 1 in braille and the voice says first floor not G for Ground with M in braille and voice says first floor.)
  9. Ensure the star symbol for each elevator matches ground level appropriate to the elevator. The star symbol indicates the floor the elevator will return to in an emergency. This means users in the elevator will open closest to the available accessible exit. If the entrance on the north side is on the second floor, the star symbol in that elevator will be next to the button that says 2. If the entrance on the south side of the building is on the 1st floor, the star symbol will be next to the button that says 1.
  10. The voice on the elevator shall be set at a volume that is audible above typical noise levels while the elevator is in use, so that people on the elevator can easily hear the audible floor announcements.
  11. Lighting levels inside the elevator will match the lighting at the elevator lobbies. Lighting will be measured at the ground level
  12. Elevators will provide colour contrast between the floor and the walls inside the cab and between the frame of the door or the doors with the wall surrounding in the elevator lobbies. Vinyl peel and stick sheets or paint will be used to cover the shiny metal which creates glare. Vinyl sheets will be plain to ensure the door looks like a door, and not like advertising
  13. In a retrofit situation where adding 2 elevators is not technically possible without undue hardship, platform lifts may be considered. Elevators that are used by all facility users are preferred to platform lifts which tend to segregate persons with disabilities and which limit space at entrance and stair locations. Furthermore, independent access is often compromised by such platform lifts,, because platform lifts are often require a key to operate. Whenever possible, integrated elevator access should be incorporated to avoid the use of lifts.
  1. Ramps
    1. A properly designed ramp can provide wait-free access for those using wheelchairs or scooters, pushing strollers or moving packages on a trolley or those who are using sign language to communicate and don’t want to stop talking as they climb stairs.
    2. A ramp’s textured surfaces, edge protection and handrails all provide important safety features.
    3. On outdoor ramps, heated surfaces shall be provided to address the safety concerns associated with snow and ice.
    4. Ramps shall only be used where the height difference between levels is no more than 1m (4ft). Longer ramps take up too much space and are too tiring for many users. Where a height difference is more than 1m in height, elevators will be provided instead.
    5. Landings will be sized to allow a large mobility device or scooter to make a 360 degree turn and/or for two people with mobility assistive devices or guide dogs to pass
    6. Slopes inside the building will be no higher than is permitted for exterior ramps in the AODA Design of Public Spaces Standard, to ensure usability without making the ramp too long.
    7. Curved ramps will not be used, because the cross slope at the turn is hard to navigate and a tipping hazard for many people.
    8. Colour and texture contrast will be provided to differentiate the full slope from any level landings. Tactile attention domes shall not be used at ramps, because they are meant only for stairs and for drop-off edges like at stages
  1. Stairs
  1. Stairs that are comfortable for many adults may be challenging for children, shorter persons seniors or persons of short stature.
  2. The leading edge of each step (aka nosing) shall not present tripping hazards, particularly to persons with prosthetic devices or those using canes and will have a bright colour contrast to the rest of the horizontal step surface.
  3. Each stair in a staircase will use the same height and depth, to avoid creating tripping hazards
  4. The rise between stairs will always be smooth, so that shoes will not catch on an abrupt edge causing a tripping hazard. These spaces will always be closed as open stairs create a tripping hazard.
  5. The top of all stair entry points will have a tactile attention indicator surface, to ensure the drop-off is identified for those who are blind or distracted.
  6. Handrails will aid all users navigating stairways safely. Handrails will be provided on both sides of all stairs, and will be provided at both the traditional height as well as a second lower rail for children or people who are shorter. These will be in a high colour contrasting colour and round in shape, without sharp edges or interruptions. Rails shall always be at a right angle to the stairs, and shall never be itched at an angle.
  7. g) Spiral, curved or irregular staircases shall never be created, as they are a serious tripping hazard.
  1. Washroom Facilities
    1. Washroom facilities will accommodate the range of people that will use the space. Although many persons with disabilities use toilet facilities independently, some may require assistance. Where the individual providing assistance is of the opposite gender then typical gender-specific washrooms are awkward, and so an individual washroom is required.
