Danger of Disability Discrimination in Access to Life-Saving Critical Medical Care Grows as Overloaded Ontario Hospitals Near the Breaking Point


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE
NEWS RELEASE – FOR IMMEDIATE RELEASE

April 8, 2021 Toronto: The newest wave of COVID is overloading Ontario intensive care units, triggering yesterday’s new provincial lockdown. The day looms dangerously closer when life-saving critical care in Ontario hospitals will be rationed or “triaged”. Yet Ontario’s mishandled critical care triage plans are an impending disaster, leading some people with disabilities to fear going to hospital. Serious concerns have been raised by disability organizations and the Ontario Human Rights Commission.

One year ago today, in an open letter to Premier Ford, over 200 community organizations first sounded the alarm that patients with disabilities will suffer disability discrimination if critical care is rationed under the Ford Government’s earlier secret triage protocol. One year later, Ford still hasn’t remove disability discrimination from the subsequent, revised January 13, 2021 critical care triage protocol that was sent to all hospitals.

Here are two examples of flagrant disability discrimination contrary to the Ontario Human Rights Code: Ontario’s January 13, 2021 critical care triage protocol improperly ranks a patient’s access to life-saving critical care lower if they are over 65, have a progressive disease, and cannot perform some or all of eleven activities of daily living without assistance, including dressing, bathing, eating, walking, getting in and out of bed, using the telephone, going shopping, preparing meals, doing housework, taking medication, or handling their own finances. As well, a cancer patient gets lower priority for critical care if they are “Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours” or if they are “Completely disabled and cannot carry out any self-care; totally confined to bed or chair”.

Under Ontario’s critical care triage protocol, each triage doctor can end up being a law unto themselves. Ontario hospitals have been quietly urged to conduct drills or simulations of how they’d choose who lives and who dies if critical care triage is ordered. This is all secret from the public. The public has a right to know whom hospitals are choosing to refuse critical care in those simulations, and how differently the same case is decided from hospital to hospital.

Ontario’s critical care triage plan does not provide patients whose life is at risk with much-needed due process and procedural fairness. Making this even worse, the Ford Government refuses to answer if critical care triage directions have been sent to ambulances, e.g. restricting which patients should be resuscitated before being taken to hospital.

There are other serious problems with Ford’s plans. The Government cannot direct which patients live or die by simply sending a memo to hospitals. Any triage protocol must be clearly mandated by valid legislation.

“Ontario must be prepared for the possibility of critical care triage, but Ontario’s plan must include a lawfully mandated triage protocol that does not violate the Charter of Rights or the Ontario Human Rights Code by discriminating against people with disabilities. They have already unfairly and disproportionately suffered from COVID-19 and from the pandemic’s worst hardships,” said David Lepofsky, Chair of the non-partisan AODA Alliance, one of the disability organizations sounding the triage alarm. “Doctors and hospitals will proceed at their peril if they use Ontario’s disability-discriminatory critical care triage protocol, which the Government has never made public, but which is revealed to all on the AODA Alliance’s website.”

A deeply-troubling January 23, 2021 online video tries to sell doctors on using the January 13, 2021 Critical Care Triage Protocol. It wrongly aims to lead doctors to think that they need not worry about inequities or the risk of legal consequences, while concealing from them that protocol’s serious human rights problems.

Some physicians have wrongly pressured the Ford Government to suspend the Health Care Consent Act so that a doctor can evict a patient from critical care who is already receiving critical care, without that patient’s consent. We oppose this and dispute that Ontario can do this. Ford hasn’t ruled this option out. Ford would be tap-dancing in a constitutional minefield to try it.

It is worrisome that Ontario is reportedly considering granting doctors some sort of blank cheque or indemnification for triage decisions to refuse a patient critical care they need. This could involve the Government paying any claims that a doctor or hospital faces for denying life-saving critical care to a patient who needs it. Such indemnification would wrongly give supreme priority to the Government protecting the income of doctors over protecting the lives of highly-vulnerable patients. Doctors should not be given immunity from the legal consequences of actions known to endanger a patient’s life. The taxpayer should not be forced to subsidize well-resourced medical insurance companies and doctors’ legal defence lawyers.

“The Ford Government’s mishandling of the critical care triage issue from the start has been plagued by harmful secrecy, evasiveness and a lack of candor,” said Lepofsky. “The Government must now rescind and fix its discriminatory January 13, 2021 critical care triage protocol, must answer our eight unanswered letters (listed below), and must directly consult the public on this issue.”

Contact: AODA Alliance Chair David Lepofsky, [email protected]

For more background
1. The AODA Alliance’s new February 25, 2021 independent report on Ontario’s plans for critical care triage if hospitals are overwhelmed by patients needing critical care.

2. Ontario’s January 13, 2021 triage protocol.

3. The eight unanswered letters from the AODA Alliance to the Ford Government on its critical care triage plan, including the AODA Alliance’s September 25, 2020 letter, its November 2, 2020 letter, its November 9, 2020 letter, its December 7, 2020 letter, its December 15, 2020 letter, its December 17, 2020 letter, its January 18, 2021 letter and its February 25, 2021 letter to Health Minister Christine Elliott.

4. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed in December 2020.

5. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.




Source link

New Report Reveals Frightening New Problems with the Ford Government’s Plans for Rationing Life-Saving Critical Medical Care if Hospitals get Overwhelmed by Another COVID-19 Surge


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE
NEWS RELEASE – FOR IMMEDIATE RELEASE

February 26, 2021 Toronto: There are frightening and indefensible new problems with the Ford Government’s plans for how to decide who lives and who dies if the COVID-19 pandemic overloads Ontario hospitals, leading to rationing or “triage” of life-saving critical care. This is revealed in an exhaustive new report made public today. This thoroughly researched report reveals that:

1. It is dangerous to relegate concern about Ontario’s critical care triage plans to the back burner, just because COVID infection rates are reducing and vaccines are gradually being distributed. There remains a real risk of another COVID-19 surge. A senior medical advisor to the Government advisor said on January 23, 2021 that such triage may already be taking place.

2. A seriously flawed, disability-discriminatory and highly objectionable online calculator has been created for triage doctors to determine who will be refused life-saving critical care during triage or rationing of critical care. Such an online calculator’s computation, based on a doctor’s keying in data, should never decide that a patient should be refused life-saving critical care they need. This is especially so when that online calculator discriminates against some patients based on their disability.

3. If hospitals start rationing or triaging critical care, there is a danger that some emergency medical technicians (EMTs) may improperly refuse to give a patient critical care they need and want before the patient even gets to the hospital an improper backdoor trickle-down form of critical care triage.

4. A transparently erroneous legal strategy has been devised for defending the legality of Ontario’s critical care triage plan. Triage doctors, hospitals and the Ontario Government are expected to argue that no one can sue them if a triage doctor refuses to give life-saving critical care to a patient who needs it and wants it, so long as they are following the January 13, 2021 Critical Care Triage Protocol (a protocol that is rife with serious problems that the AODA Alliance and other disability advocates have previously identified). They plan to say that because that document is called a “standard of care” for triage doctors (an inappropriate label for it), it provides a full defence. This new report shows that that legal defence strategy is fatally flawed.

5. A troubling January 23, 2021 webinar to train frontline critical care triage doctors wrongly minimizes the enormity of the role doctors would play, while they are making life-and-death decisions over which patients would get life-saving critical care, if critical care triage takes place. That webinar harmfully and wrongly tries to convince triage doctors not to worry about being sued, so long as they follow the January 13, 2021 Critical Care Triage Protocol. At the same time, that webinar did not alert frontline doctors to the serious disability discrimination and due process concerns that disability advocates have raised with the directions that those frontline doctors are being told to implement if critical care triage is to occur.

“We agree that Ontario must be prepared for the possibility of critical care triage, but Ontario’s plan must include a lawfully mandated triage protocol that does not violate the Charter of Rights or the Ontario Human Rights Code by discriminating against people with disabilities, who have already disproportionately suffered the hardships of the COVID-19 pandemic,” said David Lepofsky, Chair of the non-partisan AODA Alliance, which campaigns for accessibility for 2.6 million Ontarians with disabilities. “This report confirms that the Ford Government has been hearing from health professionals and their insurance representatives, but the Government needs to end its embargo on directly talking to disability community voices about this important issue. We’ve written the Ford Government, calling on it to rescind the disability-discriminatory January 13, 2021 Critical Care Triage Protocol.”

Contact: AODA Alliance Chair David Lepofsky, [email protected]

For more background on this issue, check out:
1. The AODA Alliance’s new February 25, 2021 independent report on Ontario’s plans for critical care triage if hospitals are overwhelmed by patients needing critical care, available at https://www.aodaalliance.org/whats-new/a-deeply-troubling-issue-of-life-and-death-an-independent-report-on-ontarios-seriously-flawed-plans-for-rationing-or-triage-of-critical-medical-care-if-covid-19-overwhelms-ontario-hospitals/ and the AODA Alliance’s February 25, 2021 letter to the Ford Government, sending it that report. 2. The January 13, 2021 triage protocol.
3. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.
4. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.




Source link

New Report Reveals Frightening New Problems with the Ford Government’s Plans for Rationing Life-Saving Critical Medical Care if Hospitals get Overwhelmed by Another COVID-19 Surge


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE

NEWS RELEASE – FOR IMMEDIATE RELEASE

New Report Reveals Frightening New Problems with the Ford Government’s Plans for Rationing Life-Saving Critical Medical Care if Hospitals get Overwhelmed by Another COVID-19 Surge

February 26, 2021 Toronto: There are frightening and indefensible new problems with the Ford Government’s plans for how to decide who lives and who dies if the COVID-19 pandemic overloads Ontario hospitals, leading to rationing or “triage” of life-saving critical care. This is revealed in an exhaustive new report made public today. This thoroughly researched report reveals that:

  1. It is dangerous to relegate concern about Ontario’s critical care triage plans to the back burner, just because COVID infection rates are reducing and vaccines are gradually being distributed. There remains a real risk of another COVID-19 surge. A senior medical advisor to the Government advisor said on January 23, 2021 that such triage may already be taking place.
  1. A seriously flawed, disability-discriminatory and highly objectionable online calculator has been created for triage doctors to determine who will be refused life-saving critical care during triage or rationing of critical care. Such an online calculator’s computation, based on a doctor’s keying in data, should never decide that a patient should be refused life-saving critical care they need. This is especially so when that online calculator discriminates against some patients based on their disability.
  1. If hospitals start rationing or triaging critical care, there is a danger that some emergency medical technicians (EMTs) may improperly refuse to give a patient critical care they need and want before the patient even gets to the hospital – an improper backdoor trickle-down form of critical care triage.
  1. A transparently erroneous legal strategy has been devised for defending the legality of Ontario’s critical care triage plan. Triage doctors, hospitals and the Ontario Government are expected to argue that no one can sue them if a triage doctor refuses to give life-saving critical care to a patient who needs it and wants it, so long as they are following the January 13, 2021 Critical Care Triage Protocol (a protocol that is rife with serious problems that the AODA Alliance and other disability advocates have previously identified). They plan to say that because that document is called a “standard of care” for triage doctors (an inappropriate label for it), it provides a full defence. This new report shows that that legal defence strategy is fatally flawed.
  1. A troubling January 23, 2021 webinar to train frontline critical care triage doctors wrongly minimizes the enormity of the role doctors would play, while they are making life-and-death decisions over which patients would get life-saving critical care, if critical care triage takes place. That webinar harmfully and wrongly tries to convince triage doctors not to worry about being sued, so long as they follow the January 13, 2021 Critical Care Triage Protocol. At the same time, that webinar did not alert frontline doctors to the serious disability discrimination and due process concerns that disability advocates have raised with the directions that those frontline doctors are being told to implement if critical care triage is to occur.

“We agree that Ontario must be prepared for the possibility of critical care triage, but Ontario’s plan must include a lawfully mandated triage protocol that does not violate the Charter of Rights or the Ontario Human Rights Code by discriminating against people with disabilities, who have already disproportionately suffered the hardships of the COVID-19 pandemic,” said David Lepofsky, Chair of the non-partisan AODA Alliance, which campaigns for accessibility for 2.6 million Ontarians with disabilities. “This report confirms that the Ford Government has been hearing from health professionals and their insurance representatives, but the Government needs to end its embargo on directly talking to disability community voices about this important issue. We’ve written the Ford Government, calling on it to rescind the disability-discriminatory January 13, 2021 Critical Care Triage Protocol.”

Contact: AODA Alliance Chair David Lepofsky, [email protected]

For more background on this issue, check out:

  1. The AODA Alliance’s new February 25, 2021 independent report on Ontario’s plans for critical care triage if hospitals are overwhelmed by patients needing critical care, available at https://www.aodaalliance.org/whats-new/a-deeply-troubling-issue-of-life-and-death-an-independent-report-on-ontarios-seriously-flawed-plans-for-rationing-or-triage-of-critical-medical-care-if-covid-19-overwhelms-ontario-hospitals/ and the AODA Alliance’s February 25, 2021 letter to the Ford Government, sending it that report.
  2. The January 13, 2021 triage protocol.
  3. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.
  4. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.



Source link

Today is the 40th Anniversary of Parliament Agreeing to Guarantee A Constitutional Right to Equality to People with Disabilities – A Victory Disability Advocates Now Invoke to Prevent Disability Discrimination in Access to Life-Saving Critical Care if Hospitals Start to Triage Critical Care


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE

NEWS RELEASE – FOR IMMEDIATE RELEASE

Today is the 40th Anniversary of Parliament Agreeing to Guarantee A Constitutional Right to Equality to People with Disabilities – A Victory Disability Advocates Now Invoke to Prevent Disability Discrimination in Access to Life-Saving Critical Care if Hospitals Start to Triage Critical Care

January 28, 2021 Toronto: Forty years ago today was the most important single event to protect the constitutional equality rights of millions of people with disabilities, in Canada’s first 114 years. Four decades ago today, the Joint Committee of the Senate and House of Commons on the Constitution of Canada (“the Joint Committee”) voted to add equality rights for people with disabilities to the proposed Charter of Rights, then being debated. (“The disability amendment”)

Weeks earlier, in October 1980, Prime Minister Pierre Trudeau introduced a bill into Parliament to add a new Charter of Rights to Canada’s Constitution. The proposed Charter of Rights included an equality rights provision, section 15. However, section 15 did not include equality rights for people with disabilities. Unless amended, courts could not interprete section 15 to protect disability equality.

Without the benefit of fax machines, email, the internet or social media (which were years away), people with disabilities campaigned for the disability amendment. Their blitz got little media coverage.

In fall 1980, three major disability organizations appeared before the Joint Committee to call for the disability amendment. In response, on January 12, 1981, Justice Minister Jean Chretien said no to the disability amendment.

Despite that, people with disabilities tenaciously kept up the pressure. Victory came on January 28, 1981, when the Trudeau Government withdrew its opposition to the disability amendment. That day, the Joint Committee voted to pass the disability amendment. Canada became the first western democracy to explicitly protect equality for people with disabilities in its constitution. (Hansard transcript below)

Over the forty years that followed, the disability amendment led to some important court victories for disability rights. It also helped drive the passage of several accessibility laws: Ontario’s Accessibility for Ontarians with Disabilities Act 2005, Manitoba’s Accessibility for Manitobans Act 2013, Nova Scotia’s Accessibility Act 2017, and the federal Accessible Canada Act2019.

