New Captioned Video Tells the Whole Disability Discrimination Story in Ontario’s Critical Care Triage Plan – and – More Media Reports Reveal More Cause for Worry


Accessibility for Ontarians with Disabilities Act Alliance Update

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

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

New Captioned Video Tells the Whole Disability Discrimination Story in Ontario’s Critical Care Triage Plan – and – More Media Reports Reveal More Cause for Worry

May 6, 2021

            SUMMARY

Here are six more important developments in our campaign to protect people with disabilities from disability discrimination in Ontario’s critical care triage protocol.

 1. New Captioned Video — Learn About the Disability Issues in Ontario’s Critical Care Triage Protocol

Day after day, you are getting so much information from us and others about the critical care triage issue for people with disabilities. That includes all the new information we report in this AODA Alliance Update.

Are you eager for a video that will explain what this is all about, from beginning to end? Check out the new captioned video by AODA Alliance Chair David Lepofsky where the whole story is explained. The video brings you up to date as of now. It explains the disability objections to the Ontario critical care triage, the troubling way the Ontario Government his dealing with this issue, and the bogus defences that the Government’s defenders have been giving the media, in their attempt to justify what the Government is doing.

We invite you to watch the video and share it with others. If you are teaching a course where this might be helpful, feel free to use this video. It is available at https://youtu.be/Ju8cyH7TbQo

Let us know what you think. Email your feedback to us at [email protected]

 2. Where is the Public Accountability for Critical Care Triage Now Being Conducted by Ambulance Crews?

We have been warning for months about the danger of “trickle down triage”. For example, an ambulance crew, called to a medical emergency at your home, could decide whether or not to give a patient life-saving care, before they even get to hospital. We expect ambulance crews to do all they can to save lives, and not to decide whether or not to even try to save a life.

The Ford Government has refused to answer questions about this, whether from the AODA Alliance in writing or from the opposition in Question Period in the Legislature. In a very upsetting article in the April 28, 2021 Toronto Sun, set out below, it is evident that this triage is already going on.

This is a life and death issue. The public should daily be told how many lives are lost due to any form of triage, including this roadside triage. The Ford Government should now make public any directions to ambulance and emergency crews on this kind of triage. Protections need to be put in place to avert the danger of disability discrimination. We know that there is clear disability discrimination in the directions already sent to Ontario doctors, should they have to triage critical care services. There is no reason to be confident that there is no such danger if triage is done by ambulance crews before even reaching a hospital.

 3. Who Exactly Will Live and Who Will Die if There is Critical care Triage in Hospitals? Behind Closed Doors, Practice Drills Have Been Going on For Months with No Public Accountability

The April 27, 2021 report by Global News, set out below, confirms that hospitals have been training for months on how to conduct critical care triage, in case it becomes necessary. This is all happening behind closed doors. We have no idea who ends up living and who ends up dying, according to these practice drills or simulations. We have no idea how differently the same case is decided from one hospital to the next, or from one doctor to the next. We have no word that anyone with human rights expertise is part of this, to alert doctors when they are running afoul of the Charter of Rights and the Ontario Human Rights Code. We have no idea if the Ford Government is monitoring any of this, to find out where its disability discriminatory Ontario critical care triage protocol needs to be fixed.

 4. Pulling Back the Curtain on A Troubling and Misleading Media Strategy Now In Place, Seemingly Led by Those Behind Ontario’s Disability-Discriminatory Critical Care Triage Protocol

Those who are behind the creation and implementation of Ontario’s disability-discriminatory critical care triage protocol appear now to be conducting some sort of media public relations strategy to get out their version of this controversial issue. This appears to be underway to manage public expectations about critical care triage and to respond to some bad press that The Government has gotten on this issue. In the January 23, 2021 online webinar for doctors on the critical care triage protocol, those evidently at the centre of this indicated that they were planning such a communications strategy, to be later rolled out close to the time that critical care triage may become necessary.

Among the key people quoted in these stories include Dr. James Downar, co-author of the disability-discriminatory Ontario critical care triage protocol, and Dr. David Neilipovitz, a lead at the Ford Government’s secretive Critical Care COVID-19 Command Centre. We have asked the Ford Government who are the members of that command centre, and what its mandate includes. As with all our other inquiries, the Ford Government has refused to answer.

Part of this communication strategy seems to be the repetition of bogus arguments to defend the critical care triage protocols disability discrimination. In the April 20, 2021 AODA Alliance Update, we listed some of those bogus arguments.

In the April 26, 2021 Metroland report set out below, yet another bogus defence is offered, as follows, quoting Dr. Downar:

“Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.

“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. “It’s not applied to everybody who has a disability.””

As in other contexts which we document in the April 20, 2021 AODA Alliance Update, this absurd argument presupposes that disability discrimination only exists if you discriminate against all people with disabilities at the same time. By that bankrupt approach, Nazi Germany’s viciously anti-Semitic Nuremberg laws did not discriminate because of religion. That is because they only applied to Jews and equally applied to all Jews. It would similarly justify separate schools for black children, as was the case in the US for decades, under the widely denounced 1896 U.S. Supreme Court ruling in Plessy v. Ferguson.

The Supreme Court of Canada wisely rejected such an impoverished approach to equality decades ago, in Andrews v. Law Society of BC, where the Court stated:

“The test as stated, however, is seriously deficient in that it excludes any consideration of the nature of the law. If it were to be applied literally, it could be used to justify the Nuremberg laws of Adolf Hitler. Similar treatment was contemplated for all Jews. The similarly situated test would have justified the formalistic separate but equal doctrine of Plessy v. Ferguson, 163 U.S. 637 (1896), …”

We encourage the Ford Government to get their human rights legal advice from the Ontario Human Rights Commission and human rights experts, and not from physicians.

Another bogus and misleading part of this communication strategy is to try to misleadingly water down what critical care triage is. If a patient is refused critical care triage, they are bound to die. Yet part of the communication strategy on which we pull back the curtain is to claim that no one will be refused care. The April 26, 2021 Metroland article, set out below, includes this:

“What would triaging look like in Ontario?

“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.”

Let’s decode this. If you are refused critical care you need, you won’t be kicked right out of the hospital. You will be offered some lesser form of care, like palliative care. However, that is not the care you need to have any hope o of surviving.

This would be like someone who gets a gunshot wound who is told that they can’t have surgery they need to survive, and then being told: “But we are not refusing you care. Here’s an aspirin.”

Later in this Update, a May 5, 2021 article from CBC news online includes some of the same dubious defences. It gives no attention to voices from the disability community. This appears to be another story that could well be part of the communication strategy being conducted on behalf of the Ford Government’s Critical Care COVID Command Centre, to manage public expectations.

 5. Due to Protracted and Harmful Government Secrecy, Media Must Continue to Rely on Leaks to Report on Ontario’s Critical Care Triage situation

In a May 4, 2021 news report set out below, The Globe and Mail reported that Ontario’s ICU overload may be levelling off. This could avoid the need for The Government to green light rationing or triage of critical care, even though, as noted above, this appears to be going on already in our health care system in one form or another.

It is worrisome that the Globe and Mail report is based on a leaked internal memo. Those making these decisions are still cloistered behind closed doors.

That leak could have come from an aggrieved doctor working in the system. On the other hand, it could well have come from an official at the Ministry of Health, the Premier’s office or Ontario Health. They are taking heat for the critical care triage issue. Such a leak would help deflect some of that pressure. It could lead some reporters to think (wrongly, if so) that there is no longer a story here to cover, when it comes to disability discrimination in critical care triage. However, Ontario is certainly not out of the woods by any means.

 6. Disability Accessibility, the Ford Government and the Big Picture

The Ford Government’s delays on disability accessibility just carry on. There have now been 826 days, or over 2 and a quarter years, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no effective plan of new action to implement that report. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis. The Ontario Government only has 1,336 days left until 2025, the deadline by which the Government must have led Ontario to become fully accessible to people with disabilities.

            MORE DETAILS

 Toronto Sun April 28, 2021

Originally posted at https://torontosun.com/news/local-news/to-live-or-die-waves-of-covid-reality-hit-torontos-paramedics

TO LIVE OR DIE: Waves of COVID reality hit Toronto’s paramedics

Struggling to keep up with Toronto’s third wave, city paramedics say they’re having to ‘triage’ cardiac arrest patients

Author of the article: Bryan Passifiume

Paramedics wheel a patient into the emergency department at Mount Sinai Hospital in Toronto, Wednesday, Jan. 13, 2021. PHOTO BY COLE BURSTON /The Canadian Press

As soon as the call clears, another one’s loaded and ready.

And these days, it’ll most likely be another COVID patient.

That’s the reality for Toronto’s paramedics, who say nobody among their ranks thought COVID-19’s third wave would be this bad.

“You just don’t believe the news, the news says hospitals are overwhelmed, but are they?” said a veteran Toronto advanced-care paramedic, whom the Toronto Sun agreed not to identify.

“From the horse’s mouth: we’re seeing it — that’s something we’re all now realizing.”

While Toronto’s professional lifesavers have indeed been busy this past year, he told the Sun things really started to get bad earlier this month.

In fact, he remembers the exact call.

“Honestly, it was three weeks ago,” he said, describing the short-of-breath 30-something male he and his partner were dispatched to assist.

“This guy had a fever and couldn’t get up, and we’re like, ‘Oh, damn,’” he recalled.

“He had a room-air sat of 50%.”

Patients with blood-oxygen levels that low are almost always unconscious. In fact, anything below 90% is cause for concern.

Called “silent hypoxia,” it’s one of this pandemic’s biggest medical mysteries: how patients with such dangerously low oxygen levels show little outward evidence of their dire condition.

“They don’t even look tired,” he said.

“Then you check them and realize … ‘Dude, really?! You don’t feel this?! We need to go to the hospital.’”

It’s this deceptive pathology that makes COVID such a challenge.

“It causes moments where the patient looks OK, but they’re actually really, really bad,” he said, adding those patients often crash quickly and catastrophically.

What sticks out the most are the ages — and a lack of comorbidities — of those going into the back of his ambulance.

“Waves one and two were elderly people,” he said.

“Now we’re averaging late 40s.”

What irks him and his co-workers most are those who dismiss COVID as a bad flu.

“Influenza doesn’t make your O2 (oxygen) saturation drop below your age,” he said.

“We’re seeing patients with oxygen levels not seen without opioids in play, and neither Narcan nor oxygen are going to fix it.”

Emergency rooms and ICUs are full, he said — with many receiving care in the ER normally seen in intensive care.

“That’s what overcapacity means,” he said.

“It means that there’s people in emerge receiving ICU treatment — and that’s not the place for it.”

A paramedic transports a patient to Mount Sinai Hospital in Toronto, April 17, 2020.

City Council orders check-up on Toronto paramedics

Erik Sande is the president of Medavie Health Services.

SANDE: Paramedics answer the call — across Ontario’s health system

A Region of Durham Paramedic Services ambulance.

Gravely-ill patients more likely to be pronounced dead at scene

As city hospitals steel themselves for worst-case triage protocols, paramedics say it’s a reality they’re already experiencing.

Overrun emergency rooms and intensive-care units put paramedics in the position — as well as the base physic

ians overseeing them — of having to pronounce gravely ill patients, particularly in cases of cardiac arrest, deceased on scene rather than going through the usually hopeless motions of seeking hospital treatment.

“I haven’t actively run a cardiac arrest in the past five I’ve done,” said the Toronto advanced-care paramedic.

“We just said to the family, ‘Do you want anything done?’”

Cardiac arrest, particularly in older patients, is a dire medical emergency with less than 10% survival rates, according to the Heart and Stroke Foundation.

The COVID emergency, the paramedic said, means they’re more likely to pronounce such patients dead over pursuing lifesaving efforts that only serve to prolong the inevitable.

Except in cases of obvious and catastrophic trauma, paramedics seek guidance on pronouncing death from physicians over the phone.

“I got a pronouncement in 20 seconds the other day,” the paramedic said.

The alternative, he said, is often worse.

“If you get them back, where are they going to go, into the ICU to live for a day on a vent and die?” he said.

“The family’s able to see them now, be with them — there’s no closure bringing (the patient) to the hospital where, oh by the way, they can’t come.”

This leads to paramedics forced into end-of-life discussions with grieving family members.

“You know who does those? Doctors. Doctors have those conversations,” he said.

“Now, it’s us.”

Experts, including outspoken critical care physician Dr. Michael Warner, are warning Toronto’s hospitals are just days away from ICU triage, where decisions are made on who is and isn’t entitled to lifesaving care.

“The way Dr. Warner’s talking about how we don’t want to have to triage ICU patients, we are now triaging cardiac arrest patients,” the paramedic said. “If bringing this person back or giving them hope means only living for one more day on a ventilator … man, no. Let them go.”

Families forced to make this decision, he said, are almost always grateful.

“They say ‘Thank you for not working on them, thank you for letting them pass as peacefully as possible,” he said.

“Then you walk out, do your paperwork, grab a coffee, then go on to the next one.”

[email protected]

On Twitter: @bryanpassifiume

 Global News April 27, 2021

Originally posted at https://fm96.com/news/7812658/covid-ontario-icu-emergency-triage/

Pushing Ontario’s ICUs to the brink: How some hospitals are preparing for the worst FM96 London

Rachael D’Amore GlobalNews.ca

More than a year into the COVID-19 pandemic, Ontario doctors and nurses may have more experience treating the disease but are increasingly staring life-or-death decisions in the face.

The spike in cases has strained intensive care capacity across the province. There are about 875 COVID-19 patients in Ontario hospital ICUs as of Tuesday — an all-time high — and 589 people in intensive care units (ICUs) on a ventilator. With staffing shortages — particularly the lack of ICU-trained nurses — and beds rapidly filling up, discussions about the possible need to triage life-saving care are mounting.

A “critical care triage protocol,” something that was not done during earlier waves of the virus, could be enacted, meaning health-care providers may have to decide who gets potentially life-saving care and who doesn’t.

“If you’ve ever participated in a fire drill, you understand what we’re talking about here,” said Dr. James Downar, a palliative and critical care physician in Ottawa who co-wrote Ontario’s ICU protocol.

“The purpose of training is to be prepared because if a crisis arrives and you run out of your resources and you don’t have a plan and you’re not prepared to institute your plan, things will get very, very bad.”

Ontario hospitals received a document in January laying out guidelines on how to deal with critical care triage. In other words, what to do if there aren’t enough ICU beds.

Under those guidelines, patients are essentially ranked on their likelihood to survive one year after the onset of a critical illness. The process came under criticism from human rights advocates, saying it is discriminatory, particularly toward people with disabilities and seniors.

At this point, the province has not finalized the protocol nor has it officially been published, but a widely circulating draft titled “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” – said patients could be scored by doctors on a “short-term mortality risk assessment.”

The aim would be to “prioritize those patients who are most likely to survive their critical illness,” the document reads.

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

The lists three levels of critical care triage:

  • Level 1 triage deprioritizes critical care resources for patients with a predicted mortality greater than 80 per cent.
  • Level 2 triage deprioritizes critical care resources for patients with a predicted mortality greater than 50 per cent.
  • At Level 3 triage, patients with predicted mortality of 30 per cent — or a 70 per cent chance of surviving beyond a year — will not receive critical care.

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

The leaked document was prepared by the province’s critical care COVID-19 command centre, which would ultimately declare when to use it.

Hundreds of COVID-19 ICU patient transfers planned as Ontario braces for ‘horrific’ 2 weeks

The College of Physicians and Surgeons of Ontario told doctors on April 8 that the province was considering “enacting the critical care triage protocol,” and that it would support such a tool once it is “initiated by the command tables of the province” and “even when doing so requires departing from our policy expectations.”

Downar emphasized that the protocol has not been instituted, echoing Ontario Health Minister Christine Elliott who on April 7 said “there are some emergency protocols out there” but they “have not finalized any of that yet.”

“None of us want to be in this position, none of us want to be doing this,” said Downar. “We are prepared for it if it comes to that, but we are focused on not letting it come to that.”

While a standard provincial protocol has not been formally established, some Ontario hospitals have been preparing anyway.

The University Health Network (UHN), which includes Toronto General, Toronto Western and Princess Margaret hospitals, have started virtual training sessions for staff on what to do if the virus’ growth gets the better of all other efforts to expand and accommodate the ICU system.

Dr. Niall Ferguson, the head of critical care at UHN, said while preparations for worst-case scenarios are happening, it doesn’t necessarily mean they’ll be enacted.

“We’re not expecting to be implementing them anytime in the near future… I think the likelihood is probably low,” he told Global News.

“COVID is more like a controlled train crash as opposed to an actual train crash where you’ve got a thousand critically ill people all on the same day — then triage is inevitable. When you’re getting a thousand critical care patients over the course of weeks, which we are here, then there is an opportunity to adapt the system and grow capacity and do things differently.”

Ontario’s latest modelling predictions cast doubt on short-term improvements. Even as cases slow or plateau, hospitalizations and ICU numbers are so-called “lagging indicators” of the severity of the virus in a certain jurisdiction. The provincial data predicts a peak of at least 1,500 virus cases in ICUs by the first week of May — that’s next week — and it could be higher, pushing Ontario’s total 2,000-ICU-bed capacity over the edge.

Downar said some training around emergency care standards has been “going on for months.”

He said avoiding the worst-case scenario depends on a lot of things and is not as simple as “staring at the number of COVID cases.”

“It’s tough. Everybody wants to know a number and everybody wants to know where that line is, but it’s just not something that is easily put into numbers at the moment.”

What’s unfolded over the past few weeks exemplifies just how bad it’s gotten — but also how the system has been forced to adapt, as Ferguson said. Hundreds of patients from already over-capacity hospitals in the Greater Toronto Area are being transferred to other hospitals hours away. The province has directed hospitals to “ramp down” all elective and non-emergency surgeries to help alleviate pressure on the health-care system.

“Transfers are not completely benign. There is a risk when we transfer people from one place to another,” Downar said. “It’s important for everybody to recognize that there already consequences to what we’ve been doing.”

 Metroland DurhamRegion.com April 26, 2021

Originally posted at https://www.durhamregion.com/news-story/10381003-what-would-triaging-patients-look-like-in-ontario-s-hospitals-if-invoked-/

What would triaging patients look like in Ontario’s hospitals if invoked?

Protocol created to ‘counteract implicit biases and subjectivity’

Veronica Appia

OurWindsor.Ca

Monday, April 26, 2021

This story is Part Two of a two-part explainer about the current surge of patients in Ontario’s intensive care units amid the third wave of COVID-19, and the possibility of the province invoking the Emergency Standard of Care protocol. Read Part One here.