    2. Parents and caregivers with small children and strollers also benefit from a large, individual washroom with toilet and change facilities contained within the same space.
    3. Circumstances such as wet surfaces and the act of transferring between toilet and wheelchair or scooter can make toilet facilities accident-prone areas. An individual falling in a washroom with a door that swings inward could prevent his or her own rescuers from opening the door. Due to the risk of accidents, emergency call buttons are vital in all washrooms.
    4. The appropriate design of all features will ensure the usability and safety of all toilet facilities.
    5. The identification of washrooms will include pictograms for children or people who cannot read. All signage will include braille that translates the text on the print sign, and not only the room number.
    6. There are three types of washrooms. Single use accessible washrooms, single use universal washrooms, and multi-use stalled washrooms. The number and types of washrooms used in a facility will be determined by the number of users. There will always at least be one universal washroom.
    7. All washrooms will have doors with power door opening buttons. No door washrooms will be hard to identify for people who have vision loss.
      1. In stall washrooms with urinals, all urinals will be accessible with lower rim heights. Universal washrooms will have an upper rim at the same height as typical non-accessible urinals to avoid the mess taller users can make. All urinals will provide vertical grab bars which are colour contrasted to the walls. Where dividers between urinals are used, the dividers will be colour contrasted to the walls as well.
    8. Stall washrooms accessible sized stalls – At least 2 accessible stalls shall be provided in each washroom to avoid long wait times. Facilities with accessible education programs that include a large percentage of people with mobility disabilities should have all stalls sized to accommodate a turn circle and the transfer space beside the toilet.
      1. All washrooms near rooms that will be used for public events shall include a baby change table that is accessible to all users, not placed inside a stall. It shall be colour contrasted with the surroundings and usable for those in a seated mobility device and or of shorter stature.
      2. At least one universal washroom will include an adult sized change table, with the washroom located near appropriate facilities in the facility and any public event spaces. These are important for some adults with disabilities and for children with disabilities who are too large for the baby change tables. This helps prevent anyone from needing to be changed lying on a bathroom floor.
  • Where shower stalls are provided, these shall include accessible sized stalls.
  1. Portable Toilets at Special Events shall all be accessible. At least one will include an adult sized change table.
  1. Washroom Stalls:
  1. Manoeuvrability of a wheelchair or scooter is the principal consideration in the design of an accessible stall. The increased size of the stall is required to ensure there is sufficient space to facilitate proper placement of a wheelchair or scooter to accommodate a person transferring transfer onto the toilet from their mobility device. There may also be instances where an individual requires assistance. Thus, the stall will have to accommodate a second person. Stall Door swings are normally outward for safety reasons and space considerations. However, this makes it difficult to close the door once inside. A handle mounted part way along the door makes it easier for someone inside the stall to close the door behind them. Minimum requirements for non-accessible toilet stalls are included to ensure that persons who do not use wheelchairs or scooters can be adequately accommodated within any toilet stall. Universal features include accessible hardware and a minimum stall width to accommodate persons of large stature or parents with small children.
  1. Toilets:
  1. Automatic flush controls are preferred. If flushing mechanisms are not automated, flushing controls shall be on the transfer side of the toilet, with colour contrasted and lever style handles.
  1. Sinks:
  1. Each accessible sink shall be on an accessible path of travel that other people, using other sinks or features (like hand-dryers), are not positioned to block. Automated sink controls are preferred. While faucets with remote-eye technology may initially confuse some individuals, their ease of use is notable. Individuals with hand strength or dexterity difficulties can use lever-style handles. For an individual in a wheelchair and younger children, a lower counter height and clearance for knees under the counter are required. The insulating of hot water pipes shall be assured to protect the legs of an individual using a wheelchair. This is particularly important when a disability impairs sensation such that the individual would not sense that their legs were being burned. The combination of shallow sinks and higher water pressures can cause unacceptable splashing at lavatories.
  2. Powered hand-dryers shall make minimum noise, to avoid being a barrier to people with vision loss or those with sensory integration issues for whom loud blasting sound can make a bathroom unusable.