“Canada should be proud of what was achieved forty years ago today in the name of equality and full participation for people with disabilities,” said David Lepofsky who was one of the disability advocates who appeared before Parliament to advocate for the disability amendment and who now chairs the non-partisan AODA Alliance that campaigns for disability accessibility. “However, despite the disability amendment, over six million people with disabilities in Canada still face far too many unfair barriers in areas like employment, transportation, education, health care and access to buildings. Top of mind today is the serious danger that patients with disabilities will suffer unjustified disability discrimination in access to life-saving critical medical care if the COVID-19 pandemic overloads Ontario hospitals, requiring the rationing or “triage” of critical care, dressed up as objective medical science. Those of us who fought for the disability amendment could not have imagined that forty years later, we’d need to use that victory to try to prevent disability discrimination in access to life-saving critical medical care.”

In months of public debate over the Charter of Rights four decades ago, the only new constitutional right that was added to the Charter, and which was not in the original draft, was equality for people with disabilities – something the media has also rarely covered. Even lesser known was a second disability rights victory for people who are deaf, deafened or hard of hearing at the Joint Committee four decades ago today. The Joint Committee also amended section 14 of the Charter, to guarantee the constitutional right to an interpreter for deaf persons when participating in legal proceedings. Previously, section 14’s wording did not guarantee the right to an interpreter to persons needing one due to hearing loss.

Contact: AODA Alliance Chair David Lepofsky, [email protected]

For more background, check out:

  1. Transcript of the three disability organizations’ presentations in the 1980 fall to the Joint Committee calling for the Charter disability amendment.
  1. Captioned video of the December 12, 1980 presentation by David Lepofsky to the Joint Committee, on behalf of the Canadian National Institute for the Blind. He is now chair of the AODA Alliance.
  1. Transcript of the initial refusal on January 12, 1981 by federal Justice Minister Jean Chretien to agree to the disability amendment, which he announced during his appearance before the Joint committee – a decision the Federal Government reversed forty years ago today.
  1. Online captioned lecture at the Osgoode Hall Law School by AODA Alliance Chair David Lepofsky on the history of the campaign for the Charter disability amendment.

Joint Committee of the Senate and the House of Commons of Canada on the Constitution of Canada Hansard Excerpts January 28, 1981

The following took place on Charter ss. 14 and 15 as it pertains to people with disabilities:

Mr. Robinson: Thank you, Mr. Chairman.

I would then move this amendment as follows, that Clause 14 of the proposed constitution act, 1980 be amended by striking out lines 40 to 44 on page 5 and substituting the following:

  1. Every person has the right to the assistance of an interpreter in any proceedings before a court, tribunal, commission, board or other authority in which the person is involved or is a party or a witness if the person does not understand or speak the language in which the proceedings are conducted, or is subject to a hearing impairment.

Et en français, it est proposé

Que l’article 14 du projet de Loi constitutionnelle de 1980 soit modifié par substitution, aux lignes 40 à 43, de ce qui suit:

«14. Les personnes qui ne comprennent pas ou ne parlent pas la langue dans laquelle se déroulent des procédures devant une instance judiciaire, quasi-judiciaire, administrative ou autre, ont droit à l’assistance d’un interprète; les personnes atteintes de déficiences auditives ont également ce droit dans les mêmes circonstances.»

The Joint Chairman (Mr. Joyal): Before I invite you to give an explanation, Mr. Robinson, the honourable James McGrath on a point of order.

Mr. McGrath: I am just wondering, Mr. Chairman, at first glance it would seem that our amendment, which is CP-7, Clause 14, page 5 should come first.

The Joint Chairman (Mr. Joyal): The only reason I have called the amendment proposed by the New Democratic Party, I refer to you the previous indication that the Chair would call in order the amendments, and so far as the New Democratic Party amendment deals with line 40 and your amendment deals with line 43, that is why I have to call according to the previous procedure, I have to call the New Democratic Party amendment first even though the Chair realizes that if the

[Page 84]

New Democratic Party amendment is accepted by this Committee, the amendment identified CP-7 is already included in the previous amendment, but if the amendment by the New Democratic Party is not accepted that does not prevent you from moving the amendment identified as CP-7.

Mr. Chrétien: Mr. Chairman, for a matter of clarification, you gave the background of the discussion on Clause 14. We cannot accept the amendment of Mr. Robinson and I will explain why, but we can accept the amendment of the Conservative Parvty and so perhpas we should deal with the two and I can give the explanation to Mr. Robinson so that it will not—the intention is all the same but the way of drafting one is better than the drafting of the other, and the Robinson amendment, if I can use that term, the 150th amendment, it is too vague and could create all sorts of problems.

I am informed, for example …

Mr. Robinson: Mr. Chairman, on a point of order. Mr. Chairman, with great respect to the Minister, if I might have an opportunity to at least explain the amendment before it is shot down by the Minister. That is, I believe the normal procedure.

The Joint Chairman (Mr. Joyal): I will invite Mr. Robinson to present his amendment in the usual way.

Mr. Robinson: Thank you, Mr. Chairman.

I know that the Minister still has an open mind on the subject and will be listening with great interest and will not be subject to any impairment involving hearing. it is one thing not to listen, Mr. Chairman, it is another thing to be subjected to a hearing impairment.

Mr. Chairman, the purpose of this amendment is to expand the protection presently accorded in Clause 14 to an interpreter, and it is not something which is unusual or vague or difficult to apply, as the Minister suggested, because with respect, Mr. Minister, through you, Mr. Chairman, the wording is taken precisely from the terms of Bill C-60.

Now, once again, Mr. Minister, I would have assumed that the same people who advised you on Bill C-60 would be advising you today and I am sure that they would not have wished to advise you at that time to accept something which was vague or impossible to interpret.

Mr. Chairman, it is not a question of vagueness, it is a question of scope. In Clause 14, as the amendment would read, we would be going beyond proceedings in which a person was a party or witness, but we would be going to proceedings in which a person was involved, to use the words of the proposed amendment, and we would also be expanding the words to deal with other authorities.

As I say, this is the proposal in Bill C-60, it was accepted by the MacGuigan-Lamontagne Committee, it was not considered by the government two years ago to be vague or difficult to interpret. I suggest that the amendment was reasonable and that it should be accepted. I would hope that it would be accepted by the government.

I would also say that I am pleased to hear that the government is prepared to accept the amendment with respect to

[Page 85]

deafness which is being proposed both by the Conservative Party and the New Democratic Party but I would hope that the government would recognize the desirability of expanding this in terms which it was presented in Bill C-60.

Thank you, Mr. Chairman.

The Joint Chairman (Mr. Joyal): Thank you very much, Mr. Robinson.

Mr. Chrétien: I will ask my advisor to give the explanation but the fact that it was accepted in Bill C·60, the deputy minister is not the same, perhaps he is a judge now, so we have a different troop and to explain why we feel after reflection what is better.

Mr. Ewaschuk: Obviously in relation to the proceedings the administration of justice is conducted by a provincial authorities. The expression in which the person is involved means more than the party or the witness so you can have all kinds of interested parties come to court and this would in fact give them a constitutional right to have interpreters so they could understand the proceedings.

Now, oftentimes that is so. If it is a language problem, the interpreter is there, and there is translation that goes on and there is certain accommodation, but if you were to do that for everybody who came in, who is somehow involved, they may be in fact a relative or so who does not understand the language but they are not a witness, they are not the accused and such, it could have certain important ramifications for the adminis· tration of justice and I think that the position we take is that, yes, we are not opposed to that but we would let the provincial try to work that out rather than saying that they have to in fact do it.

We say the minimal, yes, it should be for the witness, it should be for the party, extended to the deaf, but that is as far as we are willing to go at this particular time.

The Joint Chairman (Mr. Joyal): Thank you very much.

Mr. Robinson to conclude.

Mr. Robinson: Just a question, Mr. Chairman, if I may, to the officials or to the Minister.

Is it my understanding that Clause 14 as the government is proposing now would not cover the right to an interpreter of a person who is, let us say, arrested or detained; if they are being questioned, that they would not be protected by this right to an interpreter, that is my reading at least of Clause 14. Whereas, under the proposed amendment, because of the insertion of the words “or other authority” in which the person is involved, they would be protected in those circumstances?

Mr. Ewaschuk: Well, I kind of doubt that. When you are talking about procedings before another authority, I doubt that you would get a court characterizing that as being police interrogating somebody.

You must keep in mind again, and we have gone over this before, that the Crown has to prove a statement as voluntary, so if you have two English policemen who were in fact interrogating somebody who did not understand English, it is very unlikely that the judge is going to find that that statement is voluntary.

[Page 86]

So rather than say that the police have to have to bring in, anytime there is a question on whether or not somebody was being interrogated can understand English, they will do that as a matter of course if they want to get that statement in, but it would not be an absolute right in relation to proceedings because I just do not see that as being characterized as proceedings.

The Joint Chairman (Mr. Joyal): Mr. Robinson to conclude.

Mr. Robinson: Yes, Mr. Chairman.

Just to conclude, I would remind the Minister through you, Mr. Chairman, of the recent case in Toronto in which this very point was canvassed and raised in connection with an East Indian who was questioned under circumstances in which it was alleged that he did not understand the language in which he was being questioned.

I would also suggest that the words “other authority” have been interpreted by our courts to include circumstances in which a person is being questioned by the police, that the person is an authority figure, when we are dealing, for example, with confessions, and that is the way Canadian jurisprudence has interpreted those words.

I think, Mr. Chairman, with great respect to the present deputy minister, that the advice which was given in 1978 was very sound advice and I would suggest that this Committee should accept that advice.

The Joint Chairman (Mr. Joyal): Thank you, Mr. Robinson.

Amendment negatived.

The Joint Chairman (Mr. Joyal): I would like then to invite the motion identified as CP-7, Clause 14, page 5, the motion proposed by the Conservative Party to be moved and invite the Honourable James McGrath to so do.

Mr. McGrath: Mr. Chairman, before I read the amendment there is a slight change. The amendment should read “ed or who is deaf” to make it conform technically with the page.

Mr. Chairman, the amendment is as follows, I move that Clause 14 of the proposed constitution act, 1980, be amended by striking out line 43 on page 5 and substituting the following:

ed or who is deaf has the right to the assistance of an”

I will ask my colleague, Senator Tremblay, if he will read it en français, s’il vous plait.

[Translation]

Senator Tremblay: Just to please my colleague who could very well read it himself.

[Text]

Il est proposé

Que le projet de Loi constitutionnelle de 1981 …

j’imagine

[Page 87]

soit modifié par substitution …

Il faut continuer à dire 1980, n’est-ce pas? Merci, monsieur le président, de cette indication.

… soit modifié par substitution, à l’article 14, de ce qui suit:

«14. La partie ou le témoin qui ne peuvent suivre les procédures, soit parce qu’ils ne comprennent pas ou ne parlent pas la langue employée, soit parce qu’ils sont atteints de surdité, ont droit à l’assistance d’un interprète.»

[Translation]

The Joint Chairman (Mr. Joyal): Thank you, Senator Tremblay.

[Text]

Mr. McGrath, to propose the motion in the usual way?

Mr. McGrath: Thank you very much, Mr. Chairman.

I must be getting overtired or perhaps I must be developing a hearing impediment because I thought I hear the Minister say he was going to accept our amendment.

Mr. Chrétien: Yes. Yes.

Mr. McGrath: Well, Mr. Chairman, now that that fact has been so dramatically verified I expect any minute to ask the Minister to give consent to have the amendment withdrawn to be moved on a subsequent amendment. It would be more in keeping with the experience we have had here.

However, Mr. Chairman, this is a serious amendment and I am very, very encouraged by the fact that the government has seen fit to accept it because there are a number of people in this country who have a serious hearing handicap. Indeed, I stand to be corrected on this, but there are over 200,000 Canadians who are deaf or have a hearing disability to the point where they are clinically or legally deaf, and it is a serious problem because their handicap is not apparent and it becomes compounded when they are party to legal proceedings. That is why this amendment is so important.

It is not without interest to note that we are moving in the direction of recognizing the rights of these people, for example in broadcasting they have mechanical devices now in the public broadcasting system in the United States for the hard of hearing or the deaf. I understand that we are moving in that direction in Canada as well.

Mr. Chairman, I am gratified that the government has accepted our amendment and, as a matter of fact, I am speechless.

Mr. Crombie: Two good events on one motion. Two!

The Joint Chairman (Mr. Joyal): I will not speak on behalf of the government, of course, honourable James McGrath, but you might wonder why the government has changed its mind about that and I told you last week that some see the light because they found their hearts and some change their mind because they hear the voices, and that is probably what happened in the present case.

An hon. Member: I am sure they heard footsteps.

The Joint Chairman (Mr. Joyal): I see that the honourable members are ready for the vote.

Amendment agreed to.

[Page 88]

Clause 14 as amended agreed to.

On Clause 15—Equality before the law and equal protection of the law.

The Joint Chairman (Mr. Joyal): I will invite, then, honourable members to take the amendments in relation to Clause 15. There are a certain number of amendments dealing with Clause 15, especially taking into account that very clause of the proposed motion has two subclauses, Clause 15(1) and Clause 15(2), and in order to deal with the two subclauses in order I would like to invite honourable members to take the amendment identified G-20, Clause 15(1) page 6.

There are two subamendments, to that amendment. The first subamendment that the Chair will invite honourable members to take is the one identified N-21, Clause 15(1), page 6, revised, that is the one with the word “revised” on it, and the next subamendment in relation to the same main amendment is the one identified as CP—8(1), Clause 15, page 6.

So it means that the first subamendment we will be dealing with is the last one that I have mentioned, CP-8(1), Clause 15, page 6, but before we deal with that second subamendment I would like to invite Mr. Irwin to move, or Monsieur Corbin, to move the one identified G-20, subclause 15(1), Page 6.

Monsieur Corbin.

  1. Corbin: Merci, monsieur le president.

Or, je propose

Que le paragraphe 15(1) du projet de Loi constitutionnelle de 1980 soit modifié par substitution, à la rubrique qui précède la ligne 1, et aux lignes 1 à 5, page 6, de ce qui suit:

«Droits à l’égalité

  1. (1) La Loi ne fait acception de person ne et s’applique également à tous et tous ont droit à la même protection et au même bénéfice de la loi, indépendamment de toute discrimination, notamment des discriminations fondées sur la race, l’origine nationale ou ethnique, la couleur, la religion, le sexe ou l’âge.»

Mr. Chairman, I would like to move that the heading preceding Clause 15 and Clause 15(1) of the proposed constitution act, 1980, be amended by striking out the heading immediately preceding line 1 and lines 1 to 5 on page 6 and substituting the following:

“Equality Rights

  1. (1) Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex or age.”

[Translation]

Thank you, Mr. Chairman.

Le coprésident (M. Joyal): Thank you, Mr. Corbin.

[Text]

I would like to invite Mr. Robinson on behalf of the New Democratic Party to introduce the subamendment revised N-21, Clause 15(1), page 6.

Mr. Robinson: Thank you, Mr. Chairman.

[Page 89]

I am very pleased to move the subamendment as follows …

Mr. Epp: Just a point of order, Mr. Chairman.

I must have misunderstood you. I take it now that you are going to ask for the New Democratic subamendment first and then call for our subamendment to the subamendment?

The Joint Chairman (Mr. Joyal): Yes. That is what I have already stated, Mr. Epp.

Mr. Epp: I did not understand it that way. I thought you asked for our subamendment to the amendment.

The Joint Chairman (Mr. Joyal): No, that is not the way.

Go on, Mr. Robinson.

Mr. Robinson: Thank you, Mr. Chairman.

The amendment is as follows, first of all in English, this is to the proposal of the government, I move that the proposed amendment to Clause 15(1) of the proposed constitution act 1980, be amended by (a) striking out everything immediately following the words “Every individual is equal» and substituting the following:

in, before and under the law and has the right to equal protection and equal benefit of the law, and to access to employment, accommodation and public services, without unreasonable distinction on grounds including sex, race, national or ethnic origin, colour, religion or age.