Amid a rise in ICU admissions across the province, medical experts have been discussing the possibility of invoking the Emergency Standard of Care protocol, released by the Ontario Critical Care COVID-19 Command Centre earlier this year, which includes three triaging scenarios.

Dr. David Neilipovitz, the department head of critical care at the Ottawa Hospital and a lead at the Ontario Critical Care COVID-19 Command Centre, said it’s important to note that the Emergency Standard of Care protocol has different aspects to it and “not everything is triage.”

“Triage has a different connotation,” he said, adding that this would typically mean withdrawing care from patients without their family’s consent.

Neilipovitz said that while the Emergency Standard of Care protocol has similar aspects, there is no withdrawal of care.

What would triaging look like in Ontario?

“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.

Rather, he said, it would be a matter of determining other appropriate ways to support the patients that would not have access to critical care.

“The whole principle of triage is to try to maximize the number of lives saved with the resources that you have and so, in general, the concept is we want to be able to identify patients who are most likely to benefit from receiving IC services,” Wax noted.

Dr. James Downar, a palliative and critical care specialist who was responsible for creating the protocol, added that the decision as to who would have access, under the protocol, would solely be determined by mortality risk.

Is triaging patients a likely reality for Ontario’s hospitals?

“Everybody who would be considered for critical care would have two separate assessments performed by qualified physicians to assess what would be felt to be their short-term mortality risk and they would use their clinical judgment, aided by the guidance provided,” he said, adding that in cases where there is insufficient data or disagreement between physicians, the hospital would take the most optimistic approach.

What are the human rights implications?

The concept of triaging has been cause for concern for human rights advocates and disability groups.

In an April 22 statement to Metroland, Ena Chadha, chief commissioner of the Ontario Human Rights Commission (OHRC), said the Emergency Standard of Care protocol “includes potentially discriminatory triage criteria, should doctors be forced to decide who gets access to critical care and who does not.”

She stated that since December 2020, human rights groups and vulnerable populations have not been consulted on the protocol.

On April 9, the OHRC issued a public statement asking the government to provide the status of the Emergency Standard of Care protocol, confirm that the Health Care Consent Act prevails to protect the rights of patients and families, consult human rights stakeholders and require hospitals to collect data about the populations most affected by COVID-19.

In response to these concerns, Downar said that the reason the protocol was created in the first place was to ensure there wouldn’t be any human rights concerns in these scenarios.

“When human beings are overwhelmed and confronted by difficult decisions in emotional situations, that’s where implicit biases and subjectivity become major factors and undermine decision-making,” he said.

“You counteract that with explicit guidance and consistent rules.”

Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.

“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. “It’s not applied to to everybody who has a disability.”

Veronica Appia is a reporter with Torstar Corporation Community Brands, covering COVID-19 news across Ontario.

 The Globe and Mail May 4, 2021

Memo says Ontario hospitals may avoid triage protocol

By JEFF GRAY

Staff

Ontario’s hospitals, despite facing an unprecedented strain from COVID-19, will likely escape the pandemic’s third wave without resorting to a triage protocol that would have forced doctors to decide who lives and who dies, according to a memo obtained by The Globe and Mail.

Doctors and hospital officials warn that weeks of tough public-health restrictions are still needed to keep slowing the virus’s spread. Hospitals will also need to keep increasing their already ballooned intensive-care capacity, postponing non-emergency operations and helicoptering patients from jammed facilities in hot spots to other beds across the province.

As of Monday, Ontario had 881 COVID-19 patients in its ICUs, more than double the total from just a month ago.

But the rate of increase appeared to be slowing. (In all, there were just over 2,000 patients of all kinds in the province’s ICUs.)

In a message to hospital chief executives dated May 2, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says recent provincial modelling is still “concerning,” even as it shows a lower estimated number of COVID-19 ICU admissions than it did two weeks ago.

The memo asks hospitals to put 284 more ICU beds, already identified as ready to go at short notice, into operation and to prepare to receive more transferred patients. And it says the command centre will monitor staffing levels, and the effects of recent moves to transfer more elderly patients into long-term care homes, to determine whether hospitals should try to create even more critical-care capacity.

But the memo adds that it now looks as though the worst can be avoided: “I also wanted to share with you and your teams that we are increasingly confident that we will not need to activate the Emergency Standard of Care or recommend the use of the triage protocol.”

Requests for comment from Dr. Baker, who is chair of the critical-care department at St. Michael’s Hospital in Toronto, were referred to Ontario Health, the government agency that oversees health care in the province.

Ontario Health executive vice-president Chris Simpson, also a Kingston cardiologist, said the worst-case scenario from the most recent modelling by the province’s external COVID-19 Science Table – which projected the potential for more than 1,400 COVID-19 patients in the province’s ICUs by month’s end – would mean triage could be necessary.

But the province appears to be tracking the modelling’s mid-range scenario, in which ICU admissions crest around 1,000 before descending gradually.

“I think that scenario, if that were to unfold, does keep us out of triage-tool territory,” Dr. Simpson said. “But only because of the extra capacity that we have been able to bring online.”

He cautioned that the stresses on the system were already having effects on the quality of care for patients. He also raised concerns there could be “tremendous pressure” to reopen the province too quickly if cases continue to plateau or fall.

Doing so, he warned, could plunge the province into a fourth wave.

Kevin Smith, president and CEO of University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said even as numbers appear to be levelling off, hospitals and their staff are stretched past their normal limits. To avoid the worst, he said Ontarians need to keep following strict public-health rules, get vaccinated as quickly as possible and not let their guard down over the May long weekend.

“I would certainly hate for anyone to think that this is a time to relax,” he said.

“Absolutely that is not the case.”

Anthony Dale, president and CEO of the Ontario Hospital Association, said the science table predictions are cause for hope, noting that daily new infection numbers have been moderating. (Ontario recorded 3,436 new cases on Monday, down from a peak of more than 4,800 in mid-April.)

But he said nothing about COVID-19 can be taken for granted. Even if these encouraging trends continue, he said, the health care system will still be in a state of massive disruption for months, noting that more than 250,000 operations have been postponed in the pandemic.

“There’s nothing natural or normal about any of this,” Mr. Dale said.

Ontario’s triage protocol has been clouded by secrecy. A draft was only made public after a leaked copy was obtained by a disability rights group. Under the plans, incoming patients would be assessed for their likelihood of survival after 12 months. Those with the best chances would be prioritized for ICU beds.

 CBC Online News May 5, 2021

Originally posted at: https://www.cbc.ca/news/canada/toronto/doctors-describe-critical-care-triage-training-as-surreal-emotional-1.6013411

Doctors express relief, cautious optimism at news Ontario will likely avoid triage protocol

Province says no triage model has been activated in Ontario at this time

Talia Ricci CBC News

Dr. Shajan Ahmed says most of his colleagues had never done any kind of triage training before. He was part of a group of physicians at UHN who participated in mock scenarios during the second wave. (Submitted/Shajan Ahmed)

Dr. Shajan Ahmed says he always thought of triage training as something needed in other countries or in war zones, where doctors must decide who gets potentially life-saving care and who doesn’t.

So when the emergency room physician with Toronto’s University Health Network found himself watching a webinar about it to help prepare doctors for the third wave of COVID-19, he says he was in a bit of shock.

“To come to grips with this being right at our [doorsteps] here in Toronto, a place where we have all kinds of resources, it was really bizarre, it was surreal,” he told CBC Toronto.

“None of us had trained for it before and none of us really signed up for this, to be honest with you.”

Ahmed was among a group of around 60 physicians who received the training earlier this year. It included running through mock cases, reading material and referencing online resources. The virtual sessions were conducted over Zoom with experts in simulation, ethics and palliative care.

The province says no triage model has been activated in Ontario at this time, and although the overall number of ICU admissions climbed to 900 for the first time last Saturday, the rate of increase appears to have started to slow down. In a memo obtained by CBC News directed to hospital CEOs, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says projections remained “very concerning.” But the memo also adds they are “increasingly confident” that they will not need to recommend the use of the triage protocol.

But the prospect still weighs on the minds of some doctors, and for Ahmed, the training made the situation feel “very real.”

Hospitals in Ontario may not have to use triage protocol, memo says

“You read about it and you think it may come, but until you are actually doing the training it doesn’t feel real until that point,” he said, adding the sessions were more challenging than he anticipated.

“We would debrief after the sessions to talk about how it felt, and what was going through our minds and collectively everyone had to take a deep breath and, I guess, also a bit of a sigh of relief because we aren’t actually in this situation.”

Despite describing the current situation in GTA hospitals as “bursting at the seams,” Ahmed wants people to know if the triage model is activated, patients will still be cared for. The decision is not whether someone lives or dies but whether the person would be offered ICU level care.

“It’s very complex and there’s a lot of logistics involved but I don’t want the public to think we’re making decisions as to booting people to the street without providing care,” he said.

“We absolutely will provide care.”

Compassionate conversations part of the training

Dr. Erin O’ Connor, the deputy medical director of the University Health Network’s emergency departments, was part of the team that led the training.

“There’s a lot of emotion around this and this isn’t something any physician or any health-care provider wants to do, but when we were getting ever closer to it we realized we needed to prepare ourselves,” she said.

She adds that conversations with patients and their families were a big part of it.

“It helped people find the right way to say this kindly and empathetically and to also recognize and process their own emotions around it.”

Dr. Erin O’Connor is the deputy medical director of emergency departments at Toronto’s University

Health Network. O’Connor describes the process as an application of tools to help determine how likely someone is to survive and their likelihood of survival after a year of any acute illness, not just COVID-19. She says the team looked at five cases that represented typical situations in the emergency department and had participants evaluate the patients’ chances of survival.

“It was a little bit of how you would apply the tools to different cases, so it wasn’t so abstract,” she explained. She says the whole point of developing the short term mortality risk tools was to remove any bias from the system.

Canadian Armed Forces sending teams to Ontario as COVID-19 cases strain critical care capacity

“It was very clearly laid out that decisions cannot be made based on race, gender, economic status, disability, or age. This is really looking at as much as possible the medical factors that contribute to whether someone has a high chance of survival at a year,” she said.

Resources have been expanded through bringing health-care workers from other parts of the country, redeploying and retraining health-care workers, cancelling surgeries, bringing in more ventilators and transferring patients from hot-spot areas, among other measures. The Ministry of Health says the province continues to create additional hospital beds in the province, including the creation of two mobile health units.

“The logistics have been massive. But all of these things are being done to prevent us from getting into a position where we have to triage resources,” O’Connor said.

She says she’s feeling cautiously optimistic given the recent trends.

“We’re not out of the woods yet because we know patients stay in the ICU for a long time but we are slightly backing away from the need to use this.”

But Ahmed still thinks about it, and is still concerned about the current state of ICUs. He’s encouraging people to have conversations with loved ones about their goals of care.

“A lot of us lose sleep over it.”

ABOUT THE AUTHOR

Talia Ricci

Talia Ricci is a CBC reporter based in Toronto. She has travelled around the globe with her camera documenting people and places as well as volunteering. Talia enjoys covering offbeat human interest stories and exposing social justice issues. When she’s not reporting, you can find her reading or strolling the city with a film camera.



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New Captioned Video Tells the Whole Disability Discrimination Story in Ontario’s Critical Care Triage Plan and More Media Reports Reveal More Cause for Worry


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/

May 6, 2021

SUMMARY

Here are six more important developments in our campaign to protect people with disabilities from disability discrimination in Ontario’s critical care triage protocol.

1. New Captioned Video — Learn About the Disability Issues in Ontario’s Critical Care Triage Protocol

Day after day, you are getting so much information from us and others about the critical care triage issue for people with disabilities. That includes all the new information we report in this AODA Alliance Update.

Are you eager for a video that will explain what this is all about, from beginning to end? Check out the new captioned video by AODA Alliance Chair David Lepofsky where the whole story is explained. The video brings you up to date as of now. It explains the disability objections to the Ontario critical care triage, the troubling way the Ontario Government his dealing with this issue, and the bogus defences that the Government’s defenders have been giving the media, in their attempt to justify what the Government is doing.

We invite you to watch the video and share it with others. If you are teaching a course where this might be helpful, feel free to use this video. It is available at https://youtu.be/Ju8cyH7TbQo

Let us know what you think. Email your feedback to us at [email protected]

2. Where is the Public Accountability for Critical Care Triage Now Being Conducted by Ambulance Crews?

We have been warning for months about the danger of trickle down triage. For example, an ambulance crew, called to a medical emergency at your home, could decide whether or not to give a patient life-saving care, before they even get to hospital. We expect ambulance crews to do all they can to save lives, and not to decide whether or not to even try to save a life.

The Ford Government has refused to answer questions about this, whether from the AODA Alliance in writing or from the opposition in Question Period in the Legislature. In a very upsetting article in the April 28, 2021 Toronto Sun, set out below, it is evident that this triage is already going on.

This is a life and death issue. The public should daily be told how many lives are lost due to any form of triage, including this roadside triage. The Ford Government should now make public any directions to ambulance and emergency crews on this kind of triage. Protections need to be put in place to avert the danger of disability discrimination. We know that there is clear disability discrimination in the directions already sent to Ontario doctors, should they have to triage critical care services. There is no reason to be confident that there is no such danger if triage is done by ambulance crews before even reaching a hospital.

3. Who Exactly Will Live and Who Will Die if There is Critical care Triage in Hospitals? Behind Closed Doors, Practice Drills Have Been Going on For Months with No Public Accountability

The April 27, 2021 report by Global News, set out below, confirms that hospitals have been training for months on how to conduct critical care triage, in case it becomes necessary. This is all happening behind closed doors. We have no idea who ends up living and who ends up dying, according to these practice drills or simulations. We have no idea how differently the same case is decided from one hospital to the next, or from one doctor to the next. We have no word that anyone with human rights expertise is part of this, to alert doctors when they are running afoul of the Charter of Rights and the Ontario Human Rights Code. We have no idea if the Ford Government is monitoring any of this, to find out where its disability discriminatory Ontario critical care triage protocol needs to be fixed.

4. Pulling Back the Curtain on A Troubling and Misleading Media Strategy Now In Place, Seemingly Led by Those Behind Ontario’s Disability-Discriminatory Critical Care Triage Protocol

Those who are behind the creation and implementation of Ontario’s disability-discriminatory critical care triage protocol appear now to be conducting some sort of media public relations strategy to get out their version of this controversial issue. This appears to be underway to manage public expectations about critical care triage and to respond to some bad press that The Government has gotten on this issue. In the January 23, 2021 online webinar for doctors on the critical care triage protocol, those evidently at the centre of this indicated that they were planning such a communications strategy, to be later rolled out close to the time that critical care triage may become necessary.

Among the key people quoted in these stories include Dr. James Downar, co-author of the disability-discriminatory Ontario critical care triage protocol, and Dr. David Neilipovitz, a lead at the Ford Government’s secretive Critical Care COVID-19 Command Centre. We have asked the Ford Government who are the members of that command centre, and what its mandate includes. As with all our other inquiries, the Ford Government has refused to answer.

Part of this communication strategy seems to be the repetition of bogus arguments to defend the critical care triage protocols disability discrimination. In the April 20, 2021 AODA Alliance Update, we listed some of those bogus arguments.

In the April 26, 2021 Metroland report set out below, yet another bogus defence is offered, as follows, quoting Dr. Downar:

Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.

“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. It’s not applied to everybody who has a disability.”

As in other contexts which we document in the April 20, 2021 AODA Alliance Update, this absurd argument presupposes that disability discrimination only exists if you discriminate against all people with disabilities at the same time. By that bankrupt approach, Nazi Germany’s viciously anti-Semitic Nuremberg laws did not discriminate because of religion. That is because they only applied to Jews and equally applied to all Jews. It would similarly justify separate schools for black children, as was the case in the US for decades, under the widely denounced 1896 U.S. Supreme Court ruling in Plessy v. Ferguson.

The Supreme Court of Canada wisely rejected such an impoverished approach to equality decades ago, in Andrews v. Law Society of BC, where the Court stated:

The test as stated, however, is seriously deficient in that it excludes any consideration of the nature of the law. If it were to be applied literally, it could be used to justify the Nuremberg laws of Adolf Hitler. Similar treatment was contemplated for all Jews. The similarly situated test would have justified the formalistic separate but equal doctrine of Plessy v. Ferguson, 163 U.S. 637 (1896),

We encourage the Ford Government to get their human rights legal advice from the Ontario Human Rights Commission and human rights experts, and not from physicians.

Another bogus and misleading part of this communication strategy is to try to misleadingly water down what critical care triage is. If a patient is refused critical care triage, they are bound to die. Yet part of the communication strategy on which we pull back the curtain is to claim that no one will be refused care. The April 26, 2021 Metroland article, set out below, includes this:

What would triaging look like in Ontario?
“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.

Let’s decode this. If you are refused critical care you need, you won’t be kicked right out of the hospital. You will be offered some lesser form of care, like palliative care. However, that is not the care you need to have any hope o of surviving.

This would be like someone who gets a gunshot wound who is told that they can’t have surgery they need to survive, and then being told: But we are not refusing you care. Here’s an aspirin.

Later in this Update, a May 5, 2021 article from CBC news online includes some of the same dubious defences. It gives no attention to voices from the disability community. This appears to be another story that could well be part of the communication strategy being conducted on behalf of the Ford Government’s Critical Care COVID Command Centre, to manage public expectations.

5. Due to Protracted and Harmful Government Secrecy, Media Must Continue to Rely on Leaks to Report on Ontario’s Critical Care Triage situation

In a May 4, 2021 news report set out below, The Globe and Mail reported that Ontario’s ICU overload may be levelling off. This could avoid the need for The Government to green light rationing or triage of critical care, even though, as noted above, this appears to be going on already in our health care system in one form or another.

It is worrisome that the Globe and Mail report is based on a leaked internal memo. Those making these decisions are still cloistered behind closed doors.

That leak could have come from an aggrieved doctor working in the system. On the other hand, it could well have come from an official at the Ministry of Health, the Premier’s office or Ontario Health. They are taking heat for the critical care triage issue. Such a leak would help deflect some of that pressure. It could lead some reporters to think (wrongly, if so) that there is no longer a story here to cover, when it comes to disability discrimination in critical care triage. However, Ontario is certainly not out of the woods by any means.