    1. Urinals:
  3. Each urinal needs to be on an accessible path of travel with clear floor space in front of each accessible urinal to provide the manoeuvring space for a mobility device. Grab bars shall be provided to assist individuals rising from a seated position and others to steady themselves. Floor-mounted urinals accommodate children and persons of short stature as well as enabling easier access to drain personal care devices. Flush controls, where used, will be automatic preferred. Strong colour contrasts shall be provided between the urinal, the wall and the floor to assist persons with vision loss/no vision.
    1. Showers
  4. Where showers are provided, roll-in or curbless shower stalls shall be provided to eliminate the hazard of stepping over a threshold and are essential for persons with disabilities who use wheelchairs or other mobility devices in the shower. Grab bars and non-slip materials shall be included as safety measures that will support any individual. Hand-held shower heads or a water-resistant folding bench shall be included to assist people with disabilities. These are also convenient for others. Equipment that has contrasting colour from the shower stall shall be included to assist individuals with vision loss/no vision.
  1. Drinking Fountains
  2. Drinking fountain height should accommodate shorter persons, and that of a person using a wheelchair or scooter. Potentially conflicting with this, the height should strive to attempt to accommodate individuals who have difficulty bending and who would require a higher fountain. Where feasible, this may require more than one fountain, at different heights. The operating system shall account for limited hand strength or dexterity. Fountains will be recessed, to avoid protruding into the path of travel. Angled recessed alcove designs allow more flexibility and require less precision by a person using a wheelchair or scooter. Providing accessible signage with a tactile attention indicator tile will help those who with vision loss to find the fountain.
  1. Performance Stages
  2. Elevated platforms, such as stage areas, speaker podiums, etc., shall be accessible to all. A clear accessible route will be provided along the same path of access for those who are not using mobility assistive devices as those who do. Lifts will not be used to access stage or raised platforms, unless the facility is retrofitting an existing stage and it is not technically possible to provide access by other means.
  3. The stage shall include safety features to assist persons with vision loss or those momentarily blinded by stage lights from falling off the edge of a raised stage, such as a colour contrasted raised lip along the edge of the stage.
  4. Lecterns shall be accessible with an adjustable height surface, knee space and accessible audio visual (AV) and information technology (IT) equipment. Lecterns shall have a microphone that is connected to an assistive listening system, such as a hearing loop. The office and/or presentation area will have assistive listening units available for those who may request them, for example people who are hard of hearing but not yet wearing hearing aids.
  5. Lighting shall be adjustable to allow for a minimum of lighting in the public seating area and back stage to allow those who need to move or leave with sufficient lighting at floor level to be safe
  1. Offices, Work Areas, and Meeting Rooms
  2. Offices providing services or programs to the public will be accessible to all, regardless of mobility or functional needs. Offices and related support areas shall be accessible to staff and visitors with disabilities.
  3. All people, but particularly those with hearing loss/persons who are hard-of-hearing, will benefit from having a quiet acoustic environment – background noise from mechanical equipment such as fans, shall be designed to be minimal. Telephone equipment that supports the needs of individuals with hearing and vision loss shall be available.
  4. The provision of assistive speaking devices is important for the range of individuals who may have difficulty with low vocal volume thus affecting production of normal audible levels of sound. Where offices and work areas and small meeting rooms do not have assistive listening, such as hearing loops permanently installed, portable assistive hearing loops shall be available at the office
  5. Tables and workstations shall provide the knee space requirements of an individual in a mobility assistive device. Adjustable height tables allow for a full range of user needs. Circulation areas shall accommodate the spatial needs of mobility equipment as large as scooters to ensure all areas and facilities in the space can be reached with appropriate manoeuvring and turning spaces.
  6. Natural coloured task lighting, such as that provided through halogen bulbs, shall be used wherever possible to facilitate use by all, especially persons with low vision.
  7. In locations where reflective glare may be problematic, such as large expanses of glass with reflective flooring, blinds that can be louvered upwards shall be provided. Controls for blinds shall be accessible to all and usable with a closed fist without pinching or twisting
  1. Outdoor Athletic and Recreational Facilities
  2. Areas for outdoor recreation, leisure and active sport participation shall be designed to be available to people of a spectrum of abilities.