And then, Mr. Chairman, there are six additional subsections. The first is: (b) adding to Clause 15(1) the following: “physical or mental disability,”; (c) adding to Clause 15(1) the following: “marital status,”; (d) adding to Clause 15(1) the following: “sexual orientation,”; (e) adding to Clause 15(1) the following: “political belief,”; (f) adding to Clause 15(1) the following: “lack of means”; and (g) moving the word “or” so that it appears immediately after the penultimate proscribed ground of discrimination.

Mr. Chairman, those are our proposed amendments to Clause 15(1) to recognize some very fundamental and important grounds of discrimination which are not recognized in the government’s proposal.

In French, Mr. Chairman, if you would like me to read this in French.

Il est proposé

Que le projet de modification du paragraphe 15 (1) du projet de Loi constitutionnelle de 1980 soit modifié par:

  1. a) substitution, à ce qui suit le membre de phrase «La loi ne fait exception de personne», de ce qui suit:

«Tous ont droit à la même protection et au même bénéfice de la loi, ainsi qu’à l’accès aux emplois, au logement et aux services publics, indépendamment de

[Page 90]

toute distinction abusive fondee notamment sur le sexe, la race, l’origine nationale ou ethnique, la couleur, la religion ou l’âge.»

  1. b) adjonction, au paragraphe 15 (1), de ce qui suit: «les déficiences physiques ou mentales,»
  2. c) adjonction, au paragraphe 15 (1), de ce qui suit: «la situation familiale,»
  3. d) adjonction, au paragraphe 15 (1), de ce qui suit: «l’inclination sexuelle,»
  4. e) adjonction, au paragraphe 15 (1), de ce qui suit: «les croyances politiques,»
  5. f) adjonction, au paragraphe 15 (1), de ce qui suit: «l’insuffisance de moyens.»
  6. g) insertion de la conjonction «or» avant la dernière distinction discriminatoire énoncée au paragraphe 15 (1) tel que modifié.

Monsieur le president, je crois que cela doit etre «ou» et non’ pas «or».

Mr. Chairman, again these are proposed additions and changes to Clause 15(1) and I am very pleased to note that the Conservative Party will also be proposing the addition of physical and mental disability, supporting our amendment on that particular subclause.

The Joint Chairman (Mr. Joyal): Thank you, Mr. Robinson.

I would like to invite the honourable James McCrath to move the amendment on behalf of the Conservative Party.

Mr. McGrath: Mr. Chairman, my colleague, Mr. Crombie will do so.

The Joint Chairman (Mr. Joyal): The honourable David Crombie.

Mr. Crombie: Thank you, Mr. Chairman.

Mr. Chairman, dealing with Clause 15 and our amendment to it, which is numbered CP-8(1) on the sheet, I wish to move that the proposed amendment to Clause 15 of the proposed constitution act, 1980, be amended by striking out the words “or age” in Clause 15(1) thereof and substituting therefor the following words:

age or mental or physical disability.

En français, il est proposé

Que le projet de modification de I’article 15 du porjet de loi constitution ne! de 1980 soit modi fie par la substitution, a «ou l’âge», au paragraphe (1), de «l’âge ou les déficiences mentales ou physiques.»

Mr. Chairman, speaking to the motion, my understanding is that the government is willing to accept our amendment.

Now, I am not sure we can continue to take this prosperity any longer!

However, on behalf of those groups, organizations and individuals who find themselves physically and mentally dis-

[Page 91]

abled in this country, I would like, on their behalf, since I am the spokesman on their behalf at this point, to offer my thanks to the government for their acceptance of the amendment.

Thank you very much.

The Joint Chairman (Mr. Joyal): Thank you, the honourable David Crombie.

Mr. Chrétien: But who told you that I have accepted the amendment. I have not yet spoken. I think it was a good put on.

Mr. Crombie: I have already spoken to Bob Kaplan and he has said it is okay!

Mr. Chrétien: If I can have five minutes I will call the Prime Minister.

It is with great pleasure that I accept the amendment on behalf of the Government.

I do not think we should debate it. There was a great deal of debate. I was very anxious that we should proceed tonight. They were preparing to have a big group tomorrow.

You can have lots of beer on my health.

Thank you for your good representation.

The Joint Chairman (Mr. Joyal): So the amendment is carried, I should say wholeheartedly with unanimous consent.

Amendment agreed to.

The Joint Chairman (Mr. Joyal): I would like, then, to invite honourable members to come back to the first subamendment and to invite Mr. Robinson to introduce the amendment in the usual way.

Mr. Robinson: Thank you, Mr. Chairman.

I certainly would like to express my sincere gratitude to the Minister for listening to the concerns of both the physically and mentally disabled.

I know the Minister will recognize that this is in many ways unprecedented and a historic occasion, because it is a right which has not yet been recognized in many international covenants and charters; I think the Minister and the government deserves full credit for accepting the recommendations of the subcommittee and of many other Canadians.

Certainly, I want to join with my colleague and friend, Mr. Crombie, in thanking you, Mr. Minister, for accepting this very important amendment.

Mr. Chrétien: I forgot to mention, with your permission, Mr. Chairman, that I think we should thank all the members of the special committee, presided over by Mr. David Smith, who has worked very hard indeed.

I would like to thank Mr. Smith and all members of the Committee who have worked all summer very hard on the problem.

We are entering a new field, and quite properly breaking good ground. I think we should be careful that we should not take it to the extent of opening the door to a list that would be meaningless. It is on the list as an amendment which will be accepted.

[Page 92]

Mr. Robinson: Once again, Mr. Chairman, I know that the Minister will listen carefully to the representations made on the amendment which we will be proposing, just as he has listened with care to the representations of the groups representing the physically and mentally disabled.

Mr. Chairman, I also cannot resist pointing out that this fundamental right to protection from discrimination on grounds of physical and mental disability is surely one which should be accorded to all Canadians right across Canada, in every province in Canada, and that no provincial government should be permitted to opt out of providing basic and fundamental rights and freedoms to the handicapped.

Mr. Chairman, perhaps my Conservative colleagues would pay particular attention to that point, that the effect of their proposed amending formula, would grant rights to the handicapped in some provinces and not to the handicapped in other provinces which chose to opt out.

The Joint Chairman (Mr. Joyal): Mr. Robinson, I regret to interrupt, but as I have already expressed on other occasions, I think you should address yourself to the content of the proposed amendment.

The amending formula will come later on in our discussions; but at this point we are dealing on a clause which does not have any reference to the amending formula as such.

I would invite you to restrict your remarks to the contents of the proposed amendment.



Source link

CBC Program Reveals Disturbing Fact that, Far From Objective Scientific Decisions, Ontario Critical Care Triage Could Involve Doctors Guesstimating and Improvising When Deciding Which Patients Should be Refused Life-Saving Critical Medical Care They Need


And Other News on The Triage Issue

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

January 25, 2021

SUMMARY

The controversy keeps swirling around the Doug Ford Government’s secretive handling of the life-and-death question of who will be refused life-saving critical medical care if those services must be triaged or rationed, and the danger of disability discrimination, because the Government did not ensure sufficient hospital services for all who need them. Here are the three newest developments on this front.

1. The Friday, January 22, 2021 edition of CBC Radio’s health program, White Coat Black Art was devoted to the topic of how decisions will be made over who lives and who dies if the COVID-19 pandemic leads hospitals to have to ration or triage life-saving critical medical care. In his introduction, typically written after interviews were recorded, Dr. Goldman described how hospital case loads are growing, and stated:

Last week, hospitals in Ontario were given ICU (i.e. Intensive Care Unit) triage protocols from the Ministry of Health. A similar document was given to hospitals in Quebec earlier this month. These documents, which are backed by science, tell doctors how likely patients are to live or die, if they are admitted to the ICU.

Yet there is ample room from our own investigations and from Dr. Goldman’s interview that followed to question how much the Ontario triage protocol is backed by science, as opposed to a dangerous mirage of science that disguises the palpable danger of disability discrimination. Far from objective science, this program shows that triage decisions over who lives and who dies can be potentially expected to include doctors guestimating and improvising. Doctors and medicine do not have provably objective and reliable tools for predicting whether a critical care patient is likely to live beyond the next year.

This is proven by Dr. Goldman’s first guest on his program, Dr. Michael Warner, the Medical Director of Critical Care at Toronto’s Michael Garron Hospital. Describing how the January 13, 2021 triage protocol would work, he stated in part:

What’s different now is we have to essentially guesstimate what would happen a year from now. He explained that this is not how treatment decisions are now made, and that doing this would be very difficult to do because doctors will be very busy caring for patients, and not all patients will have this protocol. This head of a Toronto hospital’s ICU said candidly that he is not sure how they would action this in real life because it’s a policy on paper

Dr. Goldman asked Dr. Warner how confident he is that emergency doctors can use these new rules accurate in a chaotic and stressful environment like an emergency room. Dr. Warner responded in part:

so it’s hard to know how we would be able to effectively use a tool that’s written on a piece of paper, where two doctors have to verify someone’s mortality risk and then decide on what to do, if there are patients everywhere, you know, potentially dying. You know, I think we need something written down on paper, so that all these stakeholders can review it and provide their input, but at the end of the day, if we ever have to use it, we may have to improvise..

It is very good that this program addressed this topic. However, this program’s content was utterly lacking in desperately-needed and fundamental journalistic balance. The program’s host, Dr. Brian Goldman, only interviewed doctors, but no one from the disability community who have been raising serious concerns about disability discrimination.

That flew in the face of the program’s weekly opening line, which proclaims Welcome to White Coat Black Art, the show about medicine from all sides of the gurney. Contrary to its stated prime directive, this edition of that program took a selective look at this important issue from only one side of the gurney, that of the doctors. We have been reaching out to Dr. Goldman for months to cover the disability discrimination concerns with Ontario’s critical care triage protocol. The need for such was even flagged for the program by one of its two guests, Dr. Warner. In the only brief reference to disability perspectives on this entire program, Dr. Warner commendably stated on his own initiative:

I think that disability and other advocates should definitely educate us on how this policy may not meet the needs of all patients so that it could be fair and equitable

CBC knows well about disability community advocacy on the triage issue. This is even more troubling given the difficulty we and the disability community have had for months in getting the media to cover this issue, which has been looming throughout the pandemic.

2. Today, Ontario’s New Democratic Party commendably made public a letter sent by NDP Leader Andrea Horwath and NDP Disabilities Critic Joel Harden to Ontario Health Minister Christine Elliott. Set out below, that letter asks the Government to answer vital questions on this life-and-death issue which the Government has not answered to date. We thank the NDP for publicly asking these questions, and for endorsing the concerns on this issue that the AODA Alliance has been raising from the perspective of people with disabilities. We urge the Ford Government to end its protracted secrecy on this topic, and provide full and prompt answers.

3. The January 23, 2021 edition of the National Post included an extensive article on this issue, also below. It quoted AODA Alliance Chair David Lepofsky on some of our many concerns with the Government’s January 13, 2021 triage protocol.
We spelled those concerns out in the AODA Alliance’s January 18, 2021 letter to Health Minister Christine Elliott within days of receiving a leaked copy of that previously secret critical care triage protocol.

There have now been 725 days, or over 23 months, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no comprehensive plan of new action to implement that report. That makes still worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis, that we have been trying to address over the past eleven months.

For more background on this issue, check out:

1. The new January 13, 2021 triage protocol which the AODA Alliance received, is now making public, and has asked the Ford Government to verify. We have only acquired this in PDF format, which lacks proper accessibility. We gather some others in the community now have this document as well.

2. The AODA Alliance’s January 18, 2021 news release on the January 13, 2021 triage protocol.

3. The panel on critical care triage, including AODA Alliance Chair David Lepofsky, on the January 13, 2021 edition of TVO’s The Agenda with Steve Paikin.

4. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.

5. The AODA Alliance website’s health care web page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.

MORE DETAILS

January 22, 2021 Letter to Ontario Health Minister from Ontario New Democratic Party

Ministry of Health
5th Floor
777 Bay St.
Toronto, ON M7A 2J3

January 22, 2021

Dear Minister Elliott,

We are writing to you regarding the critical care triage protocol for Ontario hospitals in case of a major COVID-19 surge. With the latest modelling showing that ICUs may be full by early February, the prospect that doctors will have to make life and death decisions about who receives critical care and who doesn’t is not just hypothetical, it could become a reality.

On January 18, we obtained and made public a document dated January 13 written by the COVID-19 Critical Care Command Centre and issued to hospitals. It provides guidance on how hospitals should triage ICU patients in the awful event that emergency rooms are overwhelmed by COVID cases.

Disability rights organizations, including the AODA Alliance, have raised important concerns with the document. Firstly, that it was drafted in secret without the government consulting directly with disability organizations. Second, that it opens the door to discrimination on the basis of disability in the allocation of life-saving care. Finally, it does not offer patients a right of appeal outside the healthcare system, either to an independent tribunal or a court.

Instead of addressing these substantive concerns, we were puzzled by a Ministry of Health spokesperson distancing your government from the document altogether. The Ministry maintains that it is not a triage protocol, despite the fact that it lays out how hospitals should triage critical care patients. Your spokesperson also claimed that the document was not approved or endorsed by the Ministry of Health, even though it was authored by the Critical Care Command Centre your government created.

To this end, we would like you to answer the following questions: Your government says it has not approved the January 13 triage protocol, but it is in doctors’ hands right now. Will you rein in any bodies claiming to instruct hospitals on triage, and revoke the January 13 protocol?

The National Post has reported that the government’s Bioethics Table recommended temporarily suspending the law which requires patient or family consent before life-sustaining treatment is withdrawn from a critical care patient. Is your government considering this and if so, will you immediately publicize any regulations or legislation under consideration for public discussion about this life and death matter?

The Premier promised complete transparency at the start of this pandemic but Minster, your government’s approach to clinical triage has been anything but transparent. The public has a right to know what hospitals are being told to do in the event of a major COVID surge, who is telling them to do so, and to be consulted so that any protocol respects the human rights of all Ontarians, particularly those with disabilities.

We look forward to your response.

Sincerely,

Andrea Horwath Joel Harden
Leader of the Official Opposition MPP, Ottawa Centre

National Post January 23, 2021

A plan of last resort: Choosing who lives and dies if ICUs are overrun; Random selection
Graphic: Nathan Denette, The Canadian Press / If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.

It’s not quite drawing names from a hat.

But if COVID-19 pushes hospitals to crisis levels, Ontario hospitals have been instructed that, when faced with tiebreaking situations –
one empty bed in the ICU, and two, four or more critically sick people with more or less equal chances of surviving competing for it – random selection should be applied.

Each person would be assigned a number. The administrator on call would enter the numbers in a random number generator like random.org, and then click the “generate” button.

“Randomization is efficient when decisions need to be made rapidly,” reads a critical care rationing plan prepared for Ontario hospitals designed to help doctors decide who should get access to beds, intensive care or ventilators in the event of a catastrophic COVID-19 surge. Randomization avoids power struggles between doctors, the document continues. It eliminates explicit or unconscious bias and, critically, reduces the moral and psychological burden of deciding whom, ultimately, wins the bed. Who gets a chance at living.

It may sound dystopian and dehumanized. But far worse than a random number generator would be a human being having to choose, said Dr. Judy Illes, a professor of neurology at the University of British Columbia. “Because the people who have to administer those decisions are hugely at risk for moral distress and trauma.”

Doctors in Canada have never faced critical care rationing. There is no historical precedent. If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.