6. Disability Accessibility, the Ford Government and the Big Picture

The Ford Government’s delays on disability accessibility just carry on. There have now been 826 days, or over 2 and a quarter years, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no effective plan of new action to implement that report. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis. The Ontario Government only has 1,336 days left until 2025, the deadline by which the Government must have led Ontario to become fully accessible to people with disabilities.

MORE DETAILS
Toronto Sun April 28, 2021

Originally posted at https://torontosun.com/news/local-news/to-live-or-die-waves-of-covid-reality-hit-torontos-paramedics

TO LIVE OR DIE: Waves of COVID reality hit Toronto’s paramedics
Struggling to keep up with Toronto’s third wave, city paramedics say they’re having to ‘triage’ cardiac arrest patients

Author of the article: Bryan Passifiume
Paramedics wheel a patient into the emergency department at Mount Sinai Hospital in Toronto, Wednesday, Jan. 13, 2021. PHOTO BY COLE BURSTON /The Canadian Press As soon as the call clears, another one’s loaded and ready.

And these days, it’ll most likely be another COVID patient.

That’s the reality for Toronto’s paramedics, who say nobody among their ranks thought COVID-19’s third wave would be this bad.

You just don’t believe the news, the news says hospitals are overwhelmed, but are they? said a veteran Toronto advanced-care paramedic, whom the Toronto Sun agreed not to identify.

From the horse’s mouth: we’re seeing it that’s something we’re all now realizing.

While Toronto’s professional lifesavers have indeed been busy this past year, he told the Sun things really started to get bad earlier this month.

In fact, he remembers the exact call.

Honestly, it was three weeks ago, he said, describing the short-of-breath 30-something male he and his partner were dispatched to assist.

This guy had a fever and couldn’t get up, and we’re like, Oh, damn,’ he recalled.

He had a room-air sat of 50%.

Patients with blood-oxygen levels that low are almost always unconscious. In fact, anything below 90% is cause for concern.

Called silent hypoxia, it’s one of this pandemic’s biggest medical mysteries: how patients with such dangerously low oxygen levels show little outward evidence of their dire condition.

They don’t even look tired, he said.

Then you check them and realize Dude, really?! You don’t feel this?! We need to go to the hospital.’

It’s this deceptive pathology that makes COVID such a challenge.

It causes moments where the patient looks OK, but they’re actually really, really bad, he said, adding those patients often crash quickly and catastrophically.

What sticks out the most are the ages and a lack of comorbidities of those going into the back of his ambulance.

Waves one and two were elderly people, he said.

Now we’re averaging late 40s.

What irks him and his co-workers most are those who dismiss COVID as a bad flu.

Influenza doesn’t make your O2 (oxygen) saturation drop below your age, he said.

We’re seeing patients with oxygen levels not seen without opioids in play, and neither Narcan nor oxygen are going to fix it.

Emergency rooms and ICUs are full, he said with many receiving care in the ER normally seen in intensive care.

That’s what overcapacity means, he said.

It means that there’s people in emerge receiving ICU treatment and that’s not the place for it.

A paramedic transports a patient to Mount Sinai Hospital in Toronto, April 17, 2020. City Council orders check-up on Toronto paramedics
Erik Sande is the president of Medavie Health Services.
SANDE: Paramedics answer the call — across Ontario’s health system A Region of Durham Paramedic Services ambulance.

Gravely-ill patients more likely to be pronounced dead at scene
As city hospitals steel themselves for worst-case triage protocols, paramedics say it’s a reality they’re already experiencing.

Overrun emergency rooms and intensive-care units put paramedics in the position as well as the base physic
ians overseeing them of having to pronounce gravely ill patients, particularly in cases of cardiac arrest, deceased on scene rather than going through the usually hopeless motions of seeking hospital treatment.

I haven’t actively run a cardiac arrest in the past five I’ve done, said the Toronto advanced-care paramedic.

We just said to the family, Do you want anything done?’

Cardiac arrest, particularly in older patients, is a dire medical emergency with less than 10% survival rates, according to the Heart and Stroke Foundation.

The COVID emergency, the paramedic said, means they’re more likely to pronounce such patients dead over pursuing lifesaving efforts that only serve to prolong the inevitable.

Except in cases of obvious and catastrophic trauma, paramedics seek guidance on pronouncing death from physicians over the phone.

I got a pronouncement in 20 seconds the other day, the paramedic said.

The alternative, he said, is often worse.

If you get them back, where are they going to go, into the ICU to live for a day on a vent and die? he said.

The family’s able to see them now, be with them there’s no closure bringing (the patient) to the hospital where, oh by the way, they can’t come.

This leads to paramedics forced into end-of-life discussions with grieving family members.

You know who does those? Doctors. Doctors have those conversations, he said.

Now, it’s us.

Experts, including outspoken critical care physician Dr. Michael Warner, are warning Toronto’s hospitals are just days away from ICU triage, where decisions are made on who is and isn’t entitled to lifesaving care.

The way Dr. Warner’s talking about how we don’t want to have to triage ICU patients, we are now triaging cardiac arrest patients, the paramedic said. If bringing this person back or giving them hope means only living for one more day on a ventilator man, no. Let them go.

Families forced to make this decision, he said, are almost always grateful.

They say Thank you for not working on them, thank you for letting them pass as peacefully as possible, he said.

Then you walk out, do your paperwork, grab a coffee, then go on to the next one.

[email protected]
On Twitter: @bryanpassifiume

Global News April 27, 2021

Originally posted at https://fm96.com/news/7812658/covid-ontario-icu-emergency-triage/

Pushing Ontario’s ICUs to the brink: How some hospitals are preparing for the worst FM96 London

Rachael D’Amore GlobalNews.ca

More than a year into the COVID-19 pandemic, Ontario doctors and nurses may have more experience treating the disease but are increasingly staring life-or-death decisions in the face.

The spike in cases has strained intensive care capacity across the province. There are about 875 COVID-19 patients in Ontario hospital ICUs as of Tuesday an all-time high and 589 people in intensive care units (ICUs) on a ventilator. With staffing shortages particularly the lack of ICU-trained nurses and beds rapidly filling up, discussions about the possible need to triage life-saving care are mounting.

A critical care triage protocol, something that was not done during earlier waves of the virus, could be enacted, meaning health-care providers may have to decide who gets potentially life-saving care and who doesn’t.

If you’ve ever participated in a fire drill, you understand what we’re talking about here, said Dr. James Downar, a palliative and critical care physician in Ottawa who co-wrote Ontario’s ICU protocol.

The purpose of training is to be prepared because if a crisis arrives and you run out of your resources and you don’t have a plan and you’re not prepared to institute your plan, things will get very, very bad.

Ontario hospitals received a document in January laying out guidelines on how to deal with critical care triage. In other words, what to do if there aren’t enough ICU beds.

Under those guidelines, patients are essentially ranked on their likelihood to survive one year after the onset of a critical illness. The process came under criticism from human rights advocates, saying it is discriminatory, particularly toward people with disabilities and seniors.

At this point, the province has not finalized the protocol nor has it officially been published, but a widely circulating draft titled Adult Critical Care Clinical Emergency Standard of Care for Major Surge said patients could be scored by doctors on a short-term mortality risk assessment.

The aim would be to prioritize those patients who are most likely to survive their critical illness, the document reads.

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

The lists three levels of critical care triage:

Level 1 triage deprioritizes critical care resources for patients with a predicted mortality greater than 80 per cent.
Level 2 triage deprioritizes critical care resources for patients with a predicted mortality greater than 50 per cent.
At Level 3 triage, patients with predicted mortality of 30 per cent or a 70 per cent chance of surviving beyond a year will not receive critical care.

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

The leaked document was prepared by the province’s critical care COVID-19 command centre, which would ultimately declare when to use it.

Hundreds of COVID-19 ICU patient transfers planned as Ontario braces for horrific’ 2 weeks

The College of Physicians and Surgeons of Ontario told doctors on April 8 that the province was considering enacting the critical care triage protocol, and that it would support such a tool once it is initiated by the command tables of the province and even when doing so requires departing from our policy expectations.

Downar emphasized that the protocol has not been instituted, echoing Ontario Health Minister Christine Elliott who on April 7 said there are some emergency protocols out there but they have not finalized any of that yet.

None of us want to be in this position, none of us want to be doing this, said Downar.We are prepared for it if it comes to that, but we are focused on not letting it come to that.

While a standard provincial protocol has not been formally established, some Ontario hospitals have been preparing anyway.

The University Health Network (UHN), which includes Toronto General, Toronto Western and Princess Margaret hospitals, have started virtual training sessions for staff on what to do if the virus’ growth gets the better of all other efforts to expand and accommodate the ICU system.

Dr. Niall Ferguson, the head of critical care at UHN, said while preparations for worst-case scenarios are happening, it doesn’t necessarily mean they’ll be enacted.
We’re not expecting to be implementing them anytime in the near future I think the likelihood is probably low, he told Global News.
COVID is more like a controlled train crash as opposed to an actual train crash where you’ve got a thousand critically ill people all on the same day then triage is inevitable. When you’re getting a thousand critical care patients over the course of weeks, which we are here, then there is an opportunity to adapt the system and grow capacity and do things differently.

Ontario’s latest modelling predictions cast doubt on short-term improvements. Even as cases slow or plateau, hospitalizations and ICU numbers are so-called lagging indicators of the severity of the virus in a certain jurisdiction. The provincial data predicts a peak of at least 1,500 virus cases in ICUs by the first week of May that’s next week and it could be higher, pushing Ontario’s total 2,000-ICU-bed capacity over the edge.

Downar said some training around emergency care standards has been going on for months.

He said avoiding the worst-case scenario depends on a lot of things and is not as simple as staring at the number of COVID cases.

It’s tough. Everybody wants to know a number and everybody wants to know where that line is, but it’s just not something that is easily put into numbers at the moment.

What’s unfolded over the past few weeks exemplifies just how bad it’s gotten but also how the system has been forced to adapt, as Ferguson said. Hundreds of patients from already over-capacity hospitals in the Greater Toronto Area are being transferred to other hospitals hours away. The province has directed hospitals to ramp down all elective and non-emergency surgeries to help alleviate pressure on the health-care system.

Transfers are not completely benign. There is a risk when we transfer people from one place to another, Downar said. It’s important for everybody to recognize that there already consequences to what we’ve been doing.

Metroland DurhamRegion.com April 26, 2021

Originally posted at https://www.durhamregion.com/news-story/10381003-what-would-triaging-patients-look-like-in-ontario-s-hospitals-if-invoked-/

What would triaging patients look like in Ontario’s hospitals if invoked? Protocol created to ‘counteract implicit biases and subjectivity’ Veronica Appia
OurWindsor.Ca
Monday, April 26, 2021
This story is Part Two of a two-part explainer about the current surge of patients in Ontario’s intensive care units amid the third wave of COVID-19, and the possibility of the province invoking the Emergency Standard of Care protocol. Read Part One here.

Amid a rise in ICU admissions across the province, medical experts have been discussing the possibility of invoking the Emergency Standard of Care protocol, released by the Ontario Critical Care COVID-19 Command Centre earlier this year, which includes three triaging scenarios.

Dr. David Neilipovitz, the department head of critical care at the Ottawa Hospital and a lead at the Ontario Critical Care COVID-19 Command Centre, said it’s important to note that the Emergency Standard of Care protocol has different aspects to it and “not everything is triage.”

“Triage has a different connotation,” he said, adding that this would typically mean withdrawing care from patients without their family’s consent.

Neilipovitz said that while the Emergency Standard of Care protocol has similar aspects, there is no withdrawal of care.

What would triaging look like in Ontario?
“It’s really important to note that with emergency standards of care, no patient is not going to get care,” said Dr. Randy Wax, a critical care doctor who is also a lead at the Ontario Critical Care COVID-19 Command Centre.

Rather, he said, it would be a matter of determining other appropriate ways to support the patients that would not have access to critical care.

“The whole principle of triage is to try to maximize the number of lives saved with the resources that you have and so, in general, the concept is we want to be able to identify patients who are most likely to benefit from receiving IC services,” Wax noted.

Dr. James Downar, a palliative and critical care specialist who was responsible for creating the protocol, added that the decision as to who would have access, under the protocol, would solely be determined by mortality risk.

Is triaging patients a likely reality for Ontario’s hospitals?

“Everybody who would be considered for critical care would have two separate assessments performed by qualified physicians to assess what would be felt to be their short-term mortality risk and they would use their clinical judgment, aided by the guidance provided,” he said, adding that in cases where there is insufficient data or disagreement between physicians, the hospital would take the most optimistic approach.

What are the human rights implications?
The concept of triaging has been cause for concern for human rights advocates and disability groups.

In an April 22 statement to Metroland, Ena Chadha, chief commissioner of the Ontario Human Rights Commission (OHRC), said the Emergency Standard of Care protocol “includes potentially discriminatory triage criteria, should doctors be forced to decide who gets access to critical care and who does not.”

She stated that since December 2020, human rights groups and vulnerable populations have not been consulted on the protocol.

On April 9, the OHRC issued a public statement asking the government to provide the status of the Emergency Standard of Care protocol, confirm that the Health Care Consent Act prevails to protect the rights of patients and families, consult human rights stakeholders and require hospitals to collect data about the populations most affected by COVID-19.

In response to these concerns, Downar said that the reason the protocol was created in the first place was to ensure there wouldn’t be any human rights concerns in these scenarios.

“When human beings are overwhelmed and confronted by difficult decisions in emotional situations, that’s where implicit biases and subjectivity become major factors and undermine decision-making,” he said.

“You counteract that with explicit guidance and consistent rules.”

Regarding disability concerns, he added that the protocol will also ensure patients are being compared across different conditions the same way.

“There’s cancer guidance that applies only to people with cancer, heart failure guidance that only applies to people with heart failure, the frailty scale is only applied to people with frailty,” he explained. “It’s not applied to to everybody who has a disability.”

Veronica Appia is a reporter with Torstar Corporation Community Brands, covering COVID-19 news across Ontario.

The Globe and Mail May 4, 2021

Memo says Ontario hospitals may avoid triage protocol

By JEFF GRAY
Staff
Ontario’s hospitals, despite facing an unprecedented strain from COVID-19, will likely escape the pandemic’s third wave without resorting to a triage protocol that would have forced doctors to decide who lives and who dies, according to a memo obtained by The Globe and Mail.

Doctors and hospital officials warn that weeks of tough public-health restrictions are still needed to keep slowing the virus’s spread. Hospitals will also need to keep increasing their already ballooned intensive-care capacity, postponing non-emergency operations and helicoptering patients from jammed facilities in hot spots to other beds across the province.

As of Monday, Ontario had 881 COVID-19 patients in its ICUs, more than double the total from just a month ago.

But the rate of increase appeared to be slowing. (In all, there were just over 2,000 patients of all kinds in the province’s ICUs.)

In a message to hospital chief executives dated May 2, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says recent provincial modelling is still “concerning,” even as it shows a lower estimated number of COVID-19 ICU admissions than it did two weeks ago.

The memo asks hospitals to put 284 more ICU beds, already identified as ready to go at short notice, into operation and to prepare to receive more transferred patients. And it says the command centre will monitor staffing levels, and the effects of recent moves to transfer more elderly patients into long-term care homes, to determine whether hospitals should try to create even more critical-care capacity.

But the memo adds that it now looks as though the worst can be avoided: “I also wanted to share with you and your teams that we are increasingly confident that we will not need to activate the Emergency Standard of Care or recommend the use of the triage protocol.”

Requests for comment from Dr. Baker, who is chair of the critical-care department at St. Michael’s Hospital in Toronto, were referred to Ontario Health, the government agency that oversees health care in the province.

Ontario Health executive vice-president Chris Simpson, also a Kingston cardiologist, said the worst-case scenario from the most recent modelling by the province’s external COVID-19 Science Table – which projected the potential for more than 1,400 COVID-19 patients in the province’s ICUs by month’s end – would mean triage could be necessary.

But the province appears to be tracking the modelling’s mid-range scenario, in which ICU admissions crest around 1,000 before descending gradually.

“I think that scenario, if that were to unfold, does keep us out of triage-tool territory,” Dr. Simpson said. “But only because of the extra capacity that we have been able to bring online.”

He cautioned that the stresses on the system were already having effects on the quality of care for patients. He also raised concerns there could be “tremendous pressure” to reopen the province too quickly if cases continue to plateau or fall.

Doing so, he warned, could plunge the province into a fourth wave.

Kevin Smith, president and CEO of University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said even as numbers appear to be levelling off, hospitals and their staff are stretched past their normal limits. To avoid the worst, he said Ontarians need to keep following strict public-health rules, get vaccinated as quickly as possible and not let their guard down over the May long weekend.

“I would certainly hate for anyone to think that this is a time to relax,” he said.

“Absolutely that is not the case.”

Anthony Dale, president and CEO of the Ontario Hospital Association, said the science table predictions are cause for hope, noting that daily new infection numbers have been moderating. (Ontario recorded 3,436 new cases on Monday, down from a peak of more than 4,800 in mid-April.)

But he said nothing about COVID-19 can be taken for granted. Even if these encouraging trends continue, he said, the health care system will still be in a state of massive disruption for months, noting that more than 250,000 operations have been postponed in the pandemic.

“There’s nothing natural or normal about any of this,” Mr. Dale said.

Ontario’s triage protocol has been clouded by secrecy. A draft was only made public after a leaked copy was obtained by a disability rights group. Under the plans, incoming patients would be assessed for their likelihood of survival after 12 months. Those with the best chances would be prioritized for ICU beds. CBC Online News May 5, 2021

Originally posted at: https://www.cbc.ca/news/canada/toronto/doctors-describe-critical-care-triage-training-as-surreal-emotional-1.6013411 Doctors express relief, cautious optimism at news Ontario will likely avoid triage protocol Province says no triage model has been activated in Ontario at this time

Talia Ricci CBC News

Dr. Shajan Ahmed says most of his colleagues had never done any kind of triage training before. He was part of a group of physicians at UHN who participated in mock scenarios during the second wave. (Submitted/Shajan Ahmed)

Dr. Shajan Ahmed says he always thought of triage training as something needed in other countries or in war zones, where doctors must decide who gets potentially life-saving care and who doesn’t.

So when the emergency room physician with Toronto’s University Health Network found himself watching a webinar about it to help prepare doctors for the third wave of COVID-19, he says he was in a bit of shock.