  3. Outdoor spaces will allow persons with a disability to be active participants, as well as spectators, volunteers and members of staff. Spaces will be accessible including boardwalks, trails and footbridges, pathways, parks, parkettes and playgrounds, parks, parkettes and playgrounds, grandstand and other viewing areas, and playing fields
  4. Assistive listening will be provided where game or other announcements will be made for all areas including the change room, player, coach and public areas.
  5. Noise cancelling headphones shall be available to those with sensory disabilities.
  6. Outdoor exercise equipment will include options for those with a variety of disabilities including those with temporary disabilities undergoing rehabilitation.
  7. Seating and like facilities shall be inclusive and allow for all members of a disabled sports team to sit together in an integrated way that does not segregate anyone.
  8. Seating and facilities will be inclusive and allow for all members of a sports team of people with disabilities to sit together in an integrated way that does not segregate anyone.
  1. Arenas, Halls and Other Indoor Recreational Facilities
  2. Areas for recreation, leisure and active sport participation will be accessible to all members of the community.
  3. Assistive listening will be provided where game or other announcements will be made for all areas including the change room, player, coach and public areas.
  4. Noise cancelling headphones will be available to those with sensory disabilities.
  5. Access will be provided throughout outdoor facilities including: playing fields and other sports facilities, all activity areas, outdoor trails, swimming areas, play spaces, lockers, dressing/change rooms and showers.
  6. Interior access will be provided to halls, arenas, and other sports facilities, including access to the site, all activity spaces, gymnasia, fitness facilities, lockers, dressing/change rooms and showers.
  7. Spaces will allow people with disabilities to be active participants, as well as spectators, volunteers and members of staff.
  8. Indoor exercise equipment will include options for those with a variety of disabilities including those with temporary disabilities who are undergoing rehabilitation.
  9. Seating and facilities will be inclusive and allow for all members of a sports team of people with disabilities to sit together in an integrated way that does not segregate or stigmatize anyone.
  1. Swimming Pools
  2. Primary considerations for accommodating persons who have mobility impairments include accessible change facilities and a means of access into the water. Ramped access into the water is preferred over lift access, as it promotes integration (everyone will use the ramp) and independence.
  3. Persons with low vision benefit from colour and textural surfaces that are detectable and safe for both bare feet or those wearing water shoes. These surfaces will be provided along primary routes of travel leading to access points such as pool access ladders and ramps.
  4. Tactile surface markings and other barriers will be provided at potentially dangerous locations, such as the edge of the pool, at steps into the pool and at railings.
  1. Cafeterias
  2. Cafeteria serving lines and seating area designs shall reflect the lower sight lines, reduced reach, knee-space and manoeuvring requirements of a person using a wheelchair or scooter. Patrons using mobility devices may not be able to hold a tray or food items while supporting themselves on canes or while manoeuvring a wheelchair.
  3. If tray slides are provided, they will be designed to move trays with minimal effort.
  4. Food signage will be accessible.
  5. All areas where food is ordered and picked up will be designed to meet accessible service counter requirements
  6. Self-serve food will be within the reach of people who are shorter or using seated mobility assistive devices
  7. Where trays are provided, a tray cart that can be attached to seated assistive mobility devices or a staff assistant solution that is readily available shall be available on demand, because carrying trays and pushing a chair or operating a motorized assistive device can be difficult or impossible
  1. Libraries
  2. All service counters shall provide accessibility features
  3. Study carrels will accommodate the knee-space and armrest requirements of a person using a mobility device.
  4. Computer catalogues, carrels and workstations will be provided at a range of heights, to accommodate persons who are standing or sitting, as well as people of different ages and sizes.
  5. Workstations shall be equipped with assistive technology such as large displays, screen readers, to increase the accessibility of a library.
  6. Book drop-off slots shall be at different heights for standing and seated use with accessible signage, to enhance usability.