And while thousands of people aren’t getting the timely care they need – knee surgeries, hip replacements, the start of new experimental drug regimes, because of backlogs when hospitals shut down to all but urgent care – most people in Canada have never had to worry about getting rationed for life-saving care.

Critical care triage protocols, like those now being distributed to Ontario and Quebec hospitals, are formed from lessons learned in battle fields and natural disasters. “But it will be no less heart-wrenching in this situation, and maybe even more so,” because the decisions will be taken in urban hospitals, Illes said, not in fields with grenades going off.

“It’s not a question of will the public cooperate? The public will have no choice,” said Illes, who warns that our autonomy will be eroded if we don’t take better control of the situation.

Nothing is fair about COVID-19, Illes and UBC political science professor Max Cameron wrote in April, and now, nine months out, aggressive mutations are spreading. Hospitalizations and deaths are increasing. An average of 878 people were being treated in ICUs each day during the past seven days. Healthcare workers are frightened, anxious, exhausted. Social distancing is slipping, Peter Loewen reported this week in Public Policy Forum; and most Canadians won’t be vaccinated until the end of September. Ten months into the pandemic, “and there are 10 months to go,” wrote Loewen, a political science professor at the University of Toronto. “This is halftime.”

Meanwhile, Ontario surpassed 250,000 confirmed infections, Quebec a breath away from the same grim mark, and while Quebec’s health ministry told the National Post Friday the province is still a long way from triggering its ICU prioritization protocol, doctors are nervously looking at the U.K, where a new variant is turning some hospitals into “war zones.”

“We want to avoid being patients,” Illes said. “We want to exercise our autonomy to help everyone get through this viral war that we’re in and that we’re not winning right now.”

If people don’t double down on distancing and masking and other precautions, choice will no longer be relevant, she said. “Procedures will take over; protocols will supersede choice. And the focus will be on this public-centred approach, maximizing the most good for the most number of people.”

The Ontario ICU triage protocol, used as a model for triage protocols adopted in Quebec, prioritizes those with the greatest likelihood of survival. (It applies to adults only, not children). People who have a high likelihood of dying within 12 months of the onset of their critical illness would be assigned lower priority for critical care. Doctors would score each person on a “short-term mortality risk assessment,” and across a whole range of different conditions – cancer, heart failure, organ failure, trauma, stroke or severe COVID-19 – ideally before they are intubated, connected to a ventilator. It aims to reduce “preventable deaths to the degree possible” under major surge conditions, with the “least infringement of human rights.” Consultant doctors would be available 24/7 to provide a timely (within the hour) estimate of a person’s survival, “recognizing that such estimates may not be perfect,” but likely more accurate than non-expert judgment. In the final “summary and care plan,” one of two boxes would be checked: the patient will, or will not be offered critical care. Those who don’t meet “prioritization criteria” won’t be abandoned. They’ll receive appropriate medical therapy and/or comfort care.

Most controversially is what is not included in the current plan – a recommendation before the Ontario government that life-support be withdrawn from people already in the ICU whose chances of survival are low, if someone with better prospects is waiting behind them.

The Post reported this week that Ontario Premier Doug Ford’s government is being asked by its external advisory COVID-19 Bioethics Table to pass an “executive order” that would permit doctors, without the consent of patients or families, to remove breathing tubes, switch off ventilators and withdraw other life-saving care from people who are deteriorating, and where further treatment seems futile, so that someone who otherwise might live can take their place.

Withdrawing treatment from someone who hasn’t consented to it could be argued to be culpable homicide, said disability rights advocate David Lepofsky. “There are huge legal questions here, and they need to be discussed in the open, because we’re talking about possibly taking an active action that could accelerate someone’s death,” he said.

“The government can’t decide on who lives and who dies by a memo, written in secret, with no debate in the legislature.”

Under normal conditions, withdrawing treatment without consent would be an “illegitimate choice,” Annette Dufner, of the University of Bonn, wrote in the journal Bioethics. Even in a pandemic, doctors might risk legal charges.

“At the same time, it is by no mean obvious that patients already under treatment in a setting of scarcity have the same moral claim on the respective medical resources they would normally have,” Dufner wrote. When scarce, “the use of resources can, after all, come at the cost of other patients’ lives.”

Any suspension of the consent act would be temporary, said Dr. James Downar, a member of Ontario’s Bioethics Table “And, to be super clear: if there are enough resources for everybody, this never happens.”

Outside the horror of having to choose, even the practicalities of deciding who gets an ICU bed and who should be “discharged” – the dispassionate euphemism for stopping intensive care – “these kinds of equitable, distributive justice kinds of decisions are very, very complicated,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.

And how will patients, and families, be told that, “by virtue of this decree” you will, or will not, receive life-saving care? “I don’t know how it’s going to be done,” Goldberg said. “No one has ever done this.”

“Families will presumably have heard about this, from the press. But they may not. They may think this is science fiction. They may go to the courts, and I don’t know what the courts are even going to say in this case.”

Goldberg has never had to take community needs, values or resources into consideration when caring for the critically ill. “Never. Zero. When I have discussions with patients and families, my perspective is always deontological,” what’s best for the person lying in that hospital bed. That “duty to the patient” is now being supplanted by a utilitarian view that says we need to rescue the most lives, he said.

“I understand it, intellectually. But from a physician point of view that I was taught all these years, and from my own personal perspective, it’s just anathema.”

He takes comfort that admissions to his hospitals are coming down. He’s hoping it’s a trend. “The kids went back to school in Quebec yesterday, the high schoolers. The epidemiologists are telling us we may see a blip in 10 days or two weeks if schools really are a reservoir.”

“We’re waiting. We’re not putting our cards away. But we can’t get far enough away from this.”

Triage protocols, medically-guided protocols that are blind to disability, socio-economic status, cultural origin, are the only way to manage and mitigate the moral distress facing the people who will have to enact them, Illes said. “At the end of the day, it is physicians on the front line in the ICU with blood flowing on the floor who will bear the burden of decision-making.”

“How do we protect families from moral distress? I don’t know. No protocol is going to help anyone to understand that the people who cared for their loved person weren’t able to take the last-mile possible saving procedure,” she said.

“Let’s try to avoid ever going there.”

National Post

Sharon Kirkey




Source link

CBC Program Reveals Disturbing Fact that, Far From Objective Scientific Decisions, Ontario Critical Care Triage Could Involve Doctors Guesstimating and Improvising When Deciding Which Patients Should be Refused Life-Saving Critical Medical Care They Need – And Other News on The Triage Issue


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/

CBC Program Reveals Disturbing Fact that, Far From Objective Scientific Decisions, Ontario Critical Care Triage Could Involve Doctors Guesstimating and Improvising When Deciding Which Patients Should be Refused Life-Saving Critical Medical Care They Need – And Other News on The Triage Issue

January 25, 2021

            SUMMARY

The controversy keeps swirling around the Doug Ford Government’s secretive handling of the life-and-death question of who will be refused life-saving critical medical care if those services must be triaged or rationed, and the danger of disability discrimination, because the Government did not ensure sufficient hospital services for all who need them. Here are the three newest developments on this front.

  1. The Friday, January 22, 2021 edition of CBC Radio’s health program, “White Coat Black Art” was devoted to the topic of how decisions will be made over who lives and who dies if the COVID-19 pandemic leads hospitals to have to ration or triage life-saving critical medical care. In his introduction, typically written after interviews were recorded, Dr. Goldman described how hospital case loads are growing, and stated:

“Last week, hospitals in Ontario were given ICU (i.e. Intensive Care Unit) triage protocols from the Ministry of Health. A similar document was given to hospitals in Quebec earlier this month. These documents, which are backed by science, tell doctors how likely patients are to live or die, if they are admitted to the ICU.”

Yet there is ample room from our own investigations and from Dr. Goldman’s interview that followed to question how much the Ontario triage protocol is “backed by science”, as opposed to a dangerous mirage of science that disguises the palpable danger of disability discrimination. Far from objective science, this program shows that triage decisions over who lives and who dies can be potentially expected to include doctors guestimating and improvising. Doctors and medicine do not have provably objective and reliable tools for predicting whether a critical care patient is likely to live beyond the next year.

This is proven by Dr. Goldman’s first guest on his program, Dr. Michael Warner, the Medical Director of Critical Care at Toronto’s Michael Garron Hospital. Describing how the January 13, 2021 triage protocol would work, he stated in part:

“What’s different now is we have to essentially guesstimate what would happen a year from now.” He explained that this is not how treatment decisions are now made, and that doing this would be “very difficult to do…” because doctors will be very busy caring for patients, and not all patients will have this protocol. This head of a Toronto hospital’s ICU said candidly that he is not sure how they would action this in real life “because it’s a policy on paper…”

Dr. Goldman asked Dr. Warner how confident he is that emergency doctors can use these new rules accurate in a chaotic and stressful environment like an emergency room. Dr. Warner responded in part:

“…so it’s hard to know how we would be able to effectively use a tool that’s written on a piece of paper, where two doctors have to verify someone’s mortality risk and then decide on what to do, if there are patients everywhere, you know, potentially dying. You know, I think we need something written down on paper, so that all these stakeholders can review it and provide their input, but at the end of the day, if we ever have to use it, we may have to improvise..”

It is very good that this program addressed this topic. However, this program’s content was utterly lacking in desperately-needed and fundamental journalistic balance. The program’s host, Dr. Brian Goldman, only interviewed doctors, but no one from the disability community who have been raising serious concerns about disability discrimination.

That flew in the face of the program’s weekly opening line, which proclaims “Welcome to White Coat Black Art, the show about medicine from all sides of the gurney.” Contrary to its stated prime directive, this edition of that program took a selective look at this important issue from only one side of the gurney, that of the doctors. We have been reaching out to Dr. Goldman for months to cover the disability discrimination concerns with Ontario’s critical care triage protocol. The need for such was even flagged for the program by one of its two guests, Dr. Warner. In the only brief reference to disability perspectives on this entire program, Dr. Warner commendably stated on his own initiative:

“…I think that disability and other advocates should definitely educate us on how this policy may not meet the needs of all patients so that it could be fair and equitable…”

CBC knows well about disability community advocacy on the triage issue. This is even more troubling given the difficulty we and the disability community have had for months in getting the media to cover this issue, which has been looming throughout the pandemic.

  1. Today, Ontario’s New Democratic Party commendably made public a letter sent by NDP Leader Andrea Horwath and NDP Disabilities Critic Joel Harden to Ontario Health Minister Christine Elliott. Set out below, that letter asks the Government to answer vital questions on this life-and-death issue which the Government has not answered to date. We thank the NDP for publicly asking these questions, and for endorsing the concerns on this issue that the AODA Alliance has been raising from the perspective of people with disabilities. We urge the Ford Government to end its protracted secrecy on this topic, and provide full and prompt answers.
  1. The January 23, 2021 edition of the National Post included an extensive article on this issue, also below. It quoted AODA Alliance Chair David Lepofsky on some of our many concerns with the Government’s January 13, 2021 triage protocol.

We spelled those concerns out in the AODA Alliance’s January 18, 2021 letter to Health Minister Christine Elliott within days of receiving a leaked copy of that previously secret critical care triage protocol.

There have now been 725 days, or over 23 months, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no comprehensive plan of new action to implement that report. That makes still worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis, that we have been trying to address over the past eleven months.

For more background on this issue, check out:

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

            MORE DETAILS

 January 22, 2021 Letter to Ontario Health Minister from Ontario New Democratic Party

Ministry of Health

5th Floor

777 Bay St.

Toronto, ON M7A 2J3

January 22, 2021

Dear Minister Elliott,

We are writing to you regarding the critical care triage protocol for Ontario hospitals in case of a major COVID-19 surge. With the latest modelling showing that ICUs may be full by early February, the prospect that doctors will have to make life and death decisions about who receives critical care and who doesn’t is not just hypothetical, it could become a reality.

On January 18, we obtained and made public a document dated January 13 written by the COVID-19 Critical Care Command Centre and issued to hospitals. It provides guidance on how hospitals should triage ICU patients in the awful event that emergency rooms are overwhelmed by COVID cases.

Disability rights organizations, including the AODA Alliance, have raised important concerns with the document. Firstly, that it was drafted in secret without the government consulting directly with disability organizations. Second, that it opens the door to discrimination on the basis of disability in the allocation of life-saving care. Finally, it does not offer patients a right of appeal outside the healthcare system, either to an independent tribunal or a court.

Instead of addressing these substantive concerns, we were puzzled by a Ministry of Health spokesperson distancing your government from the document altogether. The Ministry maintains that it is not a triage protocol, despite the fact that it lays out how hospitals should triage critical care patients. Your spokesperson also claimed that the document was “not approved or endorsed by the Ministry of Health”, even though it was authored by the Critical Care Command Centre your government created.

To this end, we would like you to answer the following questions: Your government says it has not approved the January 13 triage protocol, but it is in doctors’ hands right now. Will you rein in any bodies claiming to instruct hospitals on triage, and revoke the January 13 protocol?

The National Post has reported that the government’s Bioethics Table recommended temporarily suspending the law which requires patient or family consent before life-sustaining treatment is withdrawn from a critical care patient. Is your government considering this and if so, will you immediately publicize any regulations or legislation under consideration for public discussion about this life and death matter?

The Premier promised “complete transparency” at the start of this pandemic but Minster, your government’s approach to clinical triage has been anything but transparent. The public has a right to know what hospitals are being told to do in the event of a major COVID surge, who is telling them to do so, and to be consulted so that any protocol respects the human rights of all Ontarians, particularly those with disabilities.

We look forward to your response.

Sincerely,

Andrea Horwath                                                                                Joel Harden

Leader of the Official Opposition                                                      MPP, Ottawa Centre

 National Post January 23, 2021

A plan of last resort: Choosing who lives and dies if ICUs are overrun; Random selection

Graphic: Nathan Denette, The Canadian Press / If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.

It’s not quite drawing names from a hat.

But if COVID-19 pushes hospitals to crisis levels, Ontario hospitals have been instructed that, when faced with tiebreaking situations – one empty bed in the ICU, and two, four or more critically sick people with more or less equal chances of surviving competing for it – random selection should be applied.

Each person would be assigned a number. The administrator on call would enter the numbers in a random number generator like random.org, and then click the “generate” button.

“Randomization is efficient when decisions need to be made rapidly,” reads a critical care rationing plan prepared for Ontario hospitals designed to help doctors decide who should get access to beds, intensive care or ventilators in the event of a catastrophic COVID-19 surge. Randomization avoids power struggles between doctors, the document continues. It eliminates explicit or unconscious bias and, critically, reduces the moral and psychological burden of deciding whom, ultimately, wins the bed. Who gets a chance at living.

It may sound dystopian and dehumanized. But far worse than a random number generator would be a human being having to choose, said Dr. Judy Illes, a professor of neurology at the University of British Columbia. “Because the people who have to administer those decisions are hugely at risk for moral distress and trauma.”

Doctors in Canada have never faced critical care rationing. There is no historical precedent. If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.

And while thousands of people aren’t getting the timely care they need – knee surgeries, hip replacements, the start of new experimental drug regimes, because of backlogs when hospitals shut down to all but urgent care – most people in Canada have never had to worry about getting rationed for life-saving care.

Critical care triage protocols, like those now being distributed to Ontario and Quebec hospitals, are formed from lessons learned in battle fields and natural disasters. “But it will be no less heart-wrenching in this situation, and maybe even more so,” because the decisions will be taken in urban hospitals, Illes said, not in fields with grenades going off.

“It’s not a question of will the public cooperate? The public will have no choice,” said Illes, who warns that our autonomy will be eroded if we don’t take better control of the situation.