“To come to grips with this being right at our [doorsteps] here in Toronto, a place where we have all kinds of resources, it was really bizarre, it was surreal,” he told CBC Toronto.

“None of us had trained for it before and none of us really signed up for this, to be honest with you.”

Ahmed was among a group of around 60 physicians who received the training earlier this year. It included running through mock cases, reading material and referencing online resources. The virtual sessions were conducted over Zoom with experts in simulation, ethics and palliative care.

The province says no triage model has been activated in Ontario at this time, and although the overall number of ICU admissions climbed to 900 for the first time last Saturday, the rate of increase appears to have started to slow down. In a memo obtained by CBC News directed to hospital CEOs, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says projections remained “very concerning.” But the memo also adds they are “increasingly confident” that they will not need to recommend the use of the triage protocol.

But the prospect still weighs on the minds of some doctors, and for Ahmed, the training made the situation feel “very real.”

Hospitals in Ontario may not have to use triage protocol, memo says
“You read about it and you think it may come, but until you are actually doing the training it doesn’t feel real until that point,” he said, adding the sessions were more challenging than he anticipated.

“We would debrief after the sessions to talk about how it felt, and what was going through our minds and collectively everyone had to take a deep breath and, I guess, also a bit of a sigh of relief because we aren’t actually in this situation.”

Despite describing the current situation in GTA hospitals as “bursting at the seams,” Ahmed wants people to know if the triage model is activated, patients will still be cared for. The decision is not whether someone lives or dies but whether the person would be offered ICU level care.

“It’s very complex and there’s a lot of logistics involved but I don’t want the public to think we’re making decisions as to booting people to the street without providing care,” he said.

“We absolutely will provide care.”

Compassionate conversations part of the training
Dr. Erin O’ Connor, the deputy medical director of the University Health Network’s emergency departments, was part of the team that led the training.

“There’s a lot of emotion around this and this isn’t something any physician or any health-care provider wants to do, but when we were getting ever closer to it we realized we needed to prepare ourselves,” she said.

She adds that conversations with patients and their families were a big part of it.

“It helped people find the right way to say this kindly and empathetically and to also recognize and process their own emotions around it.”

Dr. Erin O’Connor is the deputy medical director of emergency departments at Toronto’s University
Health Network. O’Connor describes the process as an application of tools to help determine how likely someone is to survive and their likelihood of survival after a year of any acute illness, not just COVID-19. She says the team looked at five cases that represented typical situations in the emergency department and had participants evaluate the patients’ chances of survival.

“It was a little bit of how you would apply the tools to different cases, so it wasn’t so abstract,” she explained. She says the whole point of developing the short term mortality risk tools was to remove any bias from the system.

Canadian Armed Forces sending teams to Ontario as COVID-19 cases strain critical care capacity

“It was very clearly laid out that decisions cannot be made based on race, gender, economic status, disability, or age. This is really looking at as much as possible the medical factors that contribute to whether someone has a high chance of survival at a year,” she said.

Resources have been expanded through bringing health-care workers from other parts of the country, redeploying and retraining health-care workers, cancelling surgeries, bringing in more ventilators and transferring patients from hot-spot areas, among other measures. The Ministry of Health says the province continues to create additional hospital beds in the province, including the creation of two mobile health units.

“The logistics have been massive. But all of these things are being done to prevent us from getting into a position where we have to triage resources,” O’Connor said.

She says she’s feeling cautiously optimistic given the recent trends.

“We’re not out of the woods yet because we know patients stay in the ICU for a long time but we are slightly backing away from the need to use this.”

But Ahmed still thinks about it, and is still concerned about the current state of ICUs. He’s encouraging people to have conversations with loved ones about their goals of care.

“A lot of us lose sleep over it.”

ABOUT THE AUTHOR

Talia Ricci
Talia Ricci is a CBC reporter based in Toronto. She has travelled around the globe with her camera documenting people and places as well as volunteering. Talia enjoys covering offbeat human interest stories and exposing social justice issues. When she’s not reporting, you can find her reading or strolling the city with a film camera.




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Ontario’s COVID-19 triage protocol ‘discriminates because of disability,’ advocates say


When Tracy Odell experienced bleeding in her stomach last summer during the first wave of the COVID-19 pandemic, she went to hospital but vowed she would not return.

“I don’t feel safe in hospitals and a lot of people with disabilities similar to mine, where you need this much assistance, don’t feel safe in a hospital,” she said.

Odell was born with spinal muscular atrophy and requires assistance to complete many daily tasks.

Now, amid the third wave and with critical care units filling up, Odell said she fears if she ever needed the care, she would not be able to get it.

Read more:
Pushing Ontario’s ICUs to the brink — How some hospitals are preparing for the worst

“I, personally, wouldn’t go to a hospital. I would feel it would be a waste of time and I’d feel very unsafe to go thereIt’s a real indictment, I think, of our system, that people who have disabilities, have severe needs, don’t feel safe in a place where everyone’s supposed to be safe,” she said.

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Odell is most concerned about a “critical care triage protocol” that could be activated in Ontario.

It would essentially allow health-care providers to decide who gets potentially life-saving care and who doesn’t.

Under the guidelines, as set out in a draft protocol circulating among hospitals, patients would be ranked on their likelihood to survive one year after the onset of critical illness.

Read more:
Ontario reports 3,480 new COVID-19 cases, 24 deaths

“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,” states the document.

Odell says it’s tough to predict who will survive an illness.

“They have to guess who’s going to last a year ... As a child with my disability, my projected life expectancy was like a kid … they didn’t think I’d live to be a teenager and here I am retired, so it’s a very hard thing to judge,” said Odell.

Disability advocates have been raising alarm bells over the triage protocol for months.

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David Lepofsky, of the Accessibility for Ontarians with Disabilities Act Alliance, sent multiple letters to Minister of Health Christine Elliott demanding transparency, arguing “the Ontario government’s pervasive secrecy over its critical care triage plans has made many people with disabilities terrified, angry and distrustful.”

Read more:
‘She deteriorated like she fell off a cliff’ — Vaccinated Ontario senior battles COVID-19 in hospital

“People with disabilities have disproportionately had to suffer for the past year from the most severe aspects of COVID … People with disabilities are disproportionately prone to end up in intensive care units and die from the disease,” said Lepofsky.

“Now we face the double cruelty that we are disproportionately prone to get told, ‘No, you can’t have that life-saving care.’”

Lepofsky said the document that is circulating, while not finalized, is problematic, unethical and discriminatory.

“The rules that have been given to intensive care units for deciding who gets critical care and who doesn’t, if they have to ration, may look fine because they’re full of medical jargon, but they actually explicitly discriminate because of disability,” he said.

“We agree there should be a protocol, but it can’t be one that discriminates because of disability. That’s illegal.”

John Mossa, who is living with muscular dystrophy, has been homebound for more than a year, afraid he would contract COVID-19 if he went outside and not survive it.

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Read more:
COVID-19 — Critical care nurses in high demand in Ontario as 3rd wave puts pressure on hospitals

“COVID is a very serious disease for me … if I do get COVID, I would probably become very ill and pass away because of my poor respiratory condition. I have about 30 per cent lung capacity due to my muscular dystrophy so COVID is very serious. It’s been a very scary time,” he said.

Never more frightening than right now, Mossa said, amid a surging third wave with a record number of patients in Ontario’s critical care units and the potential for triaging life-saving care.

“The people that would be affected the most are the least considered to get care … I’m afraid, I’m totally afraid to go to hospital right now,” he said.

A few weeks ago, Mossa said, he had a hip accident but he has avoided the hospital, even though he is suffering and should seek medical help.

Read more:
‘A lot of suffering’ — Front-line health-care workers describe the moments before death by COVID-19

“I should be considering going to hospital, but I’m not going to go to hospital because I know that I won’t get the care I need and if it gets any worse. I know that I wouldn’t be given an ICU bed,” he said.

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On Wednesday, when asked about the triage protocol, Elliott said it has not yet been activated.

That was echoed by Dr. James Downar, a palliative and critical care physician in Ottawa who co-wrote Ontario’s ICU protocol.

Read more:
The complications of getting COVID-19 vaccinations for non-residents in Ontario

“I don’t think that there’s any plan to initiate a triage process in the next couple of days. I think a lot is going to depend on which way our ICU numbers go. They have been climbing at a fairly alarming rate,” he said.

On concerns by advocates that the protocol discriminates against people with disabilities, Downar said, “The only criterion in the triage plan is mortality risk.”

“We absolutely don’t want to make any judgments about whose life is more valuable, certainly nothing based on ability, disability or need for accommodations … If you value all lives equally, that, I think, is the strongest argument for using an approach that would save as many lives as you can,” he said.


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Ontario to allow hospitals to move patients to long-term care, retirement homes to create room for COVID-19 patients


Ontario to allow hospitals to move patients to long-term care, retirement homes to create room for COVID-19 patients





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National CBC News Covers Disability Discrimination Problems with Ontario’s Critical Care Triage Protocol — Protocol’s Defenders Make Transparently Bogus Arguments to Defend It


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/

National CBC News Covers Disability Discrimination Problems with Ontario’s Critical Care Triage Protocol — Protocol’s Defenders Make Transparently Bogus Arguments to Defend It

April 20, 2021

            SUMMARY

Over the past week, media coverage of disability discrimination objections to the Ford Government’s critical care triage plans has ramped up. It is fuelled by the frightening rise in new COVID-19 cases and the overload crisis in Ontario intensive care units (ICUs). Here is the latest and some reflections on the bogus arguments that have been made by the defenders of the Governments triage plans. When such obviously bogus arguments are made, it is clear they have no stronger defence to offer for their actions.

This recent news makes it clear that denial of life-saving critical care could well be going on now, a terrifying thought since the Ford Government has not approved critical care triage to begin. In the April 18, 2021 edition of CBC TV’s “The National”, addressed further below, Dr. David Neilipovitz ICU director at the Ottawa Hospital, stated, in the context of ambulance attendants withholding critical care:

“…It would be naïve for us to think that triage or changes in standard of care have not already in effect come about.”

(Note: Full quotation later in this Update)

This recent media reporting also confirms a serious concern we raised most recently almost two months ago, and earlier, fully one year ago. In Ontario, if critical care triage takes place, life-saving critical care may not only be refused to a patient who needs it by doctors in ICUs, but as well, by ambulance crews, long before the patient reaches the hospital, when the ambulance arrives at your home or office in response to an emergency call.

This is even more terrifying. Read on for the details.

 1. The Latest Media Coverage

  1. As a major step forward, on Sunday evening, April 18, 2021, CBC TV’s national newscast “The National” included a lengthy 7-minute report on Ontario’s critical care triage protocol and our objections to it. Seven minutes on a national newscast is a big deal. This is the news story that exposed the danger of ambulance crews, and not just doctors, denying life-saving critical care to a patient if triage is directed for Ontario. You can watch it online at any time at http://www.cbc.ca/player/play/1887030339766

Related to this, CBC News online posted a major story on this issue on April 19, 2021. We set it out below. Below you will also find reflections on both of these reports where the bogus arguments in defence of Ontario’s critical care triage plans can be found.

  1. On Thursday April 15, 2021, CBC Radio Thunder Bay’s Superior Morning and CBC Radio’s Ontario Morning each included interviews with AODA Alliance Chair David Lepofsky. On Friday, April 16, 2021, he was interviewed on this topic on CBC Radio Windsor’s Windsor Morning, CBC Radio Toronto’s Metro Morning, and CBC Radio London’s London Morning. The Superior Morning interview is available on CBC’s website any time

We were invited on five of CBC’s eight morning radio programs in Ontario to address this issue. We’d be happy to oblige the other three programs! They just have to contact us at [email protected]

  1. On April 14, 2021, the National Post ran an article on the critical care triage issue, briefly referencing the AODA Alliance objections. We set it out below.
  1. On April 13, 2021, AODA Alliance Chair David Lepofsky was interviewed on Dahlia Kurtz’s new Canada-wide program on Sirius XM Radio. We were delighted to be part of that program’s first week on the air.
  1. On Tuesday, April 13, 2021, David Lepofsky was interviewed on this topic by journalist Karlene Nation on Sauga Radio in Mississauga.
  1. On Monday, April 12, 2021, David Lepofsky was also interviewed on this topic on AMI Radio, a service of Accessible Media. This interview is available on AMI’s website.

Amidst all this coverage, we are eager for other media outlets to step up. For example, the Toronto Star and Global News earlier covered this issue, but have not covered it in months. We are always ready to give them any help we can.

Our objections to Ontario’s critical care triage protocol are also getting extensive attention on social media. The AODA Alliance and others have been busy tweeting on Twitter on this topic. We are getting Many retweets and supportive messages, including from people with no prior connection to the AODA Alliance. Please retweet our tweets. Follow @aodaalliance

On Twitter, some members of Doug Ford’s own Bioethics Table have echoed our concerns with the critical care triage protocol. Here are the relevant parts of two examples:

  1. @LisaSchwartz224: Supporting this request from @DavidLepofsky as explained in https://healthydebate.ca/opinions/icu-triage/ @sanixto @lforman @PMCEthics @PandemicEthics

@DavidLepofsky: @BillBlair @RosieBarton @ONgov So @fordnation Doug Ford, while you’re at it, how about also pulling back your disability-discriminatory #CriticalCare #triage protocol & your Government’s refusal to meet with us to address major human disability concerns? #accessibility #OnHealth #onpoli

Alison K Thompson @PandemicEthics: The Ontario COVID-19 Science Table members and the Bioethics Table members have collectively given thousands of hour of labour pro bono to @FordNation on behalf of Ontarians. I wish I had realized earlier that we were just window dressing….

 2. CBC Confirms Danger that Critical Care Triage May Be Undertaken By Ambulance Crews Before a Patient Even Reaches Hospital

The national news story that ran on the April 18, 2021 edition of CBC’s The National established for the first time that we have seen in the media that critical care triage can include emergency medical technicians (EMTs) refusing life-saving care to a patient before they even get to the hospital. We earlier warned about this danger. For example, EMTs arriving at your home to respond to a medical emergency may not resuscitate some patients. This would be appalling.

In the April 18, 2021 edition of CBC TV’s The National, Dr. David Neilipovitz ICU director at the Ottawa Hospital had this exchange on camera:

“CBC: Will you get into a situation where ambulance attendants are told ‘Don’t intubate anyone?’

Dr. David Neilipovitz: Yeah, that can happen. It would be naïve for us to think that triage or changes in standard of care have not already in effect come about.”

We wrote Health Minister Christine Elliott about this worrisome danger back on February 25, 2021. She and the Ford Government have never answered. Here is what we asked:

“This new report also reveals that instructions may have been given or may be given to Ontario emergency services and EMTs on the possibility of not starting critical care supports in some situations for an emergency patient who needs and wants them, before reaching the hospital, if critical care triage has been directed for Ontario. This would be done so that hospitals don’t feel obligated to continue giving that patient critical care. We ask you to let us know if any such instructions have been given or have been designed or contemplated, by whom and to whom, with and with what authority? If so, we ask you to give us a copy of those instructions, past or present, and any draft instructions being considered.”

 3. Reflections on What is Being Said Now to defend the Ford Government’s Disability-Discriminatory Critical Care Triage Protocol and Plans

In the CBC national coverage, the defences offered for the disability discrimination in the Ontario critical care triage protocol are flat wrong.

Bogus Defence #1

The first bogus defence is for the Ontario Government’s defenders simply to deny reality. In the CBC News online story below, Dr. James Downar, author or co-author and lead defender of Ontario’s critical care triage protocol, denies there is any disability discrimination. He has earlier done this in other media. The April 19, 2021 CBC News online report states:

“Ottawa’s Downar, one of the numerous doctors and ethicists behind the drafting of the protocols, replies that no one is being discriminated against based on a disability. Rather, the triage protocols try to save the most lives possible, he said, by prioritizing scarce ICU resources on patients who are most likely to survive.

The criteria that reference dressing or bathing oneself or going shopping, Downar said, do so only for patients with certain underlying conditions — in this case, cancer or frailty syndrome — who fall critically ill with COVID-19. And that’s because those kinds of assessments have been shown in research studies to be strong predictors of whether people with those underlying conditions will survive in the ICU, he said.

Dr. James Downar, who co-wrote Ontario’s ICU triage protocol, acknowledges it may have disproportionate effects on some groups. But he says it’s better than having no protocol and leaving it up to chance or vulnerable to doctors’ unconscious biases. (Ottawa Hospital Research Institute/The Canadian Press)

“People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.”

Similarly, in the April 18, 2021 report on CBC’s The National, Dr. David Neilipovitz ICU director at the Ottawa Hospital, stated:

“In my opinion, and for what it’s worth, is that disabilities do not factor in as a major factor to limit care.”

Totally disproving that bogus defence, here are two illustrations of clear ways that a patient’s disability would explicitly be held against them when a doctor decides how likely the patient is to survive for one year, and hence be prioritized or deprioritized for critical care. First, the January 13, 2021 Critical Care Triage Protocol directs the use of the “Clinical Frailty Scale” as a tool for assessing some patients’ eligibility to be refused critical care, for patients over 65 with a progressive disease (like arthritis or multiple sclerosis). That Scale has doctors assess whether those patients, needing critical care, can perform 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. This focus on these activities, and the exclusion of any assistance when performing them, is rank disability discrimination. See e.g. the AODA Alliance’s August 30, 2020 written submission to the Bioethics Table, the AODA Alliance’s August 31, 2020 oral presentation to the Bioethics Table and the ARCH Disability Law Centre’s September 1, 2020 written submission to the Bioethics Table.

Second, for patients with cancer, the critical care triage protocol’s online calculator rates the following physical ability criteria all of which can be tied directly to a person’s disability:

“•     Whether a patient is “Fully active and able to carry on all pre-disease performance without restriction”

  • Whether a patient is “Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work”
  • Whether a patient is “Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours”
  • Whether a patient is “Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours”
  • Whether a patient is “Completely disabled and cannot carry out any self-care; totally confined to bed or chair” – persons in this category receive the worst rating, for getting access to critical care.”

Both those doctors, denying disability discrimination, certainly should know what the Ontario critical care triage protocol says. After all, Dr. Downar wrote or co-wrote it. Dr. David Neilipovitz heads the Ottawa Hospital Critical Care Department.

The fact that doctors will assess a patient’s likely one year mortality is no answer to this concern. The critical care triage protocol makes disability a clear criterion for assessing that one year mortality risk for some patients.