  1. Teaching Spaces and Classrooms
  2. Students, instructors and staff with disabilities will have accessibility to teaching and classroom facilities, including teaching computer labs.
  3. All teaching spaces and classrooms will provide power door operators and assistive listening systems such as hearing loops
  4. Additional considerations may be necessary for spaces and/or features specifically designated for use by students with disabilities, such as accessibility standard accommodations for complex personal care needs.
  5. Students instructors and staff with disabilities will be accommodated in all teaching spaces throughout the facility.
  6. This accessibility will include the ability to enter and move freely throughout the space, as well as to use the various built-in elements within (i.e. blackboards and/or whiteboards, switches, computer stations, sinks, etc.).
  7. Individuals with disabilities frequently use learning aids and other assistive devices that require a power supply. Additional electrical outlets shall be provided throughout teaching spaces to -accommodate the use of such equipment.
  8. Except where it is impossible, fixtures, fittings, furniture and equipment will be specified for teaching spaces, which is usable by students, faculty, teaching assistants and staff with disabilities.
  9. Providing only one size of seating does not reflect the diversity of body types of our society. Offering seats with an increased width and weight capacity is helpful for persons of large stature. Seating with increased legroom will better suit individuals that are taller. Removable armrests can be helpful for persons of larger stature as well as individuals using wheelchairs that prefer to transfer to the seat.
  1. Laboratories
  2. In addition to the requirements for classrooms, additional accessibility considerations may be necessary for spaces and/or features in laboratories.
  1. Waiting and Queuing Areas
  2. Queuing areas for information, tickets or services will permit persons who use wheelchairs, scooters and other mobility devices as well as for persons with a varying range of user ability to easily move through the line safely. All lines shall be accessible.
  3. Waiting and queuing areas will provide space for mobility devices, such as wheelchairs and scooters. Queuing lines that turn corners or double back on themselves will provide adequate space to manoeuvre mobility devices. Handrails with high colour contrast will be provided along queuing lines, because they are a useful support for individuals and guidance for those with vision loss. Benches in waiting areas shall be provided for individuals who may have difficulty with standing for extended periods.
  4. Assistive listening systems will be provided, such as hearing loops, will be provided along with accessible signage indicating this service is available.
  1. Information, Reception and Service Counters
  2. All information, reception and service counters will be accessible to the full range of visitors. Where adjustable height furniture is not used, a choice of fixed counter heights will provide a range of options for a variety of persons. Lowered sections will serve children, persons of short stature and persons using mobility devices such as a wheelchair or scooter. The choice of heights will also extend to any speaking ports and writing surfaces.
  3. Counters will provide knee space under the counter to accommodate a person using a wheelchair or a scooter.
  4. The provision of assistive speaking and listening devices is important for the range of individuals who may have difficulty with low vocal volume thus affecting production of normal audible levels of sound. The space where people are speaking will have appropriate acoustic treatment to ensure the best possible conditions for communication. Both the public and staff sides of the counter will have good lighting for the faces to help facilitate lip reading.
  5. Colour contrast will be provided to delineate the public service counters and speaking ports for people with low vision.
  1. Lockers
  2. Lockers will be accessible with colour contrast and accessible signage
  3. In change rooms an accessible bench will be provided in close proximity to lockers.
  4. Lockers at lower heights serve the reach of short people or a person using a wheelchair or scooter.
  5. The locker operating mechanisms will be at an appropriate height and operable by individuals with restrictions in hand dexterity (i.e. operable with a closed fist).
  1. Storage, Shelving and Display Units
  2. The heights of storage, shelving and display units will address a full range of vantage points including the lower sightlines of short people or a person using a wheelchair or scooter. The lower heights also serve the lower reach of these individuals.
  3. Displays and storage along a path of travel that are too low can be problematic for individuals that have difficulty bending down or who are blind. If these protrude too much into the path of travel, each will protect people with the use of a trip free cane detectable guard.