Nothing is fair about COVID-19, Illes and UBC political science professor Max Cameron wrote in April, and now, nine months out, aggressive mutations are spreading. Hospitalizations and deaths are increasing. An average of 878 people were being treated in ICUs each day during the past seven days. Healthcare workers are frightened, anxious, exhausted. Social distancing is slipping, Peter Loewen reported this week in Public Policy Forum; and most Canadians won’t be vaccinated until the end of September. Ten months into the pandemic, “and there are 10 months to go,” wrote Loewen, a political science professor at the University of Toronto. “This is halftime.”

Meanwhile, Ontario surpassed 250,000 confirmed infections, Quebec a breath away from the same grim mark, and while Quebec’s health ministry told the National Post Friday the province is still a long way from triggering its ICU prioritization protocol, doctors are nervously looking at the U.K, where a new variant is turning some hospitals into “war zones.”

“We want to avoid being patients,” Illes said. “We want to exercise our autonomy to help everyone get through this viral war that we’re in and that we’re not winning right now.”

If people don’t double down on distancing and masking and other precautions, choice will no longer be relevant, she said. “Procedures will take over; protocols will supersede choice. And the focus will be on this public-centred approach, maximizing the most good for the most number of people.”

The Ontario ICU triage protocol, used as a model for triage protocols adopted in Quebec, prioritizes those with the greatest likelihood of survival. (It applies to adults only, not children). People who have a high likelihood of dying within 12 months of the onset of their critical illness would be assigned lower priority for critical care. Doctors would score each person on a “short-term mortality risk assessment,” and across a whole range of different conditions – cancer, heart failure, organ failure, trauma, stroke or severe COVID-19 – ideally before they are intubated, connected to a ventilator. It aims to reduce “preventable deaths to the degree possible” under major surge conditions, with the “least infringement of human rights.” Consultant doctors would be available 24/7 to provide a timely (within the hour) estimate of a person’s survival, “recognizing that such estimates may not be perfect,” but likely more accurate than non-expert judgment. In the final “summary and care plan,” one of two boxes would be checked: the patient will, or will not be offered critical care. Those who don’t meet “prioritization criteria” won’t be abandoned. They’ll receive appropriate medical therapy and/or comfort care.

Most controversially is what is not included in the current plan – a recommendation before the Ontario government that life-support be withdrawn from people already in the ICU whose chances of survival are low, if someone with better prospects is waiting behind them.

The Post reported this week that Ontario Premier Doug Ford’s government is being asked by its external advisory COVID-19 Bioethics Table to pass an “executive order” that would permit doctors, without the consent of patients or families, to remove breathing tubes, switch off ventilators and withdraw other life-saving care from people who are deteriorating, and where further treatment seems futile, so that someone who otherwise might live can take their place.

Withdrawing treatment from someone who hasn’t consented to it could be argued to be culpable homicide, said disability rights advocate David Lepofsky. “There are huge legal questions here, and they need to be discussed in the open, because we’re talking about possibly taking an active action that could accelerate someone’s death,” he said.

“The government can’t decide on who lives and who dies by a memo, written in secret, with no debate in the legislature.”

Under normal conditions, withdrawing treatment without consent would be an “illegitimate choice,” Annette Dufner, of the University of Bonn, wrote in the journal Bioethics. Even in a pandemic, doctors might risk legal charges.

“At the same time, it is by no mean obvious that patients already under treatment in a setting of scarcity have the same moral claim on the respective medical resources they would normally have,” Dufner wrote. When scarce, “the use of resources can, after all, come at the cost of other patients’ lives.”

Any suspension of the consent act would be temporary, said Dr. James Downar, a member of Ontario’s Bioethics Table “And, to be super clear: if there are enough resources for everybody, this never happens.”

Outside the horror of having to choose, even the practicalities of deciding who gets an ICU bed and who should be “discharged” – the dispassionate euphemism for stopping intensive care – “these kinds of equitable, distributive justice kinds of decisions are very, very complicated,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.

And how will patients, and families, be told that, “by virtue of this decree” you will, or will not, receive life-saving care? “I don’t know how it’s going to be done,” Goldberg said. “No one has ever done this.”

“Families will presumably have heard about this, from the press. But they may not. They may think this is science fiction. They may go to the courts, and I don’t know what the courts are even going to say in this case.”

Goldberg has never had to take community needs, values or resources into consideration when caring for the critically ill. “Never. Zero. When I have discussions with patients and families, my perspective is always deontological,” what’s best for the person lying in that hospital bed. That “duty to the patient” is now being supplanted by a utilitarian view that says we need to rescue the most lives, he said.

“I understand it, intellectually. But from a physician point of view that I was taught all these years, and from my own personal perspective, it’s just anathema.”

He takes comfort that admissions to his hospitals are coming down. He’s hoping it’s a trend. “The kids went back to school in Quebec yesterday, the high schoolers. The epidemiologists are telling us we may see a blip in 10 days or two weeks if schools really are a reservoir.”

“We’re waiting. We’re not putting our cards away. But we can’t get far enough away from this.”

Triage protocols, medically-guided protocols that are blind to disability, socio-economic status, cultural origin, are the only way to manage and mitigate the moral distress facing the people who will have to enact them, Illes said. “At the end of the day, it is physicians on the front line in the ICU with blood flowing on the floor who will bear the burden of decision-making.”

“How do we protect families from moral distress? I don’t know. No protocol is going to help anyone to understand that the people who cared for their loved person weren’t able to take the last-mile possible saving procedure,” she said.

“Let’s try to avoid ever going there.”

National Post

Sharon Kirkey



Source link

Even More Reason to Worry About Secret Ontario Plans Regarding Rationing or Triage of Life-Saving Critical Medical Care Is Revealed in Two Newspaper Articles and a Letter Secretly Sent to Ontario Hospitals


Accessibility for Ontarians with Disabilities Act Alliance Update

United for a Barrier-Free Society for All People with Disabilities

Web: www.aodaalliance.org Email: [email protected] Twitter: @aodaalliance Facebook: www.facebook.com/aodaalliance/

Even More Reason to Worry About Secret Ontario Plans Regarding Rationing or Triage of Life-Saving Critical Medical Care Is Revealed in Two Newspaper Articles and a Letter Secretly Sent to Ontario Hospitals

January 22, 2021

            SUMMARY

We today share more media coverage on the Ford Government’s frightening plans for deciding who will be refused life-saving critical medical care they need, if the out-of-control COVID-19 pandemic forces the rationing or triage of critical care. More revelations give rise to more serious dangers facing Ontarians with disabilities and others if that eventuality arises – an eventuality that a key Government medical advisor Dr. James Downar described as being “close”, on the January 13, 2021 edition of TVO’s The Agenda with Steve Paikin.

We here set out two disturbing new news reports on this issue, and a letter addressed to Ontario hospitals by a member of the Ford Government’s Ontario Critical Care COVID Command Centre, Dr. Andrew Baker. Below you will find:

  1. A January 21, 2021 article in the National Post, which quotes AODA Alliance concerns, among others.
  1. A January 20, 2021 article in the Globe and Mail and, which also quotes AODA Alliance concerns, among others.
  1. An undated letter from Dr. Andrew Baker to Ontario hospitals, giving directions regarding the administration of critical care triage if it becomes necessary.

Before we set out those items below, we first explain the serious new concerns revealed here. These supplement our amply-documented major concerns with the Government’s plans and secretive planning that we have been making public over the past days, weeks and months.

For more background on this issue, check out the following:

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

            MORE DETAILS

More Terrifying News Hidden Behind a Fog of Unjustified Ford Government Secrecy

According to the January 21, 2021 National Post report set out below, the Ford Government’s external advisory Bioethics Table has recommended to the Health Ministry that the Ford Government pass an “executive order” that permits doctors to cut off life-saving critical care they have already started to administer to a patient, and which the patient needs, if critical care has to be rationed or triaged. By this, doctors would not just be told they can decide which patients in a line-up outside the intensive care ward will be allowed in, if there are too few beds for all patients in the lineup. More drastically, the doctors would also have the power to evict some patients from the intensive care unit, who were previously admitted, and give their beds and ventilators over to a patient or patients who are outside the unit, and waiting in the lineup to get in.

It is not clear to us that the Ontario Government can authorize this at all, much less by acting in secret to pass an “executive order”. On the January 13, 2021 edition of The Agenda with Steve Paikin, AODA Alliance Chair David Lepofsky raised the serious concern that for a doctor to do this could raise possible issues under the Criminal Code. We earlier raised a concern about this in the AODA Alliance’s December 17, 2020 letter to the Minister of Health Christine Elliott and in our December 21, 2020 news release. As with all our other letters to the Government on this issue, that letter has never been answered. No Ministry of Health officials ever discussed this with us.

Still worse, we are entirely unsatisfied that any such “executive order” (an American legal term) would be constitutional under the Charter of Rights and would be permissible under the Ontario Human Rights Code, especially in light of the serious disability discrimination at the core of the Ontario Critical Care COVID Command Centre’s January 13, 2021 triage protocol (addressed in detail in our unanswered January 18, 2021 letter to the Minister of Health). This shows with even greater clarity why it is wrong for the Government to leave the planning and execution of directions on this issue solely to physicians and bioethicist, who have no expertise in these important legal issues. The Ford Government should be leading a public debate on its plans, rather than cloaking it in secrecy and claiming it is all left to experts (i.e. doctors) talking to other experts (also referring to doctors). We doubt that the medical profession wishes to have the Government slough this all off on them.

This gives us serious grounds to fear that the Government may try to continue to hide from any public discussion of this issue until the last minute. It may be thinking about then secretly rushing through some sort of “executive order” or regulation behind close doors at the last minute, if it becomes necessary due to hospital overloads. We strongly urge that the Government not take such an approach. The consequences for Ontarians including Ontarians with disabilities are literally life-and-death. This requires any Government action to now be discussed and debated publicly.

Amidst this frightening news, it is noteworthy that the Bioethics Table’s September 11, 2020 report to the Ford Government said that doctors involved in triage decisions should be protected from liability. The opposite is the case. Anyone making such a life-and-death decision should not be immunized from responsibility and accountability for their conduct. No one is above the law.

Compounding this bad news is the erroneous claim in the January 20, 2021 Globe and Mail article, below, by Dr. James Downar, that says in substance that the Ontario triage protocol does not discriminate against patients with disabilities. The article, which describes Dr. Downar as the one who drafted the Ontario protocol, includes:

“Dr. Downar said the protocols “will not exclude people on the basis of disability. No iteration of the protocol would do that, and our protocols explicitly exclude it.””

The AODA Alliance, the ARCH Disability Law Centre and other disability advocates and experts last summer amply showed the Government-appointed Bioethics Table (of which Dr. Downar is a prominent member) that it would seriously discriminate against patients with disabilities for doctors to in any way use the “Clinical Frailty Scale’ when assessing any patient for possibly being triaged out of critical care services. Under the Clinical Frailty Scale as mandated in the January 13, 2021 triage protocol, in the case of a critical care patient age at least 65 with a progressive disease but who has more than six months to live, their likely mortality would be assessed in part by the number of activities of daily living that they can perform without assistance, having regard to each of these specific activities: dressing, bathing, eating, walking, getting in and out of bed, using the telephone, going shopping, preparing meals, doing housework, taking medication, or handling their own finances. The CFS is a clear illustration on its face of direct disability discrimination.

You can read what the AODA Alliance said in great detail on this in its August 30, 2020 written submission to the Bioethics Table. You can watch AODA Alliance Chair David Lepofsky explaining this to the Bioethics Table in his August 31, 2020 concluding presentation to that Table, which is available online as a captioned video. You can also read how the ARCH Disability Law Centre documented this disability discrimination in ARCH’s September 1, 2020 written submission to the bioethics Table.

Yet despite all of this advice, the Bioethics Table recommended use of the disability discriminatory Clinical Frailty Scale in some triage decisions. The January 13, 2021 triage protocol directs doctors to use it in some triage decisions. The fact that the January 13, 2021 triage protocol generally professes the need to respect the human rights of people with disabilities among others does not reduce that discrimination one iota.

It is clear from these two newspaper articles and from the January 13, 2021 edition of Agenda with Steve Paikin that Dr. Downar is now serving in effect as the key public defender if not its spokesperson of the Ford Government on this issue. It is important for the Government to make clear who is making decisions on this issue. We wrote and tweeted to Dr. Downar over a week ago to ask what involvement, if any, he has in the Ontario Critical Care COVID Command Centre.

He has not answered. We emphasized that our concern is not with any one doctor. We are concerned that the Ford Government open up and make public its secret internal actions and deliberations on this triage issue. We all have the right to know what is being planned, and who is doing all the planning and decision-making.

Finally, we are deeply troubled by the secret letter to Ontario hospitals from the Ontario Critical Care COVID Command Centre’s Dr. Andrew Baker, set out below. It shows that the Ford Government had sent an earlier secret draft critical care triage protocol to Ontario hospitals back on November 13, 2020. We were never shown that document. It was sent a mere 8 days after the Ford Government stated in the Legislature during Question Period on November 5, 2020 that it thought it unlikely that such a document would have to be sent to health professionals.

It is also clear from the letter below that the November secret 13, 2020 triage document had recommended that the triage protocol include some due process appeal opportunities for a patient who is to be denied life-saving critical care. We now know that that has subsequently been harmfully ripped right out of the January 13, 2021 triage protocol, to the serious detriment of patients fighting for their lives.

As we stated in the January 21, 2021 AODA Alliance Update, the Government is claiming that it has not approved any of these triage plans. If so, why is Dr. Baker or any other doctor or committee sending such instructions or directions to hospitals? Who is taking responsibility for this life-and-death issue?

The National Post January 21, 2021

Originally posted at https://nationalpost.com/news/canada/ontario-wrestles-with-who-gets-icu-treatment-in-event-hospitals-overwhelmed-with-covid-patients

Ontario urged to suspend need for consent before withdrawing life support when COVID crushes hospitals

Ontario is being asked to temporarily suspend the law requiring doctors get patient or family consent before withdrawing treatment from people facing a grim prognosis

Author of the article: Sharon Kirkey

The COVID-19 vaccine has started to be administered in Canada, but Ontario, Quebec and other provinces still need to prepare protocols to determine who should get critical care — and who should be left behind — in the event that hospitals become flooded with COVID patients. PHOTO BY CARLOS OSORIO/POOL/AFP VIA GETTY IMAGES

Canada’s Supreme Court ruled in 2013 that a major Toronto Hospital could not withdraw life-support from a minimally conscious and severely brain-damaged man without his family’s consent.

Now, in another sign of these extraordinary times, the Ontario government is being asked to temporarily suspend the law requiring doctors get consent of patients or families before withdrawing a ventilator or other life-sustaining treatment from people facing a grim prognosis, should COVID-19 crush hospitals.

The recommendation for an Executive Order to suspend the province’s Health Care Consent Act for withdrawal of treatment in the ICU, should the situation become so dire, comes as Ontario, Quebec and other provinces prepare protocols to determine who should get critical care — and who should be left behind — if hospitals are flooded with COVID patients.

The request, deeply disturbing to disability advocacy groups, comes from Ontario’s COVID-19 Bioethics Table, which is recommending that the province ensure “liability protection for all those who would be involved in implementing the Proposed Framework … including an Emergency Order related to any aspect requiring a deviation for the Health Care Consent Act.” The act requires doctors obtain agreement from patients, or their substitute decision makers, with disputes resolved by the Consent and Capacity Board, an independent tribunal.

This week, the Ontario Critical Care Covid Command Centre issued an “emergency standard of care” to prepare hospitals for the worst-case scenario, an Italy-like surge in demand for critical care. The over-arching objective, the document states, is to “save the most lives in the most ethical manner possible.”