Bogus Defence #2

In the quotation above, Dr. Downar argued that there is no disability discrimination because two people with the same disability might be assessed very differently. Here is that quotation again from the April 19, 2021 CBC News online report, set out in full below:

“”People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.”

That argument rests on the fatally flawed premise that disability discrimination only occurs if all people with the same disability are treated identically under the Ontario critical care triage protocol. That, however, is not how the Ontario Human Rights Code or the Charter of Rights’ equality disability rights provisions work.

Bogus Defence #3

It appears from the April 19, 2021 CBC News online report that Dr. Downar also tried to defend the Ontario critical care triage protocol by stating that it does not discriminate based on disability, because patients with certain named stable disabilities are not subject to assessment for critical care triage by considering if they can perform 11 activities of daily living without assistance. Repeating an argument he has made elsewhere in the media, (but not explicitly using his name here), the CBC report states:

“Protocols in both Ontario and Quebec have explicit language that doctors are not to rely on someone’s disability in assessing their mortality risk. A frailty syndrome assessment is excluded, for instance, for people with “long-term disabilities (e.g. cerebral palsy), learning disabilities or autism.””

What that bogus argument boils down to is this: The critical care triage protocol does not discriminate against all people with disabilities. It only discriminates against some people with disabilities. Therefore, it does not discriminate against anyone based on disability.

That, of course, is no defence to disability discrimination. It is disability discrimination to discriminate against some patients because of some disabilities, without discriminating as well because of some other disabilities.

Compare this bogus argument to the context of racial discrimination. If a company refused to hire black people, it would be no defence to a claim of racial discrimination that the companied did hire some people from other racialized communities and only held a person’s racialized situation against them if their skin is black.

Bogus Defence #4

The fourth bogus defence put forward in this media reporting is that the Ontario critical care triage protocol is better than having no protocol at all. The online April 19, 2021 CBC article states:

“Downar says any protocol is better than none, which could leave decisions vulnerable to doctors’ unconscious biases — or an even cruder determination: first come, first served.”

This bogus defence presupposes that the only way to do critical care triage is with the disability discrimination spelled out in the January 13, 2021 Critical Care Triage Protocol, and with no due process for patients. We do not agree. It is now clear that fully six members of The Government’s external advisory Bioethics Table also disagree with the general position presented in defence of the Ontario critical care triage protocol.

If those designing, approving and defending this protocol have so impoverished an approach to human rights, the Ford Government needs to find new people to design the triage protocol and plan who have a better approach.

4. Reminder Register to Attend Tonight’s Virtual Public Forum on Addressing the Disability Discrimination in Ontario’s Critical Care Triage Protocol and Plan

Please register to join us and other concerned disability organizations tonight at 7:30 p.m. for a virtual information session to learn more about Ontario’s triage protocol and why it matters.

LEARN MORE AND REGISTER NOW! (ASL and closed captioning will be available)

For background on the AODA Alliance’s efforts to battle the danger of disability discrimination in critical care triage, visit the AODA Alliance website’s health care page.

            MORE DETAILS

 CBC News Online April 19, 2021

Originally posted at https://www.cbc.ca/news/health/covid-ontario-icu-triage-1.5992188

As ICUs fill up, doctors confront grim choice of who gets life-saving care

Ontario’s protocol for critical-care triage worries disability rights advocates

Zach Dubinsky, Terence McKenna, Joseph Loiero, Albert Leung

A health-care worker cares for a COVID-19 patient in the ICU at Toronto’s Humber River Hospital. A number of Ontario medical professionals fear that they may be forced to start triaging ICU patients within weeks. (Nathan Denette/The Canadian Press)

Hospitals are shifting critically ill patients around, looking for any empty bed. Nurses and doctors are putting in exhaustion-defying amounts of overtime. Some provinces are opening new intensive care unit capacity.

But it may not be enough to stave off a point no one wants to reach in the pandemic — when only a handful of ICU beds remain but a greater number of patients need those spots.

That point is drawing perilously close in Ontario and possibly parts of Saskatchewan, even as some other provinces don’t have a single hospitalized COVID-19 patient.

It means some of the hardest decisions health-care providers ever face will have to be made: who gets potentially life-saving care and who doesn’t.

“There are people who could be saved by critical care who aren’t going to get it,” said Dr. James Downar, a palliative and critical-care physician in Ottawa who co-wrote Ontario’s ICU protocol for when that awful moment strikes.

He hopes the protocol won’t be needed.

Ontario’s latest COVID-19 modelling ‘catastrophic,’ doctor says

Families torn apart. Workers at a breaking point. Inside a hospital system hit hard by 3rd wave of COVID-19

“It’s a difficult, difficult job to make such a call … and I hope it doesn’t happen.”

Decisions about how to ration life-saving care are never easy, Downar said — and this one has been not only arduous but controversial. Bioethicists and human rights groups have raised concerns that Ontario’s protocol discriminates against people with disabilities.

Downar says any protocol is better than none, which could leave decisions vulnerable to doctors’ unconscious biases — or an even cruder determination: first come, first served.

Level 1 triage could come in weeks

Ontario’s protocol is a work in progress and hasn’t officially been published, but the latest 32-page draft to be widely circulated among doctors looks like this:

Two physicians will independently assess any patient needing an ICU bed for their “short-term mortality risk” or STMR — their likelihood of death within 12 months.

At the lowest level of triage, Level 1, anyone with short-term mortality risk greater than 80 per cent is de-prioritized for an ICU bed.

If the COVID-19 situation worsens and triage moves to Level 2, anyone with an STMR over 50 per cent is “not prioritized for critical care.”

If ICUs get even more strained and go to Level 3, only people with a less than 30 per cent risk of dying within the next year would be prioritized for a spot.

Level 1 triage might be reached within Ontario in the next two weeks if current trends continue.

Quebec has a similar ICU protocol in place, inspired by Ontario’s, that also contemplates bands of mortality risk at 80, 50 and 30 per cent.

Withdrawal of care would need government approval

An even more drastic scenario, contemplated but not yet a possibility, is that doctors could take people off life support to free up ICU space for someone deemed to have a higher chance of survival. For that to happen, the provincial government would have to enact new regulations.

That hasn’t happened yet, but one Ottawa woman says she already worries critical-care physicians are under increasing pressure from having to treat so many ICU patients.

Nadine Tabbara, left, poses with her father, Souheil Tabbara, 74, who entered the ICU at Ottawa Hospital on Feb. 1 with severe COVID-19. (Submitted by Tabbara family)

Nadine Tabbara said her 74-year-old father, Souheil, contracted COVID-19 and was admitted to the Ottawa Hospital intensive care ward Feb. 1 and put on a ventilator. He can’t speak or move his limbs.

Tabbara said doctors told her they want to withdraw life support because he is not getting better, but she worries the worsening COVID situation might be affecting his care.

“The ICU is full and the doctors are overwhelmed,” she said. “And I think they may be rushing to decisions like this.”

The hospital told the family its decision was medically motivated and it would have recommended the same approach even without COVID-19.

“Hospital capacity during the COVID-19 pandemic has not influenced access to critical care at all and does not influence decisions on moving to palliative care,” Ottawa Hospital said in a statement. “The decision to move patients from critical care to palliative care is one that no health-care worker takes lightly.”

With Ontario’s intensive care units approaching a breaking point, doctors are preparing to use triage protocols to determine which of the sickest patients there is capacity to save. 7:16

Protocol violates human rights, groups allege

One major problem with the province’s ICU decision-making protocol, a number of human rights groups and bioethics experts say, is that it risks only deepening inequities in health care.

Some of the more fiercely contested criteria for mortality risk, to be used in assessing critically ill COVID-19 patients with cancer or seniors suffering from a condition known as “frailty,” consider things like whether a patient is “capable of only limited self-care” or can dress, bathe, eat or walk without assistance, and whether they can handle their finances or go shopping.

Lawyer David Lepofsky calls Ontario’s ICU triage plan ‘raging, cruel disability discrimination, by doctors who say this is science and government that won’t even answer.’ (Simon Dingley/CBC)

“The only way to describe this is as raging, cruel disability discrimination, by doctors who say this is science and government that won’t even answer,” said lawyer and disability rights activist David Lepofsky, chair of the AODA Alliance, which has been campaigning to reform the Ontario ICU protocol since an early version emerged last spring.

“It explicitly makes having a disability count against you, and that is flagrantly contrary to the human rights code and the Canadian Charter of Rights and Freedoms.”

Pandemic made ‘exponentially scarier’

Lepofsky said doctors’ decisions on who lives and who dies won’t be subject to appeal, which denies patients and their families a fundamental right.

“If we had the death penalty, you’d have right to trial and due process,” he said.

Vivia Kay Kieswetter, a seminary student at Trinity College in Toronto and advocate for people with disabilities who has an autoimmune disorder, said reading Ontario’s ICU triage protocol has made the pandemic “exponentially scarier” for her.

“This is something that has been a source of additional stress and anxiety for those with disabilities over the course of this pandemic,” she said.

COVID-19 patients arriving ‘back to back’ at Vancouver General Hospital’s ICU, doctor says

VIDEO: ‘Very anxious’: ICU nurse describes what it’s like to treat COVID patients

Six of the bioethicists on the panel that helped draft the protocol published a dissent last week. They say the protocol doesn’t properly recognize that people with disabilities, Indigenous patients or people of colour could disproportionately be scored at a higher short-term mortality risk because of pre-existing inequities in society that weigh on their health “well before people are brought to the doors of an ICU.”

“Judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to … [consider] social disadvantage,” the dissenting bioethicists wrote.

‘Absolutely not … based on disability’

Ottawa’s Downar, one of the numerous doctors and ethicists behind the drafting of the protocols, replies that no one is being discriminated against based on a disability. Rather, the triage protocols try to save the most lives possible, he said, by prioritizing scarce ICU resources on patients who are most likely to survive.

The criteria that reference dressing or bathing oneself or going shopping, Downar said, do so only for patients with certain underlying conditions — in this case, cancer or frailty syndrome — who fall critically ill with COVID-19. And that’s because those kinds of assessments have been shown in research studies to be strong predictors of whether people with those underlying conditions will survive in the ICU, he said.

Dr. James Downar, who co-wrote Ontario’s ICU triage protocol, acknowledges it may have disproportionate effects on some groups. But he says it’s better than having no protocol and leaving it up to chance or vulnerable to doctors’ unconscious biases. (Ottawa Hospital Research Institute/The Canadian Press)

“People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.

Protocols in both Ontario and Quebec have explicit language that doctors are not to rely on someone’s disability in assessing their mortality risk. A frailty syndrome assessment is excluded, for instance, for people with “long-term disabilities (e.g. cerebral palsy), learning disabilities or autism.”

Still, Downar acknowledged that the effect of using short-term mortality risk to triage patients for ICU care “is going to necessarily affect some demographic groups more than others.”

“What we lack is a way to correct for it that would be fair, objective and that everybody would agree on. It’s not that we haven’t looked…. But so far we have yet to see one that would be fair.”

 The National Post April 14, 2021

Originally posted at https://nationalpost.com/news/canada/surging-like-absolute-crazy-ontario-hospitals-pray-they-dont-reach-last-resort-stage-in-third-wave

‘Surging like absolute crazy’: Ontario hospitals ‘pray’ they don’t reach last-resort stage in third wave

The triage protocol would mean choosing which patients should be offered potentially life-prolonging care

Author of the article: Sharon Kirkey

A tent city has been erected in the parking lot of Toronto’s Sunnybrook hospital to handle a surge in COVID-19 cases. PHOTO BY PETER J. THOMPSON/NATIONAL POST/FILE

The idea of people being removed from intensive care, unhooked from ventilators that might have saved them to make room for someone else more likely to survive is almost unfathomable, says the president and CEO of Canada’s largest university hospital.

“I believe we’ll fight that one as long as humanly possible, and I pray we never get to the point of having to consider that,” said Dr. Kevin Smith, head of Toronto’s University Health Network and co-chair of Ontario’s COVID-19 critical care table.

Staged withdrawals of life-support from people with low chances of survival are not part of a 32-page emergency triage protocol that would be enacted should Ontario ICU’s become saturated.

“Only the provincial government can take the steps necessary to enable physicians to withdraw life-sustaining treatment without consent” in order to give that care to someone with better prospects, the College of Physicians and Surgeons of Ontario said in a notice to physicians last week.

The triage protocol would, however, mean choosing which new patients should be offered potentially life-prolonging care — who to admit and who not to admit to the ICU, whether for COVID or a heart attack.

Hospitals are working flat out to avoid enacting the protocol — transferring hundreds of patients from hot spots to communities with extra space, cancelling non-urgent surgeries to free up 700 critical care beds, and redeploying nursing and other health-care staff.

“Is it optimal and what we’d love to be doing? No. It’s where we find ourselves at this point in this rapid growth of the pandemic,” Smith said.

Admissions to ICUs have not only been rising, people are arriving in emergency rooms needing intensive care — immediately. “The virus has attacked them, literally, so quickly, it over came them so fast” that some are arriving in emergency desperately ill, before even having been tested for COVID, said Vicki McKenna, a registered nurse and provincial president with the Ontario Nurses Association.

As of midnight Monday, 1,892 people were in intensive care in Ontario hospitals, roughly a third — 623 — with COVID.

Should the number of people — with or without COVID — needing critical care approach 3,000, “that’s when we’re going to be precariously close to having to consider other options, and much less attractive options,” Smith said.

Those options include treating ICU patients outside ICUs, staffing ratios “we wouldn’t be very pleased by or comfortable with,” more field hospitals, bringing in doctors who don’t normally practise in hospitals, air lifting patients to Sudbury or Thunder Bay, “and, of course, last resort, thinking about the triage tool,” Smith said.

MORE ON THIS TOPIC

A recent study found that the neighbourhoods in Toronto and Peel region that had the most essential workers and lowest incomes had the great number of COVID-19 cases.

What the numbers fail to tell us about how and where COVID-19 spreads

According to a Statistics Canada report last month, this country saw 13,798 more deaths than would be expected by mid-December of 2020, based on previous years and after accounting for the aging population.

How ‘excess deaths’ show COVID-19’s real impact

Nationally, more than 3,000 people with COVID were being treated in hospital each day over the past seven days, a 29 per cent increase over the previous week. ICU admissions are up 24 per cent.

The number of deaths has averaged around 30 a day for several weeks, a dramatic drop from the peaks of wave one and two, when Canada saw the highest rates of nursing home deaths globally. Deaths are down because jurisdictions prioritized seniors in long-term care and retirement home for vaccines.

But if rapidly spreading variants make more people severely ill, that mortality trend could change, federal health officials warned Tuesday.

British Columbia saw a record 121 people with COVID in critical care on Monday, and hospitalizations are starting to stretch the capacities of some hospitals in Metro Vancouver, the Vancouver Sun reported. Provincial health officer Dr. Bonnie Henry is pleading with British Columbians to not leave their neighbourhoods as the fearsome Brazilian P.1 variant spreads. Quebec is also reporting a rise in hospitalizations and ICU admissions.

Under an emergency protocol for a major surge developed for Ontario hospitals, those with the best chance of surviving 12 months would be given priority for an ICU bed.

In Ontario, “we’re moving patients like absolute crazy; we’re surging like absolute crazy,” one critical care specialist said. Ontario quietly issued emergency orders last week allowing hospitals to transfer patients to other hospitals, if needed, without their consent.

About 1,300 to 1,400 people have been shuttled around the province so far, mostly from the GTA to southern Ontario, and “it isn’t without the realization of how stressful that is for families,” Smith said.

Ontario reported 3,670 new COVID cases Tuesday, down from Sunday’s 4,456 record high. But infections are based on exposures a week or so ago. And hospital admissions and deaths lag infections by a week or two.

Today’s ICU admissions reflect when case numbers in Ontario were in the 2,000-range, said Ottawa critical care physician Dr. James Downar. “Very likely the stay-at-home order, coupled with the delayed March (school) break, will have the effect of blunting and flattening this a little bit. But that’s going to take a while.”

Among his concerns, “super-loading” nurses. Ontario already had the worst registered nurse-to-population ratio of all Canadian provinces before the pandemic. ICU nurses are highly specialized and after 14 months of the pandemic are burning out.

Normally in the ICU, it’s a one-to-one, nurse-patient ratio. Occasionally, they might have two patients. “But when they get added, and loaded up, that’s when the situation is unbearable for the nurse, and very high concern of course for the number of patients they’re trying to care for at any one time,” McKenna said.

Under an emergency protocol for a major surge developed for Ontario hospitals, those with the best chance of surviving 12 months would be given priority for an ICU bed. The protocol includes a “short-term mortality risk” calculator physicians could use to input information on the person’s condition — whether they have heart failure, cancer, chronic liver disease or severe COVID — that gives the person’s triage priority score.

While no one wants it, it’s a rational approach based on core principles and criteria, said Downar, one of the authors. “You apply the same rule to everybody.”

The group Accessibility for Ontarians with Disabilities Act Alliance has said the protocol is discriminatory, reduces life and death decisions “to a cold digitized computation” and, if consent legislation was changed, would allow doctors to “evict” someone from critical care.

Quebec hospitals haven’t yet been hit hard in the third wave, despite rising infections. However, Montreal ICUs are still dealing with people who survived COVID in the second wave, and need critical care for “respiratory compromise,” said Dr. Peter Goldberg, director of critical care at the McGill University Health Centre.

“About one-third of all our ICU beds are committed to either active or recovering COVID patients,” Goldberg said in an email.

“I can’t imagine that we’ll escape another ICU admission blip over the next couple of weeks,” he said. But he added, “thankfully,” there are no discussions about implementing Quebec’s triage protocol.



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National CBC News Covers Disability Discrimination Problems with Ontario’s Critical Care Triage Protocol — Protocol’s Defenders Make Transparently Bogus Arguments to Defend It


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/

April 20, 2021

SUMMARY

Over the past week, media coverage of disability discrimination objections to the Ford Government’s critical care triage plans has ramped up. It is fuelled by the frightening rise in new COVID-19 cases and the overload crisis in Ontario intensive care units (ICUs). Here is the latest and some reflections on the bogus arguments that have been made by the defenders of the Governments triage plans. When such obviously bogus arguments are made, it is clear they have no stronger defence to offer for their actions.