  4. Appropriate lighting and colour contrast is particularly important for persons with vision loss.
  5. Signage provided will be accessible with braille, text, colour contrast and tactile features
  1. Public Address Systems
  2. Public address systems will be designed to best accommodate all users, especially those that may be hard of hearing. They will be easy to hear above the ambient background noise of the environment with no distortion or feedback. Background noise or music will be minimized.
  3. Technology for visual equivalents of information being broadcast will be available for individuals with hearing loss/persons who are hard-of-hearing who may not hear an audible public address system.
  4. Classrooms, library, hallways, and other areas will have assistive listening equipment that is tied into the general public address system.
  1. Emergency Exits, Fire Evacuation and Areas of Rescue Assistance
  2. In order to be accessible to all individuals, emergency exits will include the same accessibility features as other doors. The doors and routes will be marked in a way that is accessible to all individuals, including those who may have difficulty with literacy, such as persons speaking a different language.
  3. Persons with vision loss/no vision will be provided a means to quickly locate exits – audio or talking signs could assist.
  4. In the event of fire when elevators cannot be used, areas of rescue assistance shall be provided especially for anyone who has difficulty traversing sets of stairs. Areas of rescue assistance will be provided on all floors above or below the ground floor. Exit stairs will provide an area of rescue assistance on the landing with at least two spaces for people with mobility assistive devices sized to ensure those spaces do not block the exit route for those using the stairs. The number of spaces necessary should be sized by the number of people on each floor. Each area of refuge will provide a 2-way communication system with both video and audio to allow those using the space to communicate that they are waiting there and to communicate with fire safety services and or security. All signage associated with the area of rescue assistance will be accessible and include braille for all controls and information.
  1. Space and Reach Requirements
  2. The dimensions and manoeuvring characteristics of wheelchairs, scooters and other mobility devices will allow for a full array of equipment that is used by individuals to access and use facilities, as well as the diverse range of user ability.
  1. Ground and Floor Surfaces
  2. Irregular surfaces, such as cobblestones or pea-gravel finished concrete, shall be avoided because they are difficult for both walking and pushing a wheelchair. Slippery surfaces are to be avoided because they are hazardous to all individuals and especially hazardous for seniors and others who may not be sure-footed.
  3. Glare from polished floor surfaces is to be avoided because it can be uncomfortable for all users and can be a particular obstacle to persons with vision loss by obscuring important orientation and safety features. Pronounced colour contrast between walls and floor finishes are helpful for persons with vision loss, as are changes in colour/texture where a change in level or function occurs.
  4. Patterned floors should be avoided, as they can create visual confusion.
  5. Thick pile carpeting is to be avoided as it makes pushing a wheelchair very difficult. Small and uneven changes in floor level represent a further barrier to using a wheelchair and present a tripping hazard to ambulatory persons.
  6. Openings in any ground or floor surface such as grates or grilles are to be avoided because they can catch canes or wheelchair wheels.
  1. Universal Design Practices Beyond Typical Accessibility Requirements
  2. Areas of refuge should be provided even when a building has a sprinkler system.
  3. No hangout steps* should ever be included in the building or facility.
  4. Hangout steps are a socializing area that is sometimes used for presentations. It looks similar to bleachers. Each seating level is further away from the front and higher up but here people sit on the floor rather than on seats. Each seating level is about as deep as four stairs and about 3 stairs high. There is typically a regular staircase provided on one side that leads from the front or stage area to the back at the top. The stairs allow ambulatory people access to all levels of the seating areas, but the only seating spaces for those who use mobility assistive devices are at the front or at the top at the back but these are not integrated in any way with the other seating options.
  5. There should never be “stramps”. A stramp is a stair case that someone has built a ramp running back and forth across it. These create accessibility problems rather than solving them.
  6. Rest areas should be differentiated from walking surfaces or paths by texture- and colour-contrast
  7. Keypads angled to be usable from both a standing and a seated position
  8. Finishes
  9. No floor-to-ceiling mirrors
  10. Colour luminance contrast between:
  1. Door or door frame to wall
  2. Door hardware to door
  3. Controls to wall surfaces
  1. Furniture – Arrange seating in square arrangement so all participants can see each other for those who are lip reading or using sign language

 



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