A critical care triage should be considered an option of last resort, invoked only after all reasonable attempts have been made to move people to other hospitals where there is space and staff to care for them, and only for as long as the surge lasts, the document says.

The goal is to minimize deaths, minimize the risk of discrimination and “unconscious bias” against people with disabilities, racialized communities and other vulnerable groups, and minimize “moral injury and burnout” among staff forced to decide who may live and who may die.

According to the document, prepared on behalf of Ontario’s critical care COVID command centre, priority should be given to people with the greatest likelihood of surviving whatever it is that brought them to hospital — COVID-19, heart attack, liver disease, a bleed in the brain or other life-threatening illness. Those with a high likelihood of dying within 12 months from that critical sickness would receive lower priority for an ICU bed.

“It’s really important to be clear here — this is not about how long you’re likely to live, it’s not a life span question,” said Dr. James Downar, head of the division of palliative care at the University of Ottawa and a member of the Bioethics Table. “It’s your probability of being alive 12 months after developing critical illness.”

The protocol is meant to be applied to new patients, or people already in hospital whose condition is worsening. “We’re suggesting, out of a principle of fairness, the same approach should apply to people inside the ICU,” Downar said. “It would be unfair to treat people differently depending on the timing that they presented.”

“Nobody likes the idea of ever withdrawing life-support on somebody without their permission, without their consent,” Downar said. “But in a triage scenario, we’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole, and trying to maximize the number of people who will survive an overwhelming surge.”

Dr. James Downar: “We’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole.” PHOTO BY OTTAWA HOSPITAL RESEARCH INSTITUTE VIA CP

The document now being circulated to Ontario hospitals doesn’t include a provision for withdrawal of potentially life-sustaining treatment without consent. Instead, it says that ICU doctors should regularly reassess people admitted to ICU, and consider withdrawal of life support “through a shared decision-making process with SDMs (substitute decision-makers) if a patient does not appear to be improving.”

But Downar and other doctors said it’s not possible to operate a triage model in which all decisions are made with the consent and permission of people involved, because many people would simply opt out.

“We are going to say, ‘by the way, we are taking your family member off the ventilator in lieu of another patient who we feel has a better prognosis, given this pandemic condition. Do you agree?’ I think that if we did that we would not get consent. Nobody is going to give us consent,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.

The Bioethics Table’s request is now before the Ontario Health Ministry. “We are hopeful that, as part of the state of emergency, should we need it, that there will be an executive order allowing us to withdraw,” Downar said

With an Executive Order in place, doctors could put off escalating triage and continue to offer intensive care to every person who might benefit, including borderline cases — “right up to the point that the critical care beds are literally full,” he said. ICUs could run at full capacity. Only then, as new patients come in who meet the triage criteria — a lower risk of death — and who need beds would ICU care slowly start to be withdrawn from people who aren’t responding and are least likely to, Downar said.

Without the Executive Order, triage would have to be started sooner, in order to reserve beds for people with a high likelihood of survival. Fewer people would be offered intensive care, and more people would die, Downar said.

“It’s difficult to imagine how troubling that would be, that we would actually have to suspend the consent act,” said Dr. Andrea Frolic, director of the Program for Ethics and Care Ecologies at Hamilton Health Sciences and a consultant to Ontario’s COVID critical care command centre.

“It would be a rare circumstance that we would have to resort to implementing a care plan that would not have the consent of the patient or substitute decision-maker,” Frolic said.

It’s not a life span question. It’s your probability of being alive 12 months after developing critical illness

But should hospitals become maxed out, with a massive surge of people coming through the doors who have a very high chance of survival, and people in the ICU who aren’t benefitting from critical care and who are highly likely to die — “if we don’t have the tool to provide equitable access to care, that will create a lot of distress on the system,” Frolic said.

It becomes a first-come, first-served system, she said — a car crash victim who needs surgery and a short ICU stay to save his life can’t get into the ICU, because he arrived after a person with end-stage cancer and COVID-related pneumonia who may not be likely to survive their critical illness, or weeks later. “That is a situation of inequity caused by fate, really, or chance. One person happened to get critically ill before another person.”

Withdrawing treatment without consent would be very rare, happen only after every effort to reach consensus with the patient and family has been exhausted, and only as a last resort, Frolic added.

Families who feel strongly could use all avenues of advocacy, she said. “The hope is that families will see what’s happening around them. You can imagine if we get to this level of surge, there are patients in hallways; there are patients in gymnasiums. My hope is that families will see their own patient deteriorating but will see the context that we’re in a public health emergency, that it’s not personal, it’s not what we wish to do, it’s a situation caused by the pandemic.”

Mariam Shanouda, a lawyer at ARCH Disability Law Centre in Toronto, said she was “flabbergasted” when told by the National Post about the prospect of an order to allow doctors to operate outside the consent act.

“This is literally life and death and to not only give doctors that power to operate outside (the act) but to insulate them from any liability whatsoever, that is not something to be taken likely,” Shanouda said.

“We don’t know the process by which these decisions will be made, who will be making the decisions to withdraw care. Is there going to be an appeal procedure whereby a family can challenge that decision? Is there going to be accountability?”

“There are huge legal questions here and they need to be discussed in the open because we are talking about possibly taking an active action that could accelerate someone’s death,” said David Lepofsky, chair of the Accessibility for Ontarians with Disabilities Act Alliance (AODA).

“If they were to amend the consent legislation, and if that were valid, and if it were constitutional and if it got around all the criminal law problems, what will that mean? It means if anybody goes to hospital and gets intensive care, they don’t have any confidence they’re going to be able to stay there,” Lepofsky said.

“They’ve got to lie there knowing not only are they fighting for their life, but they are also aware that, at any time, a doctor could decide their chances aren’t so good, somebody coming in has got better chances, ‘sorry, we’re pulling the plug on you.’”

Globe and Mail January 20, 2021

Originally posted at https://www.theglobeandmail.com/canada/article-how-doctors-in-quebec-ontario-will-decide-who-gets-care-if-coronavirus/

How doctors in Quebec, Ontario will decide who gets care if coronavirus hospitalizations continue to surge

LES PERREAUX

If the pandemic gets much worse in Canada’s hardest-hit provinces, grading systems developed by doctors and approved by provinces will help physicians decide who gets potential lifesaving treatment and who does not.

The purpose of the grading systems, filled with scores, scales and categories, is to establish a ranking of patients in need of critical care – including COVID-19 patients – with the aim of determining who will get access to increasingly scarce critical care beds, ventilators and ICU staff. The pandemic critical care triage protocol scores patients on severity of injury or illness, likelihood of immediate survival, and one-year prognosis beyond the intensive care unit.

Another objective, to limit bias and to depersonalize who will receive care, is spelled out at the top of each of the nine pages of the Quebec version of the Intensive Care Access Form. “Do not write the name,” it says.

“Our usual way to work is we treat the patient in front of us, one person at a time. This says we have to start thinking about what’s best for the largest number of people,” said Dr. Paul Warshawsky, chief of critical care at Montreal’s Jewish General Hospital. “It’s to help us select patients in a way that is fair and equitable, not based on how loudly a family is advocating.” Across the country, medical systems are already triaging tens of thousands of patients who need scheduled surgeries but must wait as COVID-19 taxes resources.

Intensive care triage is the next major step for hospital life-and-death decisions.

Critical care triage protocols are circulating in several provinces, including hard-hit Ontario and Alberta. Only Quebec has so far made its final triage form public, along with a 48-page explainer.

Ontario’s full, official protocol, similar to Quebec’s, is expected to be publicly released soon, according to Dr. James Downar, a specialist in critical care at The Ottawa Hospital who drafted Ontario’s protocol. It is not clear if Alberta will make its protocol public.

No Canadian medical system has had to invoke formal critical care triage during the pandemic. New York hospitals invoked “crisis standards of care” in the first wave, but doctors complained the triage guidelines were more theoretical than practical. They often ended up improvising who received care. Los Angeles County put protocols in place this month but has yet to formally start triage.

“If you run out of resources, you have three options: First-come first-serve, which is deeply unfair and brings a lot of extra mortality. A pure lottery random system has lower risk of inequity, but would lead to a lot of preventable death,” Dr. Downar said. “They’re not morally defensible.”

“You are left with option three: Try your very best to come up with criteria that can be applied consistently and explicitly, based on evidence. Avoid criterion that would assign value to a human being, but just assign probability they would live.”

If the protocol is invoked, doctors in Quebec would fill out the ICU access form for every patient in critical care or waiting for it. A team of two doctors and an ethicist for each hospital would receive them, rank patients and make the final calls.

The Quebec form would decide who gets into ICU but also who could be removed from ventilators if patients with a higher probability of survival need them.

It is not clear if Ontario’s final protocol will contain this piece.

In Quebec, the intensive care protocol is supposed to kick in once the province reaches 200 per cent of normal ICU capacity. Most ICUs in Quebec are not full, but some in Montreal are above 100 per cent. Critical patients in Toronto are being moved to hospitals across Southern Ontario.

“It’s scary, we’re not at the doorstep of the protocol but we’re near it,” Dr. Warshawsky said. The Jewish General ICU is “currently running at 130 per cent. I’m not sure we can get to 200 per cent.” Intensive care has two main functions when dealing with an influx of COVID-19 patients. One is constant monitoring – each nurse is in charge of no more than two patients in Quebec. The other is breathing assistance, where ventilators pump oxygen into a patient’s lungs.

Most intensive care triage plans set out three crisis stages. At the first stage, patients with only a 20 per cent chance or less of survival within a year would be denied intensive care. Two other stages with survival rates of 50 per cent and 70 per cent, respectively, kick in if the situation deteriorates.

Then, patients are sorted. In the Quebec form, physicians complete a trauma- and injury-severity score if the patient needs care for a major accident. With cardiac arrest, organ failure and metastatic cancer patients, a number of indicators are used for the first two stages. At stage three, the existence of these afflictions alone would prevent treatment in the ICU.

Patients over 60 years old with burns over 40 per cent or more of their bodies would be denied any ICU care.

The form’s final pages rank conditions that make recovery from assisted breathing less likely, such as dementia and frailty, raising alarm among disability advocates. Weight and muscle loss, diminished ability to walk are among clinical frailty symptoms.

“The tools they use conflate disability with frailty,” said Mariam Shanouda, a lawyer with the Toronto’s ARCH legal clinic, who represents people with disabilities. “We already know there are demographic sectors more affected by COVID-19. Black people, other racialized minorities, Indigenous people, people with disabilities … they will inevitably be most affected by this protocol and they have not been sufficiently consulted.”

The Quebec protocol was reviewed by committees involving dozens of medical professionals, lawyers and ethicists, but a handful of patients. “I don’t know why this wasn’t examined prior to the pandemic as part of pandemic preparedness,” said Vardit Ravitsky, a professor of bioethics at the University of Montreal.

“Public consultation on something involving life-and-death decisions like this should be as inclusive as possible.”

Judging frailty or dementia could discriminate against both the elderly and disabled, said David Lepofsky, chairman of advocacy group Accessibility for Ontarians with Disabilities Act Alliance. He warned the protocol will turn triage doctors “into a law unto themselves.”

Mr. Lepofsky, an adjunct professor at the University of Toronto’s law school, has written to Ontario Health Minister Christine Elliott to demand the protocol be scrapped and a process launched for a full debate and legislation. “They have had 11 months to figure this out,” Mr. Lepofsky said. “And they haven’t.”

Dr. Downar said the protocols “will not exclude people on the basis of disability. No iteration of the protocol would do that, and our protocols explicitly exclude it.”

Dr. Downar added doctors and nurses left with “impromptu triage practices” would create far greater risk of bias. But, he acknowledged, “even a system that controls subjectivity and implicit bias and is purely focused on mortality risk will still affect some groups more than others. Mortality risk is not evenly distributed in society.”

The final page of Quebec’s protocol outlines criteria for resolving ties, putting a priority on younger people and workers in the health care system, elements not part of Ontario’s draft protocol.

In both Ontario and Quebec, if all else is equal, random chance will be used for the final selection of critical care patients.

With a report from Jeff Gray in Toronto.

Undated Letter from A Member of the Ontario Government’s Critical Care COVID Command Centre to Ontario Hospitals

Ontario Critical Care COVID19 Command Centre_ Readiness for Emergency Standard of Care for Critical Care communication January 13 2021.pdf

Dear Colleagues:

Please find attached documents that describe how to implement an emergency standard of care for admission to critical care.

This emergency standard of care does not apply now. This will require a clear, distinct, and specific time of initiation and discontinuation by the Ontario Critical Care COVID19 Command Centre.

Matt Anderson, in his recent memo Further Actions for Optimizing Care, indicated that, “All hospitals are asked to review and standardize their critical care admission criteria in consultation with the Ontario Critical Care COVID-19 Command Centre”. The emergency standard of care (attached) is intended to support this action. It operates within the Health Care Consent Act of Ontario; it does not involve the protocol-driven withdrawal of invasive physiologic support, but does involve the protocol-driven decisions to not offer admission to critical care.

It would be advisable for physicians and your hospital to prepare now to operationalize this emergency standard for when it is initiated. While the forms are included in the document, they are attached here as separate pdfs for ease of printing. Furthermore, here is a site that contains these documents as well as a narrated slide deck for use with knowledge translation. This site can be referenced for updates to these documents and supplementary resources to support implementation.

Along with developing readiness for this change, I recommend concurrently refreshing a commitment to consistent and proactive approaches to goals of care conversations with patients. Some of the tools within this document may be useful in this regard.

Please note that on November 13, 2020, I sent a draft Protocol which does involve protocol-driven withdrawal of invasive physiologic support. This emergency standard of care document supersedes that draft protocol. The substantive differences between this document and the November 13, 2020 draft Protocol are:

  1. Removal of the requirement of a triage team that makes ICU bed allocation decisions; 2. Removal of reference to an external appeals committee; 3. No protocol-driven withdrawal of invasive physiologic support, which would require an executive order from Cabinet to operate outside of the Health Care Consent Act.

However, an updated version of the Protocol may be sent in the near future. Readiness of physicians and hospitals for an updated Protocol will be expedited by preparing to implement this emergency standard of care. The same principles and tools apply to both this Emergency Standard of Care and the forthcoming Protocol. Both approaches benefit from being derived from a Framework developed by the Ontario COVID-19 Bioethics Table. Both approaches emphasize a commitment to human rights, ethical principles, continuous improvement, and fair processes. A system of data collection about the application of this emergency standard of care is being created for the purpose of monitoring and revision of this approach. Information about how to transmit data to this system will be forthcoming soon.

Thank you so much for all you are doing,

Andrew Baker Incident Commander Ontario Critical Care COVID19 Command Centre



Source link

Even More Reason to Worry About Secret Ontario Plans Regarding Rationing or Triage of Life-Saving Critical Medical Care Is Revealed in Two Newspaper Articles and a Letter Secretly Sent to Ontario Hospitals


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

January 22, 2021

SUMMARY

We today share more media coverage on the Ford Government’s frightening plans for deciding who will be refused life-saving critical medical care they need, if the out-of-control COVID-19 pandemic forces the rationing or triage of critical care. More revelations give rise to more serious dangers facing Ontarians with disabilities and others if that eventuality arises an eventuality that a key Government medical advisor Dr. James Downar described as being close, on the January 13, 2021 edition of TVO’s The Agenda with Steve Paikin.