This recent news makes it clear that denial of life-saving critical care could well be going on now, a terrifying thought since the Ford Government has not approved critical care triage to begin. In the April 18, 2021 edition of CBC TV’s The National, addressed further below, Dr. David Neilipovitz ICU director at the Ottawa Hospital, stated, in the context of ambulance attendants withholding critical care:

It would be naïve for us to think that triage or changes in standard of care have not already in effect come about. (Note: Full quotation later in this Update)

This recent media reporting also confirms a serious concern we raised most recently almost two months ago, and earlier, fully one year ago. In Ontario, if critical care triage takes place, life-saving critical care may not only be refused to a patient who needs it by doctors in ICUs, but as well, by ambulance crews, long before the patient reaches the hospital, when the ambulance arrives at your home or office in response to an emergency call.

This is even more terrifying. Read on for the details.

1. The Latest Media Coverage

1. As a major step forward, on Sunday evening, April 18, 2021, CBC TV’s national newscast The National included a lengthy 7-minute report on Ontario’s critical care triage protocol and our objections to it. Seven minutes on a national newscast is a big deal. This is the news story that exposed the danger of ambulance crews, and not just doctors, denying life-saving critical care to a patient if triage is directed for Ontario. You can watch it online at any time at http://www.cbc.ca/player/play/1887030339766

Related to this, CBC News online posted a major story on this issue on April 19, 2021. We set it out below. Below you will also find reflections on both of these reports where the bogus arguments in defence of Ontario’s critical care triage plans can be found.

2. On Thursday April 15, 2021, CBC Radio Thunder Bay’s Superior Morning and CBC Radio’s Ontario Morning each included interviews with AODA Alliance Chair David Lepofsky. On Friday, April 16, 2021, he was interviewed on this topic on CBC Radio Windsor’s Windsor Morning, CBC Radio Toronto’s Metro Morning, and CBC Radio London’s London Morning. The Superior Morning interview is available on CBC’s website any time

We were invited on five of CBC’s eight morning radio programs in Ontario to address this issue. We’d be happy to oblige the other three programs! They just have to contact us at [email protected]

3. On April 14, 2021, the National Post ran an article on the critical care triage issue, briefly referencing the AODA Alliance objections. We set it out below.

4. On April 13, 2021, AODA Alliance Chair David Lepofsky was interviewed on Dahlia Kurtz’s new Canada-wide program on Sirius XM Radio. We were delighted to be part of that program’s first week on the air.

5. On Tuesday, April 13, 2021, David Lepofsky was interviewed on this topic by journalist Karlene Nation on Sauga Radio in Mississauga.

6. On Monday, April 12, 2021, David Lepofsky was also interviewed on this topic on AMI Radio, a service of Accessible Media. This interview is available on AMI’s website.

Amidst all this coverage, we are eager for other media outlets to step up. For example, the Toronto Star and Global News earlier covered this issue, but have not covered it in months. We are always ready to give them any help we can.

Our objections to Ontario’s critical care triage protocol are also getting extensive attention on social media. The AODA Alliance and others have been busy tweeting on Twitter on this topic. We are getting Many retweets and supportive messages, including from people with no prior connection to the AODA Alliance. Please retweet our tweets. Follow @aodaalliance

On Twitter, some members of Doug Ford’s own Bioethics Table have echoed our concerns with the critical care triage protocol. Here are the relevant parts of two examples:

1. @LisaSchwartz224: Supporting this request from @DavidLepofsky as explained in https://healthydebate.ca/opinions/icu-triage/ @sanixto @lforman @PMCEthics @PandemicEthics
@DavidLepofsky: @BillBlair @RosieBarton @ONgov So @fordnation Doug Ford, while you’re at it, how about also pulling back your disability-discriminatory #CriticalCare #triage protocol & your Government’s refusal to meet with us to address major human disability concerns? #accessibility #OnHealth #onpoli

Alison K Thompson @PandemicEthics: The Ontario COVID-19 Science Table members and the Bioethics Table members have collectively given thousands of hour of labour pro bono to @FordNation on behalf of Ontarians. I wish I had realized earlier that we were just window dressing.

2. CBC Confirms Danger that Critical Care Triage May Be Undertaken By Ambulance Crews Before a Patient Even Reaches Hospital

The national news story that ran on the April 18, 2021 edition of CBC’s The National established for the first time that we have seen in the media that critical care triage can include emergency medical technicians (EMTs) refusing life-saving care to a patient before they even get to the hospital. We earlier warned about this danger. For example, EMTs arriving at your home to respond to a medical emergency may not resuscitate some patients. This would be appalling.

In the April 18, 2021 edition of CBC TV’s The National, Dr. David Neilipovitz ICU director at the Ottawa Hospital had this exchange on camera:

CBC: Will you get into a situation where ambulance attendants are told Don’t intubate anyone?’

Dr. David Neilipovitz: Yeah, that can happen. It would be naïve for us to think that triage or changes in standard of care have not already in effect come about.

We wrote Health Minister Christine Elliott about this worrisome danger back on February 25, 2021. She and the Ford Government have never answered. Here is what we asked:

This new report also reveals that instructions may have been given or may be given to Ontario emergency services and EMTs on the possibility of not starting critical care supports in some situations for an emergency patient who needs and wants them, before reaching the hospital, if critical care triage has been directed for Ontario. This would be done so that hospitals don’t feel obligated to continue giving that patient critical care. We ask you to let us know if any such instructions have been given or have been designed or contemplated, by whom and to whom, with and with what authority? If so, we ask you to give us a copy of those instructions, past or present, and any draft instructions being considered.

3. Reflections on What is Being Said Now to defend the Ford Government’s Disability-Discriminatory Critical Care Triage Protocol and Plans

In the CBC national coverage, the defences offered for the disability discrimination in the Ontario critical care triage protocol are flat wrong.

Bogus Defence #1

The first bogus defence is for the Ontario Government’s defenders simply to deny reality. In the CBC News online story below, Dr. James Downar, author or co-author and lead defender of Ontario’s critical care triage protocol, denies there is any disability discrimination. He has earlier done this in other media. The April 19, 2021 CBC News online report states:

Ottawa’s Downar, one of the numerous doctors and ethicists behind the drafting of the protocols, replies that no one is being discriminated against based on a disability. Rather, the triage protocols try to save the most lives possible, he said, by prioritizing scarce ICU resources on patients who are most likely to survive.

The criteria that reference dressing or bathing oneself or going shopping, Downar said, do so only for patients with certain underlying conditions in this case, cancer or frailty syndrome who fall critically ill with COVID-19. And that’s because those kinds of assessments have been shown in research studies to be strong predictors of whether people with those underlying conditions will survive in the ICU, he said.

Dr. James Downar, who co-wrote Ontario’s ICU triage protocol, acknowledges it may have disproportionate effects on some groups. But he says it’s better than having no protocol and leaving it up to chance or vulnerable to doctors’ unconscious biases. (Ottawa Hospital Research Institute/The Canadian Press)

“People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.

Similarly, in the April 18, 2021 report on CBC’s The National, Dr. David Neilipovitz ICU director at the Ottawa Hospital, stated:

In my opinion, and for what it’s worth, is that disabilities do not factor in as a major factor to limit care.

Totally disproving that bogus defence, here are two illustrations of clear ways that a patient’s disability would explicitly be held against them when a doctor decides how likely the patient is to survive for one year, and hence be prioritized or deprioritized for critical care. First, the January 13, 2021 Critical Care Triage Protocol directs the use of the Clinical Frailty Scale as a tool for assessing some patients’ eligibility to be refused critical care, for patients over 65 with a progressive disease (like arthritis or multiple sclerosis). That Scale has doctors assess whether those patients, needing critical care, can perform 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. This focus on these activities, and the exclusion of any assistance when performing them, is rank disability discrimination. See e.g. the AODA Alliance’s August 30, 2020 written submission to the Bioethics Table, the AODA Alliance’s August 31, 2020 oral presentation to the Bioethics Table and the ARCH Disability Law Centre’s September 1, 2020 written submission to the Bioethics Table.

Second, for patients with cancer, the critical care triage protocol’s online calculator rates the following physical ability criteria all of which can be tied directly to a person’s disability:

Whether a patient is Fully active and able to carry on all pre-disease performance without restriction
Whether a patient is Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work
Whether a patient is Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
Whether a patient is Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
Whether a patient is Completely disabled and cannot carry out any self-care; totally confined to bed or chair persons in this category receive the worst rating, for getting access to critical care.

Both those doctors, denying disability discrimination, certainly should know what the Ontario critical care triage protocol says. After all, Dr. Downar wrote or co-wrote it. Dr. David Neilipovitz heads the Ottawa Hospital Critical Care Department.

The fact that doctors will assess a patient’s likely one year mortality is no answer to this concern. The critical care triage protocol makes disability a clear criterion for assessing that one year mortality risk for some patients.

Bogus Defence #2

In the quotation above, Dr. Downar argued that there is no disability discrimination because two people with the same disability might be assessed very differently. Here is that quotation again from the April 19, 2021 CBC News online report, set out in full below:

“People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.

That argument rests on the fatally flawed premise that disability discrimination only occurs if all people with the same disability are treated identically under the Ontario critical care triage protocol. That, however, is not how the Ontario Human Rights Code or the Charter of Rights’ equality disability rights provisions work.

Bogus Defence #3

It appears from the April 19, 2021 CBC News online report that Dr. Downar also tried to defend the Ontario critical care triage protocol by stating that it does not discriminate based on disability, because patients with certain named stable disabilities are not subject to assessment for critical care triage by considering if they can perform 11 activities of daily living without assistance. Repeating an argument he has made elsewhere in the media, (but not explicitly using his name here), the CBC report states:

Protocols in both Ontario and Quebec have explicit language that doctors are not to rely on someone’s disability in assessing their mortality risk. A frailty syndrome assessment is excluded, for instance, for people with “long-term disabilities (e.g. cerebral palsy), learning disabilities or autism.”

What that bogus argument boils down to is this: The critical care triage protocol does not discriminate against all people with disabilities. It only discriminates against some people with disabilities. Therefore, it does not discriminate against anyone based on disability.

That, of course, is no defence to disability discrimination. It is disability discrimination to discriminate against some patients because of some disabilities, without discriminating as well because of some other disabilities.

Compare this bogus argument to the context of racial discrimination. If a company refused to hire black people, it would be no defence to a claim of racial discrimination that the companied did hire some people from other racialized communities and only held a person’s racialized situation against them if their skin is black.

Bogus Defence #4

The fourth bogus defence put forward in this media reporting is that the Ontario critical care triage protocol is better than having no protocol at all. The online April 19, 2021 CBC article states:

Downar says any protocol is better than none, which could leave decisions vulnerable to doctors’ unconscious biases or an even cruder determination: first come, first served.

This bogus defence presupposes that the only way to do critical care triage is with the disability discrimination spelled out in the January 13, 2021 Critical Care Triage Protocol, and with no due process for patients. We do not agree. It is now clear that fully six members of The Government’s external advisory Bioethics Table also disagree with the general position presented in defence of the Ontario critical care triage protocol.

If those designing, approving and defending this protocol have so impoverished an approach to human rights, the Ford Government needs to find new people to design the triage protocol and plan who have a better approach.

4. Reminder Register to Attend Tonight’s Virtual Public Forum on Addressing the Disability Discrimination in Ontario’s Critical Care Triage Protocol and Plan

Please register to join us and other concerned disability organizations tonight at 7:30 p.m. for a virtual information session to learn more about Ontario’s triage protocol and why it matters. LEARN MORE AND REGISTER NOW! (ASL and closed captioning will be available)

For background on the AODA Alliance’s efforts to battle the danger of disability discrimination in critical care triage, visit the AODA Alliance website’s health care page.

MORE DETAILS

CBC News Online April 19, 2021

Originally posted at https://www.cbc.ca/news/health/covid-ontario-icu-triage-1.5992188

As ICUs fill up, doctors confront grim choice of who gets life-saving care

Ontario’s protocol for critical-care triage worries disability rights advocates Zach Dubinsky, Terence McKenna, Joseph Loiero, Albert Leung

A health-care worker cares for a COVID-19 patient in the ICU at Toronto’s Humber River Hospital. A number of Ontario medical professionals fear that they may be forced to start triaging ICU patients within weeks. (Nathan Denette/The Canadian Press)
Hospitals are shifting critically ill patients around, looking for any empty bed. Nurses and doctors are putting in exhaustion-defying amounts of overtime. Some provinces are opening new intensive care unit capacity.

But it may not be enough to stave off a point no one wants to reach in the pandemic when only a handful of ICU beds remain but a greater number of patients need those spots.

That point is drawing perilously close in Ontario and possibly parts of Saskatchewan, even as some other provinces don’t have a single hospitalized COVID-19 patient.

It means some of the hardest decisions health-care providers ever face will have to be made: who gets potentially life-saving care and who doesn’t.

“There are people who could be saved by critical care who aren’t going to get it,” said Dr. James Downar, a palliative and critical-care physician in Ottawa who co-wrote Ontario’s ICU protocol for when that awful moment strikes.

He hopes the protocol won’t be needed.

Ontario’s latest COVID-19 modelling ‘catastrophic,’ doctor says
Families torn apart. Workers at a breaking point. Inside a hospital system hit hard by 3rd wave of COVID-19
“It’s a difficult, difficult job to make such a call … and I hope it doesn’t happen.”

Decisions about how to ration life-saving care are never easy, Downar said and this one has been not only arduous but controversial. Bioethicists and human rights groups have raised concerns that Ontario’s protocol discriminates against people with disabilities.

Downar says any protocol is better than none, which could leave decisions vulnerable to doctors’ unconscious biases or an even cruder determination: first come, first served.

Level 1 triage could come in weeks
Ontario’s protocol is a work in progress and hasn’t officially been published, but the latest 32-page draft to be widely circulated among doctors looks like this:

Two physicians will independently assess any patient needing an ICU bed for their “short-term mortality risk” or STMR their likelihood of death within 12 months.
At the lowest level of triage, Level 1, anyone with short-term mortality risk greater than 80 per cent is de-prioritized for an ICU bed.
If the COVID-19 situation worsens and triage moves to Level 2, anyone with an STMR over 50 per cent is “not prioritized for critical care.”
If ICUs get even more strained and go to Level 3, only people with a less than 30 per cent risk of dying within the next year would be prioritized for a spot.
Level 1 triage might be reached within Ontario in the next two weeks if current trends continue.

Quebec has a similar ICU protocol in place, inspired by Ontario’s, that also contemplates bands of mortality risk at 80, 50 and 30 per cent.

Withdrawal of care would need government approval
An even more drastic scenario, contemplated but not yet a possibility, is that doctors could take people off life support to free up ICU space for someone deemed to have a higher chance of survival. For that to happen, the provincial government would have to enact new regulations.

That hasn’t happened yet, but one Ottawa woman says she already worries critical-care physicians are under increasing pressure from having to treat so many ICU patients.

Nadine Tabbara, left, poses with her father, Souheil Tabbara, 74, who entered the ICU at Ottawa Hospital on Feb. 1 with severe COVID-19. (Submitted by Tabbara family)
Nadine Tabbara said her 74-year-old father, Souheil, contracted COVID-19 and was admitted to the Ottawa Hospital intensive care ward Feb. 1 and put on a ventilator. He can’t speak or move his limbs.

Tabbara said doctors told her they want to withdraw life support because he is not getting better, but she worries the worsening COVID situation might be affecting his care.

“The ICU is full and the doctors are overwhelmed,” she said. “And I think they may be rushing to decisions like this.”

The hospital told the family its decision was medically motivated and it would have recommended the same approach even without COVID-19.

“Hospital capacity during the COVID-19 pandemic has not influenced access to critical care at all and does not influence decisions on moving to palliative care,” Ottawa Hospital said in a statement. “The decision to move patients from critical care to palliative care is one that no health-care worker takes lightly.”

With Ontario’s intensive care units approaching a breaking point, doctors are preparing to use triage protocols to determine which of the sickest patients there is capacity to save. 7:16

Protocol violates human rights, groups allege
One major problem with the province’s ICU decision-making protocol, a number of human rights groups and bioethics experts say, is that it risks only deepening inequities in health care.

Some of the more fiercely contested criteria for mortality risk, to be used in assessing critically ill COVID-19 patients with cancer or seniors suffering from a condition known as “frailty,” consider things like whether a patient is “capable of only limited self-care” or can dress, bathe, eat or walk without assistance, and whether they can handle their finances or go shopping.

Lawyer David Lepofsky calls Ontario’s ICU triage plan ‘raging, cruel disability discrimination, by doctors who say this is science and government that won’t even answer.’ (Simon Dingley/CBC)

“The only way to describe this is as raging, cruel disability discrimination, by doctors who say this is science and government that won’t even answer,” said lawyer and disability rights activist David Lepofsky, chair of the AODA Alliance, which has been campaigning to reform the Ontario ICU protocol since an early version emerged last spring.

“It explicitly makes having a disability count against you, and that is flagrantly contrary to the human rights code and the Canadian Charter of Rights and Freedoms.”

Pandemic made ‘exponentially scarier’
Lepofsky said doctors’ decisions on who lives and who dies won’t be subject to appeal, which denies patients and their families a fundamental right.

“If we had the death penalty, you’d have right to trial and due process,” he said.

Vivia Kay Kieswetter, a seminary student at Trinity College in Toronto and advocate for people with disabilities who has an autoimmune disorder, said reading Ontario’s ICU triage protocol has made the pandemic “exponentially scarier” for her.

“This is something that has been a source of additional stress and anxiety for those with disabilities over the course of this pandemic,” she said.

COVID-19 patients arriving ‘back to back’ at Vancouver General Hospital’s ICU, doctor says
VIDEO: ‘Very anxious’: ICU nurse describes what it’s like to treat COVID patients
Six of the bioethicists on the panel that helped draft the protocol published a dissent last week. They say the protocol doesn’t properly recognize that people with disabilities, Indigenous patients or people of colour could disproportionately be scored at a higher short-term mortality risk because of pre-existing inequities in society that weigh on their health “well before people are brought to the doors of an ICU.”

“Judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to … [consider] social disadvantage,” the dissenting bioethicists wrote.

‘Absolutely not … based on disability’
Ottawa’s Downar, one of the numerous doctors and ethicists behind the drafting of the protocols, replies that no one is being discriminated against based on a disability. Rather, the triage protocols try to save the most lives possible, he said, by prioritizing scarce ICU resources on patients who are most likely to survive.

The criteria that reference dressing or bathing oneself or going shopping, Downar said, do so only for patients with certain underlying conditions in this case, cancer or frailty syndrome who fall critically ill with COVID-19. And that’s because those kinds of assessments have been shown in research studies to be strong predictors of whether people with those underlying conditions will survive in the ICU, he said.