We here set out two disturbing new news reports on this issue, and a letter addressed to Ontario hospitals by a member of the Ford Government’s Ontario Critical Care COVID Command Centre, Dr. Andrew Baker. Below you will find:

1. A January 21, 2021 article in the National Post, which quotes AODA Alliance concerns, among others.

2. A January 20, 2021 article in the Globe and Mail and, which also quotes AODA Alliance concerns, among others.

3. An undated letter from Dr. Andrew Baker to Ontario hospitals, giving directions regarding the administration of critical care triage if it becomes necessary.

Before we set out those items below, we first explain the serious new concerns revealed here. These supplement our amply-documented major concerns with the Government’s plans and secretive planning that we have been making public over the past days, weeks and months.

For more background on this issue, check out the following:

1. The new January 13, 2021 triage protocol which the AODA Alliance received, is now making public, and has asked the Ford Government to verify. We have only acquired this in PDF format, which lacks proper accessibility. We gather some others in the community now have this document as well.

2. The AODA Alliance’s January 18, 2021 news release on the January 13, 2021 triage protocol.

3. The panel on critical care triage, including AODA Alliance Chair David Lepofsky, on the January 13, 2021 edition of TVO’s The Agenda with Steve Paikin.

4. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.

5. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.

MORE DETAILS

More Terrifying News Hidden Behind a Fog of Unjustified Ford Government Secrecy

According to the January 21, 2021 National Post report set out below, the Ford Government’s external advisory Bioethics Table has recommended to the Health Ministry that the Ford Government pass an executive order that permits doctors to cut off life-saving critical care they have already started to administer to a patient, and which the patient needs, if critical care has to be rationed or triaged. By this, doctors would not just be told they can decide which patients in a line-up outside the intensive care ward will be allowed in, if there are too few beds for all patients in the lineup. More drastically, the doctors would also have the power to evict some patients from the intensive care unit, who were previously admitted, and give their beds and ventilators over to a patient or patients who are outside the unit, and waiting in the lineup to get in.
It is not clear to us that the Ontario Government can authorize this at all, much less by acting in secret to pass an executive order. On the January 13, 2021 edition of The Agenda with Steve Paikin, AODA Alliance Chair David Lepofsky raised the serious concern that for a doctor to do this could raise possible issues under the Criminal Code. We earlier raised a concern about this in the AODA Alliance’s December 17, 2020 letter to the Minister of Health Christine Elliott and in our December 21, 2020 news release. As with all our other letters to the Government on this issue, that letter has never been answered. No Ministry of Health officials ever discussed this with us.
Still worse, we are entirely unsatisfied that any such executive order (an American legal term) would be constitutional under the Charter of Rights and would be permissible under the Ontario Human Rights Code, especially in light of the serious disability discrimination at the core of the Ontario Critical Care COVID Command Centre’s January 13, 2021 triage protocol (addressed in detail in our unanswered January 18, 2021 letter to the Minister of Health). This shows with even greater clarity why it is wrong for the Government to leave the planning and execution of directions on this issue solely to physicians and bioethicist, who have no expertise in these important legal issues. The Ford Government should be leading a public debate on its plans, rather than cloaking it in secrecy and claiming it is all left to experts (i.e. doctors) talking to other experts (also referring to doctors). We doubt that the medical profession wishes to have the Government slough this all off on them.
This gives us serious grounds to fear that the Government may try to continue to hide from any public discussion of this issue until the last minute. It may be thinking about then secretly rushing through some sort of executive order or regulation behind close doors at the last minute, if it becomes necessary due to hospital overloads. We strongly urge that the Government not take such an approach. The consequences for Ontarians including Ontarians with disabilities are literally life-and-death. This requires any Government action to now be discussed and debated publicly.
Amidst this frightening news, it is noteworthy that the Bioethics Table’s September 11, 2020 report to the Ford Government said that doctors involved in triage decisions should be protected from liability. The opposite is the case. Anyone making such a life-and-death decision should not be immunized from responsibility and accountability for their conduct. No one is above the law.
Compounding this bad news is the erroneous claim in the January 20, 2021 Globe and Mail article, below, by Dr. James Downar, that says in substance that the Ontario triage protocol does not discriminate against patients with disabilities. The article, which describes Dr. Downar as the one who drafted the Ontario protocol, includes:
Dr. Downar said the protocols will not exclude people on the basis of disability. No iteration of the protocol would do that, and our protocols explicitly exclude it.

The AODA Alliance, the ARCH Disability Law Centre and other disability advocates and experts last summer amply showed the Government-appointed Bioethics Table (of which Dr. Downar is a prominent member) that it would seriously discriminate against patients with disabilities for doctors to in any way use the Clinical Frailty Scale’ when assessing any patient for possibly being triaged out of critical care services. Under the Clinical Frailty Scale as mandated in the January 13, 2021 triage protocol, in the case of a critical care patient age at least 65 with a progressive disease but who has more than six months to live, their likely mortality would be assessed in part by the number of activities of daily living that they can perform without assistance, having regard to each of these specific activities: dressing, bathing, eating, walking, getting in and out of bed, using the telephone, going shopping, preparing meals, doing housework, taking medication, or handling their own finances. The CFS is a clear illustration on its face of direct disability discrimination.
You can read what the AODA Alliance said in great detail on this in its August 30, 2020 written submission to the Bioethics Table. You can watch AODA Alliance Chair David Lepofsky explaining this to the Bioethics Table in his August 31, 2020 concluding presentation to that Table, which is available online as a captioned video. You can also read how the ARCH Disability Law Centre documented this disability discrimination in ARCH’s September 1, 2020 written submission to the bioethics Table.
Yet despite all of this advice, the Bioethics Table recommended use of the disability discriminatory Clinical Frailty Scale in some triage decisions. The January 13, 2021 triage protocol directs doctors to use it in some triage decisions. The fact that the January 13, 2021 triage protocol generally professes the need to respect the human rights of people with disabilities among others does not reduce that discrimination one iota.
It is clear from these two newspaper articles and from the January 13, 2021 edition of Agenda with Steve Paikin that Dr. Downar is now serving in effect as the key public defender if not its spokesperson of the Ford Government on this issue. It is important for the Government to make clear who is making decisions on this issue. We wrote and tweeted to Dr. Downar over a week ago to ask what involvement, if any, he has in the Ontario Critical Care COVID Command Centre.
He has not answered. We emphasized that our concern is not with any one doctor. We are concerned that the Ford Government open up and make public its secret internal actions and deliberations on this triage issue. We all have the right to know what is being planned, and who is doing all the planning and decision-making.
Finally, we are deeply troubled by the secret letter to Ontario hospitals from the Ontario Critical Care COVID Command Centre’s Dr. Andrew Baker, set out below. It shows that the Ford Government had sent an earlier secret draft critical care triage protocol to Ontario hospitals back on November 13, 2020. We were never shown that document. It was sent a mere 8 days after the Ford Government stated in the Legislature during Question Period on November 5, 2020 that it thought it unlikely that such a document would have to be sent to health professionals.
It is also clear from the letter below that the November secret 13, 2020 triage document had recommended that the triage protocol include some due process appeal opportunities for a patient who is to be denied life-saving critical care. We now know that that has subsequently been harmfully ripped right out of the January 13, 2021 triage protocol, to the serious detriment of patients fighting for their lives.
As we stated in the January 21, 2021 AODA Alliance Update, the Government is claiming that it has not approved any of these triage plans. If so, why is Dr. Baker or any other doctor or committee sending such instructions or directions to hospitals? Who is taking responsibility for this life-and-death issue?

The National Post January 21, 2021

Originally posted at https://nationalpost.com/news/canada/ontario-wrestles-with-who-gets-icu-treatment-in-event-hospitals-overwhelmed-with-covid-patients
Ontario urged to suspend need for consent before withdrawing life support when COVID crushes hospitals

Ontario is being asked to temporarily suspend the law requiring doctors get patient or family consent before withdrawing treatment from people facing a grim prognosis Author of the article: Sharon Kirkey
The COVID-19 vaccine has started to be administered in Canada, but Ontario, Quebec and other provinces still need to prepare protocols to determine who should get critical care and who should be left behind in the event that hospitals become flooded with COVID patients. PHOTO BY CARLOS OSORIO/POOL/AFP VIA GETTY IMAGES
Canada’s Supreme Court ruled in 2013 that a major Toronto Hospital could not withdraw life-support from a minimally conscious and severely brain-damaged man without his family’s consent.
Now, in another sign of these extraordinary times, the Ontario government is being asked to temporarily suspend the law requiring doctors get consent of patients or families before withdrawing a ventilator or other life-sustaining treatment from people facing a grim prognosis, should COVID-19 crush hospitals.
The recommendation for an Executive Order to suspend the province’s Health Care Consent Act for withdrawal of treatment in the ICU, should the situation become so dire, comes as Ontario, Quebec and other provinces prepare protocols to determine who should get critical care and who should be left behind if hospitals are flooded with COVID patients.
The request, deeply disturbing to disability advocacy groups, comes from Ontario’s COVID-19 Bioethics Table, which is recommending that the province ensure liability protection for all those who would be involved in implementing the Proposed Framework including an Emergency Order related to any aspect requiring a deviation for the Health Care Consent Act. The act requires doctors obtain agreement from patients, or their substitute decision makers, with disputes resolved by the Consent and Capacity Board, an independent tribunal.
This week, the Ontario Critical Care Covid Command Centre issued an emergency standard of care to prepare hospitals for the worst-case scenario, an Italy-like surge in demand for critical care. The over-arching objective, the document states, is to save the most lives in the most ethical manner possible.
A critical care triage should be considered an option of last resort, invoked only after all reasonable attempts have been made to move people to other hospitals where there is space and staff to care for them, and only for as long as the surge lasts, the document says.

The goal is to minimize deaths, minimize the risk of discrimination and unconscious bias against people with disabilities, racialized communities and other vulnerable groups, and minimize moral injury and burnout among staff forced to decide who may live and who may die.
According to the document, prepared on behalf of Ontario’s critical care COVID command centre, priority should be given to people with the greatest likelihood of surviving whatever it is that brought them to hospital COVID-19, heart attack, liver disease, a bleed in the brain or other life-threatening illness. Those with a high likelihood of dying within 12 months from that critical sickness would receive lower priority for an ICU bed.
It’s really important to be clear here this is not about how long you’re likely to live, it’s not a life span question, said Dr. James Downar, head of the division of palliative care at the University of Ottawa and a member of the Bioethics Table. It’s your probability of being alive 12 months after developing critical illness.
The protocol is meant to be applied to new patients, or people already in hospital whose condition is worsening. We’re suggesting, out of a principle of fairness, the same approach should apply to people inside the ICU, Downar said. It would be unfair to treat people differently depending on the timing that they presented.
Nobody likes the idea of ever withdrawing life-support on somebody without their permission, without their consent, Downar said. But in a triage scenario, we’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole, and trying to maximize the number of people who will survive an overwhelming surge.
Dr. James Downar: We’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole. PHOTO BY OTTAWA HOSPITAL RESEARCH INSTITUTE VIA CP
The document now being circulated to Ontario hospitals doesn’t include a provision for withdrawal of potentially life-sustaining treatment without consent. Instead, it says that ICU doctors should regularly reassess people admitted to ICU, and consider withdrawal of life support through a shared decision-making process with SDMs (substitute decision-makers) if a patient does not appear to be improving.
But Downar and other doctors said it’s not possible to operate a triage model in which all decisions are made with the consent and permission of people involved, because many people would simply opt out.

We are going to say, by the way, we are taking your family member off the ventilator in lieu of another patient who we feel has a better prognosis, given this pandemic condition. Do you agree?’ I think that if we did that we would not get consent. Nobody is going to give us consent, said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.
The Bioethics Table’s request is now before the Ontario Health Ministry. We are hopeful that, as part of the state of emergency, should we need it, that there will be an executive order allowing us to withdraw, Downar said
With an Executive Order in place, doctors could put off escalating triage and continue to offer intensive care to every person who might benefit, including borderline cases right up to the point that the critical care beds are literally full, he said. ICUs could run at full capacity. Only then, as new patients come in who meet the triage criteria a lower risk of death and who need beds would ICU care slowly start to be withdrawn from people who aren’t responding and are least likely to, Downar said.
Without the Executive Order, triage would have to be started sooner, in order to reserve beds for people with a high likelihood of survival. Fewer people would be offered intensive care, and more people would die, Downar said.
It’s difficult to imagine how troubling that would be, that we would actually have to suspend the consent act, said Dr. Andrea Frolic, director of the Program for Ethics and Care Ecologies at Hamilton Health Sciences and a consultant to Ontario’s COVID critical care command centre.
It would be a rare circumstance that we would have to resort to implementing a care plan that would not have the consent of the patient or substitute decision-maker, Frolic said.
It’s not a life span question. It’s your probability of being alive 12 months after developing critical illness
But should hospitals become maxed out, with a massive surge of people coming through the doors who have a very high chance of survival, and people in the ICU who aren’t benefitting from critical care and who are highly likely to die if we don’t have the tool to provide equitable access to care, that will create a lot of distress on the system, Frolic said.
It becomes a first-come, first-served system, she said a car crash victim who needs surgery and a short ICU stay to save his life can’t get into the ICU, because he arrived after a person with end-stage cancer and COVID-related pneumonia who may not be likely to survive their critical illness, or weeks later. That is a situation of inequity caused by fate, really, or chance. One person happened to get critically ill before another person.
Withdrawing treatment without consent would be very rare, happen only after every effort to reach consensus with the patient and family has been exhausted, and only as a last resort, Frolic added.
Families who feel strongly could use all avenues of advocacy, she said. The hope is that families will see what’s happening around them. You can imagine if we get to this level of surge, there are patients in hallways; there are patients in gymnasiums. My hope is that families will see their own patient deteriorating but will see the context that we’re in a public health emergency, that it’s not personal, it’s not what we wish to do, it’s a situation caused by the pandemic.
Mariam Shanouda, a lawyer at ARCH Disability Law Centre in Toronto, said she was flabbergasted when told by the National Post about the prospect of an order to allow doctors to operate outside the consent act.
This is literally life and death and to not only give doctors that power to operate outside (the act) but to insulate them from any liability whatsoever, that is not something to be taken likely, Shanouda said.
We don’t know the process by which these decisions will be made, who will be making the decisions to withdraw care. Is there going to be an appeal procedure whereby a family can challenge that decision? Is there going to be accountability?
There are huge legal questions here and they need to be discussed in the open because we are talking about possibly taking an active action that could accelerate someone’s death, said David Lepofsky, chair of the Accessibility for Ontarians with Disabilities Act Alliance (AODA).
If they were to amend the consent legislation, and if that were valid, and if it were constitutional and if it got around all the criminal law problems, what will that mean? It means if anybody goes to hospital and gets intensive care, they don’t have any confidence they’re going to be able to stay there, Lepofsky said.
They’ve got to lie there knowing not only are they fighting for their life, but they are also aware that, at any time, a doctor could decide their chances aren’t so good, somebody coming in has got better chances, sorry, we’re pulling the plug on you.’ Email: [email protected] | Twitter: sharon_kirkey

Globe and Mail January 20, 2021

Originally posted at https://www.theglobeandmail.com/canada/article-how-doctors-in-quebec-ontario-will-decide-who-gets-care-if-coronavirus/
How doctors in Quebec, Ontario will decide who gets care if coronavirus hospitalizations continue to surge