Dr. James Downar, who co-wrote Ontario’s ICU triage protocol, acknowledges it may have disproportionate effects on some groups. But he says it’s better than having no protocol and leaving it up to chance or vulnerable to doctors’ unconscious biases. (Ottawa Hospital Research Institute/The Canadian Press)

“People with literally the same disabilities could have totally different mortality risks and thus would be treated very differently. So it’s absolutely not a triage based on disability,” Downar said.

Protocols in both Ontario and Quebec have explicit language that doctors are not to rely on someone’s disability in assessing their mortality risk. A frailty syndrome assessment is excluded, for instance, for people with “long-term disabilities (e.g. cerebral palsy), learning disabilities or autism.”

Still, Downar acknowledged that the effect of using short-term mortality risk to triage patients for ICU care “is going to necessarily affect some demographic groups more than others.”

“What we lack is a way to correct for it that would be fair, objective and that everybody would agree on. It’s not that we haven’t looked…. But so far we have yet to see one that would be fair.”

The National Post April 14, 2021
Originally posted at https://nationalpost.com/news/canada/surging-like-absolute-crazy-ontario-hospitals-pray-they-dont-reach-last-resort-stage-in-third-wave ‘Surging like absolute crazy’: Ontario hospitals ‘pray’ they don’t reach last-resort stage in third wave
The triage protocol would mean choosing which patients should be offered potentially life-prolonging care

Author of the article: Sharon Kirkey
A tent city has been erected in the parking lot of Toronto’s Sunnybrook hospital to handle a surge in COVID-19 cases. PHOTO BY PETER J. THOMPSON/NATIONAL POST/FILE

The idea of people being removed from intensive care, unhooked from ventilators that might have saved them to make room for someone else more likely to survive is almost unfathomable, says the president and CEO of Canada’s largest university hospital.

I believe we’ll fight that one as long as humanly possible, and I pray we never get to the point of having to consider that, said Dr. Kevin Smith, head of Toronto’s University Health Network and co-chair of Ontario’s COVID-19 critical care table.

Staged withdrawals of life-support from people with low chances of survival are not part of a 32-page emergency triage protocol that would be enacted should Ontario ICU’s become saturated.

Only the provincial government can take the steps necessary to enable physicians to withdraw life-sustaining treatment without consent in order to give that care to someone with better prospects, the College of Physicians and Surgeons of Ontario said in a notice to physicians last week.

The triage protocol would, however, mean choosing which new patients should be offered potentially life-prolonging care who to admit and who not to admit to the ICU, whether for COVID or a heart attack.

Hospitals are working flat out to avoid enacting the protocol transferring hundreds of patients from hot spots to communities with extra space, cancelling non-urgent surgeries to free up 700 critical care beds, and redeploying nursing and other health-care staff.

Is it optimal and what we’d love to be doing? No. It’s where we find ourselves at this point in this rapid growth of the pandemic, Smith said.

Admissions to ICUs have not only been rising, people are arriving in emergency rooms needing intensive care immediately. The virus has attacked them, literally, so quickly, it over came them so fast that some are arriving in emergency desperately ill, before even having been tested for COVID, said Vicki McKenna, a registered nurse and provincial president with the Ontario Nurses Association.

As of midnight Monday, 1,892 people were in intensive care in Ontario hospitals, roughly a third 623 with COVID.

Should the number of people with or without COVID needing critical care approach 3,000, that’s when we’re going to be precariously close to having to consider other options, and much less attractive options, Smith said.

Those options include treating ICU patients outside ICUs, staffing ratios we wouldn’t be very pleased by or comfortable with, more field hospitals, bringing in doctors who don’t normally practise in hospitals, air lifting patients to Sudbury or Thunder Bay, and, of course, last resort, thinking about the triage tool, Smith said.

MORE ON THIS TOPIC

A recent study found that the neighbourhoods in Toronto and Peel region that had the most essential workers and lowest incomes had the great number of COVID-19 cases.

What the numbers fail to tell us about how and where COVID-19 spreads
According to a Statistics Canada report last month, this country saw 13,798 more deaths than would be expected by mid-December of 2020, based on previous years and after accounting for the aging population. How ‘excess deaths’ show COVID-19’s real impact

Nationally, more than 3,000 people with COVID were being treated in hospital each day over the past seven days, a 29 per cent increase over the previous week. ICU admissions are up 24 per cent.

The number of deaths has averaged around 30 a day for several weeks, a dramatic drop from the peaks of wave one and two, when Canada saw the highest rates of nursing home deaths globally. Deaths are down because jurisdictions prioritized seniors in long-term care and retirement home for vaccines.

But if rapidly spreading variants make more people severely ill, that mortality trend could change, federal health officials warned Tuesday.

British Columbia saw a record 121 people with COVID in critical care on Monday, and hospitalizations are starting to stretch the capacities of some hospitals in Metro Vancouver, the Vancouver Sun reported. Provincial health officer Dr. Bonnie Henry is pleading with British Columbians to not leave their neighbourhoods as the fearsome Brazilian P.1 variant spreads. Quebec is also reporting a rise in hospitalizations and ICU admissions.

Under an emergency protocol for a major surge developed for Ontario hospitals, those with the best chance of surviving 12 months would be given priority for an ICU bed.

In Ontario, we’re moving patients like absolute crazy; we’re surging like absolute crazy, one critical care specialist said. Ontario quietly issued emergency orders last week allowing hospitals to transfer patients to other hospitals, if needed, without their consent.

About 1,300 to 1,400 people have been shuttled around the province so far, mostly from the GTA to southern Ontario, and it isn’t without the realization of how stressful that is for families, Smith said.

Ontario reported 3,670 new COVID cases Tuesday, down from Sunday’s 4,456 record high. But infections are based on exposures a week or so ago. And hospital admissions and deaths lag infections by a week or two.

Today’s ICU admissions reflect when case numbers in Ontario were in the 2,000-range, said Ottawa critical care physician Dr. James Downar. Very likely the stay-at-home order, coupled with the delayed March (school) break, will have the effect of blunting and flattening this a little bit. But that’s going to take a while.

Among his concerns, super-loading nurses. Ontario already had the worst registered nurse-to-population ratio of all Canadian provinces before the pandemic. ICU nurses are highly specialized and after 14 months of the pandemic are burning out.

Normally in the ICU, it’s a one-to-one, nurse-patient ratio. Occasionally, they might have two patients. But when they get added, and loaded up, that’s when the situation is unbearable for the nurse, and very high concern of course for the number of patients they’re trying to care for at any one time, McKenna said.

Under an emergency protocol for a major surge developed for Ontario hospitals, those with the best chance of surviving 12 months would be given priority for an ICU bed. The protocol includes a short-term mortality risk calculator physicians could use to input information on the person’s condition whether they have heart failure, cancer, chronic liver disease or severe COVID that gives the person’s triage priority score.

While no one wants it, it’s a rational approach based on core principles and criteria, said Downar, one of the authors. You apply the same rule to everybody.

The group Accessibility for Ontarians with Disabilities Act Alliance has said the protocol is discriminatory, reduces life and death decisions to a cold digitized computation and, if consent legislation was changed, would allow doctors to evict someone from critical care.

Quebec hospitals haven’t yet been hit hard in the third wave, despite rising infections. However, Montreal ICUs are still dealing with people who survived COVID in the second wave, and need critical care for respiratory compromise, said Dr. Peter Goldberg, director of critical care at the McGill University Health Centre.

About one-third of all our ICU beds are committed to either active or recovering COVID patients, Goldberg said in an email.

I can’t imagine that we’ll escape another ICU admission blip over the next couple of weeks, he said. But he added, thankfully, there are no discussions about implementing Quebec’s triage protocol.

Email: [email protected] | Twitter: sharon_kirkey




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Register for April 20, 2021 Virtual Public Forum on Disability Concerns with Ontario’s Critical Care Triage Plans


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/

April 16, 2021

SUMMARY

Please save the date for these two important events that are fast approaching. For the first one, register now. For the second one, stay tuned for details on how to register to take part.

Please publicize both of these events widely on social media, and by carrier pigeon (but only if the birds are socially distancing).

MORE DETAILS

1. Register to Attend the Online Public Forum on Tuesday, April 20, 2021, on the Danger Facing People with Disabilities if Ontario Must Ration or Triage Life-Saving Critical Care

The newest wave of COVID is overloading Ontario intensive care units, which is what triggered Ontario’s latest lockdown. As a result, life-saving critical care in Ontario hospitals could very soon be rationed or “triaged.” Serious concerns about the triage protocol have been raised by disability organizations such as ARCH Disability Law Centre and the Accessibility for Ontarians with Disabilities Act Alliance.

This is a time-sensitive issue. We encourage you to join us on Tuesday, April 20 at 7:30 p.m. for a virtual information session to learn more about Ontario’s triage protocol and why it matters. LEARN MORE AND REGISTER NOW! (ASL and closed captioning will be available)

For background on the AODA Alliance’s efforts to battle the danger of disability discrimination in critical care triage, visit the AODA Alliance website’s health care page.

2. Save the Date! On Wednesday, April 28, 2021, Tell the Online Meeting of Toronto’s Infrastructure and Environment Committee Not to Allow Electric Scooters in Toronto

On Wednesday, April 28, 2021, the City of Toronto’s Infrastructure and Environment Committee will be discussing whether Toronto should lift the ban on riding electric scooters in public places. Members of the public will be able to register in advance to speak to that Committee at that meeting before it debates the issue. We urge as many people as possible to sign up to speak against allowing e-scooters. E-scooters endanger the safety of the public, including people with disabilities, and will create new barriers impeding people with disabilities.

We will let you know when you can sign up, and how to register to present. That opportunity to register may not open up until just a few days before the April 28, 2021 meeting.

Members of the public each get only 3 to 5 minutes to speak, so you don’t have to talk long. You can even speak for a shorter time and just tell the members of City Council not to allow e-scooters.

We know the e-scooter corporate lobbyists will be organizing to again pressure City Council. We want City Council to stand up for people with disabilities and to stand up to the e-scooter corporate lobbyists.

Stay tuned for more information on this. You can learn all about our efforts to protect people with disabilities from e-scooters by visiting the AODA Alliance website’s e-scooter page.




Source link

Register for April 20, 2021 Virtual Public Forum on Disability Concerns with Ontario’s Critical Care Triage Plans – Plan to Tell The Virtual April 28, 2021 Toronto Infrastructure and Environment Committee Meeting Not to Allow Electric Scooters


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/

Register for April 20, 2021 Virtual Public Forum on Disability Concerns with Ontario’s Critical Care Triage Plans – Plan to Tell The Virtual April 28, 2021 Toronto Infrastructure and Environment Committee Meeting Not to Allow Electric Scooters

April 16, 2021

            SUMMARY

Please save the date for these two important events that are fast approaching. For the first one, register now. For the second one, stay tuned for details on how to register to take part.

Please publicize both of these events widely on social media, and by carrier pigeon (but only if the birds are socially distancing).

            MORE DETAILS

1. Register to Attend the Online Public Forum on Tuesday, April 20, 2021, on the Danger Facing People with Disabilities if Ontario Must Ration or Triage Life-Saving Critical Care

The newest wave of COVID is overloading Ontario intensive care units, which is what triggered Ontario’s latest lockdown. As a result, life-saving critical care in Ontario hospitals could very soon be rationed or “triaged.” Serious concerns about the triage protocol have been raised by disability organizations such as ARCH Disability Law Centre and the Accessibility for Ontarians with Disabilities Act Alliance.

This is a time-sensitive issue. We encourage you to join us on Tuesday, April 20 at 7:30 p.m. for a virtual information session to learn more about Ontario’s triage protocol and why it matters.

LEARN MORE AND REGISTER NOW! (ASL and closed captioning will be available)

For background on the AODA Alliance’s efforts to battle the danger of disability discrimination in critical care triage, visit the AODA Alliance website’s health care page.

2. Save the Date! On Wednesday, April 28, 2021, Tell the Online Meeting of Toronto’s Infrastructure and Environment Committee Not to Allow Electric Scooters in Toronto

On Wednesday, April 28, 2021, the City of Toronto’s Infrastructure and Environment Committee will be discussing whether Toronto should lift the ban on riding electric scooters in public places. Members of the public will be able to register in advance to speak to that Committee at that meeting before it debates the issue. We urge as many people as possible to sign up to speak against allowing e-scooters. E-scooters endanger the safety of the public, including people with disabilities, and will create new barriers impeding people with disabilities.

We will let you know when you can sign up, and how to register to present. That opportunity to register may not open up until just a few days before the April 28, 2021 meeting.

Members of the public each get only 3 to 5 minutes to speak, so you don’t have to talk long. You can even speak for a shorter time and just tell the members of City Council not to allow e-scooters.

We know the e-scooter corporate lobbyists will be organizing to again pressure City Council. We want City Council to stand up for people with disabilities and to stand up to the e-scooter corporate lobbyists.

Stay tuned for more information on this. You can learn all about our efforts to protect people with disabilities from e-scooters by visiting the AODA Alliance website’s e-scooter page.



Source link

As COVID-19 Infections Hit Record Highs and Hospital ICUs Reach the Brink, Six Bioethicists on The Ford Government’s Bioethics Table Release a Public Statement Revealing Major Concerns with Ontario’s Plans for Triage of Critical Care, that Echo Disability Community Objections


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE

NEWS RELEASE – FOR IMMEDIATE RELEASE

As COVID-19 Infections Hit Record Highs and Hospital ICUs Reach the Brink, Six Bioethicists on The Ford Government’s Bioethics Table Release a Public Statement Revealing Major Concerns with Ontario’s Plans for Triage of Critical Care, that Echo Disability Community Objections

April 15, 2021 Toronto: A body blow has just been delivered to the Ford Government’s controversial plans for deciding which patients would be refused life-saving critical care, if the crisis overload in Ontario hospital intensive care units requires that life-saving critical care must be rationed or “triaged”. Six members of the Ford Government’s own advisory “Bioethics Table” have today published an online statement, set out below, that strongly criticizes Ontario’s critical care triage plans. Their concerns reflect serious objections to Ontario’s triage plans from the disability community, including from the AODA Alliance.

The six bioethicists (who don’t claim to speak for the entire Bioethics Table) urge that the Government should now reveal its secret critical care triage plans to the public, should consult the public, and should hold and open discussion of how critical care should be triaged, if rationing becomes necessary, without treating this as a purely clinical issue or one for bioethicists to monopolize. (Key excerpts also set out below)

These six authors make it clear that Ontario needs a better approach to critical care triage. This is a direct blast at the Ford Government’s persistent secrecy on this issue and its refusal to speak directly to key stakeholders like those from the disability community. We offer the example that the Government has refused to even answer eight detailed letters from the AODA Alliance since last September which identify well-researched objections.

The six bioethicists explain that decisions over who should get life-saving critical care and who should be refused it during critical care triage is not simply a clinical question (i.e. one of medical science alone). Ontario’s secret critical care triage protocol treats this triage as purely a clinical question. The six authors humbly emphasize that bioethicists themselves have no monopoly on wisdom in the area of how critical care triage should be conducted.

These authors urge that it is important to respect the human rights of disadvantaged groups in society. We add that the AODA Alliance and others have been showing for months that Ontario’s plans are replete with disability discrimination, contrary to the Ontario Human Rights Code.

We expect that the Ford Government will answer that the Bioethics Table, of whom these six authors are a part, held consultations with a number of disability advocates, including the AODA Alliance. That would be no answer. Those discussions ended months ago. The external Bioethics Table only gives advice to The Government. The Bioethics Table makes no decisions on how critical care triage should be conducted, and rejected some of our major concerns without giving reasons for doing so. Those in the Government who do make the decisions have steadfastly refused to talk to us. The Government has hidden behind them for months, like human shields.

The secret January 13, 2021 Critical Care Triage Protocol is not available on any Government website, but is available on the AODA Alliance website.

In light of this important statement by several of The Government’s own external advisors, the AODA Alliance calls on the Ford Government to take these four urgent steps:

  1. Now make public the current version of the critical care triage protocol, all reports and recommendations by its external Bioethics Table since September 11, 2021, The Government’s plan of action for rolling out critical care triage if needed, and the results of drills or simulations of critical care triage held at any Ontario hospitals.
  2. Remove disability discrimination from the January 13, 2021 Critical Care Triage Protocol, and
  3. Immediately hold a public consultation on how critical care triage should be conducted.
  4. Introduce legislation on critical care triage for debate in the Legislature, rather than dealing with it by an internal memo to hospitals.

Key statements to this effect by the six bioethicists on the Ford Government’s external Bioethics Table in this article include:

“As bioethicists involved in developing an ethical framework for ICU triage at the Ontario COVID-19 Bioethics Table, we have serious concerns about the lack of transparency and public engagement around the constraints the Table works under.”

“We are beholden to the public as bioethicists helping to develop guidance for the ethical use of public resources – especially to the people most likely to be impacted by intensive care triage decisions – as well as to the physicians who will be forced to make these fraught decisions. This requires that the process be informed, transparent, inclusive, reasonable and subject to revision in light of new information or legitimate concerns or claims.

To date, these requirements have not been met in several provinces, including Ontario, and we entreat governments to make available their triage frameworks and protocols for public deliberation.”

“Science alone cannot tell us how to allocate ICU beds.”

“Whose lives we save is not just a matter of how we apply clinical criteria. It is a matter of redressing unfair inequalities in health and a matter of protecting fundamental human rights.

And while utility is one worthwhile objective of health policy, it must be balanced with due consideration of the human rights of people who might be disproportionately, unjustifiably or morally harmed by clinically based triage decisions. Relying on clinical criteria like judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to help distribute health benefits fairly across society through explicit consideration of social disadvantage.

Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.

The public needs to join the conversation on an ethical approach to triage”

“Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.”

“It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.

“We join the COVID-19 Bioethics Table, the Ontario Human Rights Commission and disability rights advocates in calling for transparency and public deliberation on the unfinished work of developing Ontario’s approach to critical care triage in a major surge during the COVID-19 pandemic.”

“The protection of fundamental legal and human rights during an emergency is a litmus test for society, and we need to do everything in our power to avoid overriding rights unjustifiably. Without public discussion, the vulnerability of already marginalized groups is intensified and trust eroded.”

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.