LES PERREAUX

If the pandemic gets much worse in Canada’s hardest-hit provinces, grading systems developed by doctors and approved by provinces will help physicians decide who gets potential lifesaving treatment and who does not.
The purpose of the grading systems, filled with scores, scales and categories, is to establish a ranking of patients in need of critical care including COVID-19 patients with the aim of determiningwho will get access to increasingly scarce critical care beds, ventilators and ICU staff. The pandemic critical care triage protocol scores patients on severity of injury or illness, likelihood of immediate survival, and one-year prognosis beyond the intensive care unit.
Another objective, to limit bias and to depersonalize who will receive care, is spelled out at the top of each of the nine pages of the Quebec version of the Intensive Care Access Form. Do not write the name, it says.
Our usual way to work is we treat the patient in front of us, one person at a time. This says we have to start thinking about what’s best for the largest number of people, said Dr. Paul Warshawsky, chief of critical care at Montreal’s Jewish General Hospital. It’s to help us select patients in a way that is fair and equitable, not based on how loudly a family is advocating. Across the country, medical systems are already triaging tens of thousands of patients who need scheduled surgeries but must wait as COVID-19 taxes resources.
Intensive care triage is the next major step for hospital life-and-death decisions.
Critical care triage protocols are circulating in several provinces, including hard-hit Ontario and Alberta. Only Quebec has so far made its final triage form public, along with a 48-page explainer.
Ontario’s full, official protocol, similar to Quebec’s, is expected to be publicly released soon, according to Dr. James Downar, a specialist in critical care at The Ottawa Hospital who drafted Ontario’s protocol. It is not clear if Alberta will make its protocol public.
No Canadian medical system has had to invoke formal critical care triage during the pandemic. New York hospitals invoked crisis standards of care in the first wave, but doctors complained the triage guidelines were more theoretical than practical. They often ended up improvising who received care. Los Angeles County put protocols in place this month but has yet to formally start triage.
If you run out of resources, you have three options: First-come first-serve, which is deeply unfair and brings a lot of extra mortality. A pure lottery random system has lower risk of inequity, but would lead to a lot of preventable death, Dr. Downar said. They’re not morally defensible.
You are left with option three: Try your very best to come up with criteria that can be applied consistently and explicitly, based on evidence. Avoid criterion that would assign value to a human being, but just assign probability they would live.
If the protocol is invoked, doctors in Quebec would fill out the ICU access form for every patient in critical care or waiting for it. A team of two doctors and an ethicist for each hospital would receive them, rank patients and make the final calls.
The Quebec form would decide who gets into ICU but also who could be removed from ventilators if patients with a higher probability of survival need them. It is not clear if Ontario’s final protocol will contain this piece.
In Quebec, the intensive care protocol is supposed to kick in once the province reaches 200 per cent of normal ICU capacity. Most ICUs in Quebec are not full, but some in Montreal are above 100 per cent. Critical patients in Toronto are being moved to hospitals across Southern Ontario.
It’s scary, we’re not at the doorstep of the protocol but we’re near it, Dr. Warshawsky said. The Jewish General ICU is currently running at 130 per cent. I’m not sure we can get to 200 per cent. Intensive care has two main functions when dealing with an influx of COVID-19 patients. One is constant monitoring each nurse is in charge of no more than two patients in Quebec. The other is breathing assistance, where ventilators pump oxygen into a patient’s lungs.
Most intensive care triage plans set out three crisis stages. At the first stage, patients with only a 20 per cent chance or less of survival within a year would be denied intensive care. Two other stages with survival rates of 50 per cent and 70 per cent, respectively, kick in if the situation deteriorates.
Then, patients are sorted. In the Quebec form, physicians complete a trauma- and injury-severity score if the patient needs care for a major accident. With cardiac arrest, organ failure and metastatic cancer patients, a number of indicators are used for the first two stages. At stage three, the existence of these afflictions alone would prevent treatment in the ICU.
Patients over 60 years old with burns over 40 per cent or more of their bodies would be denied any ICU care.
The form’s final pages rank conditions that make recovery from assisted breathing less likely, such as dementia and frailty, raising alarm among disability advocates. Weight and muscle loss, diminished ability to walk are among clinical frailty symptoms.
The tools they use conflate disability with frailty, said Mariam Shanouda, a lawyer with the Toronto’s ARCH legal clinic, who represents people with disabilities. We already know there are demographic sectors more affected by COVID-19. Black people, other racialized minorities, Indigenous people, people with disabilities they will inevitably be most affected by this protocol and they have not been sufficiently consulted.
The Quebec protocol was reviewed by committees involving dozens of medical professionals, lawyers and ethicists, but a handful of patients. I don’t know why this wasn’t examined prior to the pandemic as part of pandemic preparedness, said Vardit Ravitsky, a professor of bioethics at the University of Montreal.
Public consultation on something involving life-and-death decisions like this should be as inclusive as possible.
Judging frailty or dementia could discriminate against both the elderly and disabled, said David Lepofsky, chairman of advocacy group Accessibility for Ontarians with Disabilities Act Alliance. He warned the protocol will turn triage doctors into a law unto themselves.
Mr. Lepofsky, an adjunct professor at the University of Toronto’s law school, has written to Ontario Health Minister Christine Elliott to demand the protocol be scrapped and a process launched for a full debate and legislation. They have had 11 months to figure this out, Mr. Lepofsky said. And they haven’t.
Dr. Downar said the protocols will not exclude people on the basis of disability. No iteration of the protocol would do that, and our protocols explicitly exclude it.
Dr. Downar added doctors and nurses left with impromptu triage practices would create far greater risk of bias. But, he acknowledged, even a system that controls subjectivity and implicit bias and is purely focused on mortality risk will still affect some groups more than others. Mortality risk is not evenly distributed in society.
The final page of Quebec’s protocol outlines criteria for resolving ties, putting a priority on younger people and workers in the health care system, elements not part of Ontario’s draft protocol.
In both Ontario and Quebec, if all else is equal, random chance will be used for the final selection of critical care patients. With a report from Jeff Gray in Toronto.

Undated Letter from A Member of the Ontario Government’s Critical Care COVID Command Centre to Ontario Hospitals

Ontario Critical Care COVID19 Command Centre_ Readiness for Emergency Standard of Care for Critical Care communication January 13 2021.pdf Dear Colleagues:
Please find attached documents that describe how to implement an emergency standard of care for admission to critical care.
This emergency standard of care does not apply now. This will require a clear, distinct, and specific time of initiation and discontinuation by the Ontario Critical Care COVID19 Command Centre.
Matt Anderson, in his recent memo Further Actions for Optimizing Care, indicated that, All hospitals are asked to review and standardize their critical care admission criteria in consultation with the Ontario Critical Care COVID-19 Command Centre. The emergency standard of care (attached) is intended to support this action. It operates within the Health Care Consent Act of Ontario; it does not involve the protocol-driven withdrawal of invasive physiologic support, but does involve the protocol-driven decisions to not offer admission to critical care.
It would be advisable for physicians and your hospital to prepare now to operationalize this emergency standard for when it is initiated. While the forms are included in the document, they are attached here as separate pdfs for ease of printing. Furthermore, here is a site that contains these documents as well as a narrated slide deck for use with knowledge translation. This site can be referenced for updates to these documents and supplementary resources to support implementation.
Along with developing readiness for this change, I recommend concurrently refreshing a commitment to consistent and proactive approaches to goals of care conversations with patients. Some of the tools within this document may be useful in this regard.
Please note that on November 13, 2020, I sent a draft Protocol which does involve protocol-driven withdrawal of invasive physiologic support. This emergency standard of care document supersedes that draft protocol. The substantive differences between this document and the November 13, 2020 draft Protocol are:
1. Removal of the requirement of a triage team that makes ICU bed allocation decisions; 2. Removal of reference to an external appeals committee; 3. No protocol-driven withdrawal of invasive physiologic support, which would require an executive order from Cabinet to operate outside of the Health Care Consent Act.
However, an updated version of the Protocol may be sent in the near future. Readiness of physicians and hospitals for an updated Protocol will be expedited by preparing to implement this emergency standard of care. The same principles and tools apply to both this Emergency Standard of Care and the forthcoming Protocol. Both approaches benefit from being derived from a Framework developed by the Ontario COVID-19 Bioethics Table. Both approaches emphasize a commitment to human rights, ethical principles, continuous improvement, and fair processes. A system of data collection about the application of this emergency standard of care is being created for the purpose of monitoring and revision of this approach. Information about how to transmit data to this system will be forthcoming soon. Thank you so much for all you are doing,
Andrew Baker Incident Commander Ontario Critical Care COVID19 Command Centre




Source link

Ontario Patients to Be Ranked for Life-Saving Care Should ICUs Become Full, Documents Show


Codi Wilson Web Content Writer, CP24
Published Monday, January 18, 2021

TORONTO –Patients with the greatest chance of survival beyond 12 months should be prioritized for critical care in the event that overwhelmed Ontario hospitals need to begin rationing life-saving treatments, the provincial government said in a document sent to hospitals earlier this month.

The province’s triage protocol guidance states that patients should be assessed and placed in a colour-coded framework based on their risk of short-term mortality, which is defined as survival beyond 12 months after the onset of critical illness.

“In the context of a major surge in demand for critical care resources, where the demand actually exceeds the number who can be safely managed with available resources (including ventilators, supplies and trained staff), it is inevitable that some who may have otherwise benefited from critical care will not receive it, and as a result, some will die who would otherwise have lived,” reads the province’s triage protocol document, dated Jan. 13, 2021.

“In such a context, an emergency standard of care is appropriate in order to mitigate the worst effects of this surge. This document represents an emergency standard of care that aims to reduce preventable deaths to the degree possible.”

According to the document, patients with a short-term mortality risk of 80 to 99 per cent should be labelled “red,” those with a 50 to 79 per cent risk should be labelled “purple.” Those with a short-term mortality risk of 30 to 49 should be categorized as “yellow” and patients with a risk of 1 to 29 should be labelled “green.”

The province states that in a “level 1 triage scenario,” patients who have a greater than 20 per cent chance of surviving twelve months should be prioritized and in a “level 2 scenario,” those with a greater than 50 per cent chance should be prioritized for care.

“Under a Level 2 triage, the hospital and regional authorities should continue to coordinate transportation of patients and resources to optimize the utilization of all critical care resources before initiating a level 3 triage,” the document reads.

In a “level 3 triage scenario,” those with a greater than 70 per cent chance of surviving 12 months should be prioritized for critical care.

“At level 3 triage patients who have suffered a cardiac arrest will be deprioritized for critical care, as their predicted mortality is greater than 30 (per cent). Thus, Code Blue may no longer be called for cardiac arrest, and out-of-hospital cardiac arrests may not be transferred to hospitals in Level 3 triage,” the document states.

All patients being considered for critical care treatment must be assessed by two physicians and if a consensus about the patient’s mortality risk is not reached, the more optimistic prognosis will be selected.

“If demand for critical care continues to exceed available resources at Level 3, there may be little clinical evidence to guide triage decisions on the basis of predicted short term mortality. As a result, triage decisions must appeal to procedural fairness,” the document concludes.

“If triage decisions must be made between multiple patients who cannot be distinguished on the basis of predicted short term mortality, a system of random selection among eligible and not-yet-admitted patients should be implemented by an administrator on call.”

Patients should be assessed “on an ongoing basis,” according to the document.

“ICU physicians should also reassess patients admitted to ICU at regular intervals, and consider withdrawal of life support through a shared decision-making process with SDMs (substitute decision-makers) if a patient does not appear to be improving despite receiving critical care,” the document continues.

The province has not said at what point hospitals will have to implement the triage protocol but speaking to CP24 last week, Dr. Michael Warner, the medical director of critical care at Michael Garron Hospital, said with around 400 COVID-19 patients in intensive care units around the province, that day could soon be coming.

“Once we get to the 550 number, which we will exceed for sure, that is where a potential triage protocol could be implemented whereby patients who are more likely to survive their COVID-19 or other illness will be given life support preferentially over others if those resources are not available for everybody,” he said.

The chair of the province’s science table said last week that about 25 per cent of all Ontario hospitals have no available ICU beds while another 25 per cent only have one or two remaining.

The province’s latest modelling released last Tuesday indicated that with three per cent case growth, Ontario hospitals could see 1,000 COVID-19 patients in intensive care by early February.

It should be noted that over the past week, COVID-19 case growth in Ontario has significantly slowed.

“We are at a dangerous point,” epidemiologist Dr. Adalsteinn Brown, co-chair of the province’s COVID-19 science table, said while releasing the modelling last week.

“As we climb closer to 1,000 intensive care beds, about half of our capacity filled with COVID-19 patients in February, we will have to confront choices that no doctor ever wants to make and no family ever wants to hear.”

Ontario NDP Leader Andrea Horwath accused the Ford government of keeping the triage protocol document “secret.”

“This document shows us all that we are on the path to heart-wrenching choices and devastating loss if we don’t make this lockdown count with stronger measures ” paid sick days, more help in long-term care, and in-workplace and in-school testing,” Horwath said in a written statement released Monday.

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

The Accessibility for Ontarians with Disabilities Act Alliance (AODA Alliance) also released a statement on Monday, outlining “dire concerns” they have about the protocol’s impact on those living with disabilities.

The group said setting a patient’s 12-month likely survival as the benchmark risks further discrimination against those living with disabilities.

“People with disabilities have been disproportionately exposed to the risk of getting COVID-19, and of suffering its most serious impacts,” David Lepofsky, chair of the AODA Alliance, said in a written statement.

“Compounding this cruel reality, this secret document shows that some patients with disabilities now risk being de-prioritized in access to life-saving critical care that they will disproportionately need if Ontario hospitals, now near the breaking point, cannot provide life-saving critical medical care to all patients needing it.”

The document sent to hospitals stresses the need to consider Ontario’s Human Rights Code when considering decisions on prioritizing care.

Speaking about the triage guidance at a news conference on Monday, Dr. David Williams, the province’s chief medical officer of health, said provincial officials hope that the protocol never has to be implemented.

“You don’t want to think of it in the heat of it, you want to lay these things out ahead of time. So I think they’ve done that with the hope of saying, we hope to never have to use this,” Williams said.

“I think that they are moving it around to look at because you want to have all of the different ones weigh in with their commentary… It’s hard to get a group of doctors in a room together to agree on everything and it is better if you socialize that and get the input and the collective knowledge and wisdom in a worse-case scenario hoping that it’s not something you are going to pull off the shelf.”

He said the province remains in a “precarious” position when it comes to ICU capacity.

“That is just one of the many things that is being done throughout the whole sector to prepare for… different scenarios that we are going to have to face as now our ICU beds are over that 400,” he said.

He noted that the province hopes to eventually bring the number of COVID-19 patients in ICU down below 150.

“That’s where the modellers said we could get back to doing all of the other procedures at the same time. That is a target to head for. I think we can get there,” he said.

“But it’s uncertain… we are plateauing but that doesn’t mean we can’t jump up again because places like the UK, and others, plateaued and then went up very rapidly when the UK variant took off.”

Original at https://toronto.ctvnews.ca/ontario-patients-to-be-ranked-for-life-saving-care-should-icus-become-full-documents-show-1.5271774




Source link

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


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

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

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

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

It lists three levels of critical care triage:

Story continues below advertisement

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

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

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

Read more:
Toronto hospital capacity crunch prompts pediatric transfers to SickKids to make space

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

[ Sign up for our Health IQ newsletter for the latest coronavirus updates ]

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

Step 1 says hospitals should build surge capacity.

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

Story continues below advertisement

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

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

Read more:
Ontario hospitals told to prepare for out-of-region patients amid rising coronavirus cases

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

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

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

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

Story continues below advertisement

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

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

“I sincerely hope we never need to use this because it is terrible for patients, terrible for their families, causes moral distress for health-care workers, and it’s something that we should do everything possible to avoid having to implement,” Warner said.

David Lepofsky, the chairman of Accessibility for Ontarians with Disabilities Act Alliance, said the triage guidelines are discriminatory.

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

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





© 2021 The Canadian Press





Source link