Healthy Debate April 15, 2021

Originally posted at https://healthydebate.ca/opinions/icu-triage/?utm_source=mailpoet&utm_medium=email&utm_campaign=we-need-to-talk-about-triaging-critical-care_12

Opinion

Public conversation on the ethics of intensive care triage during pandemic is overdue

by Alison Thompson, Paula Chidwick, Lisa Jennifer Schwartz, Stephanie Nixon, Lisa Forman, Robert Sibbald

COVID-19 has highlighted the ethical challenges in our health-care system, and nowhere is this more apparent than in an overcrowded intensive care unit. ICUs are where the sickest of the sick receive life-saving treatments and where their crashing bodily functions are taken over by high-tech machines.

Even when there isn’t a pandemic, not everyone can get access to intensive care, and not everyone will benefit from it. It is costly, invasive and requires a highly skilled workforce to make it run.

In the early days of the COVID-19 pandemic, people around the world were shocked by the images of ICU doctors working around the clock in Wuhan, Turin and New York. Their faces were etched with bruises from their tight-fitting face masks. Their eyes were haunted by the sheer number of patients they were treating – and by the sheer number they couldn’t treat.

These early warnings from other countries signaled that Canadian provinces needed to avoid a major surge of patients that would strain intensive care resources. But, preparing for the worst, work on guidance for intensive care triage began very early on in the pandemic, with Saskatchewan and Quebec starting in late winter 2020 and Ontario in the spring of 2020 across several of its COVID-19 advisory tables.

As bioethicists involved in developing an ethical framework for ICU triage at the Ontario COVID-19 Bioethics Table, we have serious concerns about the lack of transparency and public engagement around the constraints the Table works under. To be clear, we do not speak on behalf of the COVID-19 Bioethics Table, but we do speak as scholars in clinical and public health ethics and in human rights law who are also members of that Table.

We are beholden to the public as bioethicists helping to develop guidance for the ethical use of public resources – especially to the people most likely to be impacted by intensive care triage decisions – as well as to the physicians who will be forced to make these fraught decisions. This requires that the process be informed, transparent, inclusive, reasonable and subject to revision in light of new information or legitimate concerns or claims.

To date, these requirements have not been met in several provinces, including Ontario, and we entreat governments to make available their triage frameworks and protocols for public deliberation.

Rationing intensive care beds is fundamentally an ethical endeavour

Science alone cannot tell us how to allocate ICU beds. Should they go to the sickest patients? Should they go to those who are most likely to benefit from treatment? Should we use a lottery system? Should we withdraw treatment from patients if they are not going to have a meaningful recovery to give the bed to someone who will? And what constitutes a meaningful recovery? These are ethical questions requiring value judgements.

Many pandemic response plans focus on maximizing the benefit of scarce resources to save the most lives. Allocating ICU beds to people who are unlikely to benefit from them is often considered unethical and inefficient. Clinicians who work in the ICU often talk about the moral difficulty of providing treatments that sometimes do more harm than good. The moral burden of care in these circumstances weighs heavily on ICU clinicians when left to make these decisions alone and without ethical guidance.

How should health equity be balanced with utility in intensive care triage?

Society’s failure to address upstream causes of ill health and inequities means that the futility or efficacy of ICU care is often determined well before people are brought to the doors of an ICU. To fail to attend to this in triage frameworks and clinical protocols undermines trust. Whose lives we save is not just a matter of how we apply clinical criteria. It is a matter of redressing unfair inequalities in health and a matter of protecting fundamental human rights.

And while utility is one worthwhile objective of health policy, it must be balanced with due consideration of the human rights of people who might be disproportionately, unjustifiably or morally harmed by clinically based triage decisions. Relying on clinical criteria like judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to help distribute health benefits fairly across society through explicit consideration of social disadvantage.

Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.

The public needs to join the conversation on an ethical approach to triage

Consensus on a proposed ethical framework for pandemic triage, even just among bioethicists, is unrealistic. Nor is it necessarily desirable. In fact, the role of dissensus in bioethics is crucial to avoiding the narrowing of possible policy avenues and avoiding presumptive constructions of various stakeholders.

As bioethicists, our expertise is in sketching the moral landscape, providing options and framing ethical debate. Our job is to propose a possible approach to intensive care triage that the public and stakeholders can then weigh and deliberate. It is also to propose and promote accessible and ethically defensible processes for doing so.

Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.

To be sure, public deliberation will not make the decisions about how to prioritize patients for intensive care any easier, nor will it necessarily make it easier to live with the consequences. But it would ensure that all voices have been heard, innovative approaches have been considered, and that new ethical considerations can come to light. It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.

We join the COVID-19 Bioethics Table, the Ontario Human Rights Commission and disability rights advocates in calling for transparency and public deliberation on the unfinished work of developing Ontario’s approach to critical care triage in a major surge during the COVID-19 pandemic. Other provinces must also follow suit. Specific attention needs to be paid to partnering with people who have been marginalized by both the process and the products of ICU triage development.

The protection of fundamental legal and human rights during an emergency is a litmus test for society, and we need to do everything in our power to avoid overriding rights unjustifiably. Without public discussion, the vulnerability of already marginalized groups is intensified and trust eroded.

No province in Canada can claim to have a morally legitimate and human rights compliant approach to triage until an accessible and public discussion takes place about how to balance equity with the aim of saving lives in a pandemic.



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As COVID-19 Infections Hit Record Highs and Hospital ICUs Reach the Brink, Five Bioethicists on The Ford Government’s Bioethics Table Release a Public Statement Revealing Major Concerns with Ontario’s Plans for Triage of Critical Care, that Echo Disability Community Objections


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

April 15, 2021 Toronto: A body blow has just been delivered to the Ford Government’s controversial plans for deciding which patients would be refused life-saving critical care, if the crisis overload in Ontario hospital intensive care units requires that life-saving critical care must be rationed or “triaged”. Five members of the Ford Government’s own advisory “Bioethics Table” have today published an online statement, set out below, that strongly criticizes Ontario’s critical care triage plans. Their concerns reflect serious objections to Ontario’s triage plans from the disability community, including from the AODA Alliance.

The five bioethicists (who don’t claim to speak for the entire Bioethics Table) urge that the Government should now reveal its secret critical care triage plans to the public, should consult the public, and should hold and open discussion of how critical care should be triaged, if rationing becomes necessary, without treating this as a purely clinical issue or one for bioethicists to monopolize. (Key excerpts also set out below)

These five authors make it clear that Ontario needs a better approach to critical care triage. This is a direct blast at the Ford Government’s persistent secrecy on this issue and its refusal to speak directly to key stakeholders like those from the disability community. We offer the example that the Government has refused to even answer eight detailed letters from the AODA Alliance since last September which identify well-researched objections.

The five bioethicists explain that decisions over who should get life-saving critical care and who should be refused it during critical care triage is not simply a clinical question (i.e. one of medical science alone). Ontario’s secret critical care triage protocol treats this triage as purely a clinical question. The five authors humbly emphasize that bioethicists themselves have no monopoly on wisdom in the area of how critical care triage should be conducted.

These authors urge that it is important to respect the human rights of disadvantaged groups in society. We add that the AODA Alliance and others have been showing for months that Ontario’s plans are replete with disability discrimination, contrary to the Ontario Human Rights Code.

We expect that the Ford Government will answer that the Bioethics Table, of whom these five authors are a part, held consultations with a number of disability advocates, including the AODA Alliance. That would be no answer. Those discussions ended months ago. The external Bioethics Table only gives advice to The Government. The Bioethics Table makes no decisions on how critical care triage should be conducted, and rejected some of our major concerns without giving reasons for doing so. Those in the Government who do make the decisions have steadfastly refused to talk to us. The Government has hidden behind them for months, like human shields.

The secret January 13, 2021 Critical Care Triage Protocol is not available on any Government website, but is available on the AODA Alliance website.

In light of this important statement by several of The Government’s own external advisors, the AODA Alliance calls on the Ford Government to take these four urgent steps:

1. Now make public the current version of the critical care triage protocol, all reports and recommendations by its external Bioethics Table since September 11, 2021, The Government’s plan of action for rolling out critical care triage if needed, and the results of drills or simulations of critical care triage held at any Ontario hospitals.

2. Remove disability discrimination from the January 13, 2021 Critical Care Triage Protocol, and

3. Immediately hold a public consultation on how critical care triage should be conducted.

4. Introduce legislation on critical care triage for debate in the Legislature, rather than dealing with it by an internal memo to hospitals.

Key statements to this effect by the five bioethicists on the Ford Government’s external Bioethics Table in this article include:

“As bioethicists involved in developing an ethical framework for ICU triage at the Ontario COVID-19 Bioethics Table, we have serious concerns about the lack of transparency and public engagement around the constraints the Table works under.”

“We are beholden to the public as bioethicists helping to develop guidance for the ethical use of public resources especially to the people most likely to be impacted by intensive care triage decisions as well as to the physicians who will be forced to make these fraught decisions. This requires that the process be informed, transparent, inclusive, reasonable and subject to revision in light of new information or legitimate concerns or claims.

To date, these requirements have not been met in several provinces, including Ontario, and we entreat governments to make available their triage frameworks and protocols for public deliberation.”

“Science alone cannot tell us how to allocate ICU beds.”

“Whose lives we save is not just a matter of how we apply clinical criteria. It is a matter of redressing unfair inequalities in health and a matter of protecting fundamental human rights.

And while utility is one worthwhile objective of health policy, it must be balanced with due consideration of the human rights of people who might be disproportionately, unjustifiably or morally harmed by clinically based triage decisions. Relying on clinical criteria like judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to help distribute health benefits fairly across society through explicit consideration of social disadvantage.

Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.

The public needs to join the conversation on an ethical approach to triage”

“Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.”

“It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.

“We join the COVID-19 Bioethics Table, the Ontario Human Rights Commission and disability rights advocates in calling for transparency and public deliberation on the unfinished work of developing Ontario’s approach to critical care triage in a major surge during the COVID-19 pandemic.”

“The protection of fundamental legal and human rights during an emergency is a litmus test for society, and we need to do everything in our power to avoid overriding rights unjustifiably. Without public discussion, the vulnerability of already marginalized groups is intensified and trust eroded.”

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.

Healthy Debate April 15, 2021

Originally posted at https://healthydebate.ca/opinions/icu-triage/?utm_source=mailpoet&utm_medium=email&utm_campaign=we-need-to-talk-about-triaging-critical-care_12

Opinion

Public conversation on the ethics of intensive care triage during pandemic is overdue
by Alison Thompson, Paula Chidwick, Lisa Jennifer Schwartz, Stephanie Nixon, Lisa Forman, Robert Sibbald

COVID-19 has highlighted the ethical challenges in our health-care system, and nowhere is this more apparent than in an overcrowded intensive care unit. ICUs are where the sickest of the sick receive life-saving treatments and where their crashing bodily functions are taken over by high-tech machines.

Even when there isn’t a pandemic, not everyone can get access to intensive care, and not everyone will benefit from it. It is costly, invasive and requires a highly skilled workforce to make it run.

In the early days of the COVID-19 pandemic, people around the world were shocked by the images of ICU doctors working around the clock in Wuhan, Turin and New York. Their faces were etched with bruises from their tight-fitting face masks. Their eyes were haunted by the sheer number of patients they were treating and by the sheer number they couldn’t treat.

These early warnings from other countries signaled that Canadian provinces needed to avoid a major surge of patients that would strain intensive care resources. But, preparing for the worst, work on guidance for intensive care triage began very early on in the pandemic, with Saskatchewan and Quebec starting in late winter 2020 and Ontario in the spring of 2020 across several of its COVID-19 advisory tables.

As bioethicists involved in developing an ethical framework for ICU triage at the Ontario COVID-19 Bioethics Table, we have serious concerns about the lack of transparency and public engagement around the constraints the Table works under. To be clear, we do not speak on behalf of the COVID-19 Bioethics Table, but we do speak as scholars in clinical and public health ethics and in human rights law who are also members of that Table.

We are beholden to the public as bioethicists helping to develop guidance for the ethical use of public resources especially to the people most likely to be impacted by intensive care triage decisions as well as to the physicians who will be forced to make these fraught decisions. This requires that the process be informed, transparent, inclusive, reasonable and subject to revision in light of new information or legitimate concerns or claims.

To date, these requirements have not been met in several provinces, including Ontario, and we entreat governments to make available their triage frameworks and protocols for public deliberation.

Rationing intensive care beds is fundamentally an ethical endeavour

Science alone cannot tell us how to allocate ICU beds. Should they go to the sickest patients? Should they go to those who are most likely to benefit from treatment? Should we use a lottery system? Should we withdraw treatment from patients if they are not going to have a meaningful recovery to give the bed to someone who will? And what constitutes a meaningful recovery? These are ethical questions requiring value judgements.

Many pandemic response plans focus on maximizing the benefit of scarce resources to save the most lives. Allocating ICU beds to people who are unlikely to benefit from them is often considered unethical and inefficient. Clinicians who work in the ICU often talk about the moral difficulty of providing treatments that sometimes do more harm than good. The moral burden of care in these circumstances weighs heavily on ICU clinicians when left to make these decisions alone and without ethical guidance.

How should health equity be balanced with utility in intensive care triage?

Society’s failure to address upstream causes of ill health and inequities means that the futility or efficacy of ICU care is often determined well before people are brought to the doors of an ICU. To fail to attend to this in triage frameworks and clinical protocols undermines trust. Whose lives we save is not just a matter of how we apply clinical criteria. It is a matter of redressing unfair inequalities in health and a matter of protecting fundamental human rights.

And while utility is one worthwhile objective of health policy, it must be balanced with due consideration of the human rights of people who might be disproportionately, unjustifiably or morally harmed by clinically based triage decisions. Relying on clinical criteria like judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to help distribute health benefits fairly across society through explicit consideration of social disadvantage.

Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.

The public needs to join the conversation on an ethical approach to triage

Consensus on a proposed ethical framework for pandemic triage, even just among bioethicists, is unrealistic. Nor is it necessarily desirable. In fact, the role of dissensus in bioethics is crucial to avoiding the narrowing of possible policy avenues and avoiding presumptive constructions of various stakeholders.

As bioethicists, our expertise is in sketching the moral landscape, providing options and framing ethical debate. Our job is to propose a possible approach to intensive care triage that the public and stakeholders can then weigh and deliberate. It is also to propose and promote accessible and ethically defensible processes for doing so.

Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.

To be sure, public deliberation will not make the decisions about how to prioritize patients for intensive care any easier, nor will it necessarily make it easier to live with the consequences. But it would ensure that all voices have been heard, innovative approaches have been considered, and that new ethical considerations can come to light. It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.

We join the COVID-19 Bioethics Table, the Ontario Human Rights Commission and disability rights advocates in calling for transparency and public deliberation on the unfinished work of developing Ontario’s approach to critical care triage in a major surge during the COVID-19 pandemic. Other provinces must also follow suit. Specific attention needs to be paid to partnering with people who have been marginalized by both the process and the products of ICU triage development.

The protection of fundamental legal and human rights during an emergency is a litmus test for society, and we need to do everything in our power to avoid overriding rights unjustifiably. Without public discussion, the vulnerability of already marginalized groups is intensified and trust eroded.

No province in Canada can claim to have a morally legitimate and human rights compliant approach to triage until an accessible and public discussion takes place about how to balance equity with the aim of saving lives in a pandemic.




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More Advocacy Action, More Media, and More Ford Government Secrecy on Ontario’s Disability-Discriminatory Plans for Critical Care Triage If Hospital ICUs Run Out of Space for All Patients Needing Life-Saving Care


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/

April 14, 2021

SUMMARY

Disability advocacy keeps up the pressure on the critical care triage issue while the Ford Government keeps up the secrecy.

a) On April 13, 2021, the ARCH Disability Law Centre wrote the College of Physicians and Surgeons of Ontario. Its excellent letter is set out below. CPSO regulates Ontario physicians. ARCH echoed the AODA Alliance’s serious objections to the position on critical care triage that the CPSO sent to all Ontario doctors last week. The AODA Alliance s objections are set out in our April 9, 2021 letter and our April 13, 2021 letter to the CPSO, all of which we have made public.

ARCH’s letter amplified our disability concerns. We thank ARCH for its letter, and for working so closely together with the AODA Alliance and other disability advocates on this issue.

b) On April 13, 2021 Andrea Horwath, Ontario’s Leader of the Official Opposition, and Joel Harden, the Ontario NDP disability critic, released a strong statement on the critical care triage issue, also set out below. It blasts the Ford Government for its secret critical care triage protocol that wrongly discriminates based on disability. We thank the NDP for this action, and urge it to give this urgent issue as much public attention as possible.

c) On April 12, 2021, the Thunder Bay Family Network held a Zoom public forum to rally disability rights organizers and advocates in northern Ontario on the disability discrimination concerns with the Ontario critical care triage protocol and plan. AODA Alliance Chair David Lepofsky spoke at that event. A video of that event is posted on TBFN’s Facebook page. We congratulate TBFN and all those who attended and who made this such a success. We urge other organizations to hold similar events. We’d be delighted to help. Email the AODA Alliance at [email protected]l.com.

d) There continues to be some media attention on the critical care triage issue, but we need more of it!

We congratulate the fiery Dahlia Kurtz for her new national program on Sirius-XM Radio Channel 167, and applaud her for including AODA Alliance Chair David Lepofsky on that show’s third day on the air on April 14, 2021. That should be available later today at https://soundcloud.com/canadatalks

Below we set out the April 8, 2021 Toronto Star report on where the Ford Government stands on the idea of it agreeing in advance to pay all doctors’ claims for deaths due to critical care triage under the disability-discriminatory Ontario critical care triage protocol. We regret that the Toronto Star did not identify or address the disability issues here, as the Star last did several months ago.

We also set out below a column in the April 2, 2021 London Free Press. It identified AODA Alliance concerns with the Ford Government’s mishandling of the critical care triage issue.

e) The Ford Government’s delays on disability accessibility seem interminable. There have now been 804 days, or over 2 and a quarter years, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has announced no comprehensive plan of new action to implement that report. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis. The Ontario Government only has 1,358 days left until 2025, the deadline by which the Government must have led Ontario to become fully accessible to people with disabilities.

For More on these issues, 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.

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 Alliances 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.

6. You can also visit the AODA Alliance’s COVID-19 web page to see what we have been up to, trying to ensure that the needs of people with disabilities during the COVID-19 crisis are properly addressed. Send us your feedback! Write us at [email protected] Please stay safe!

MORE DETAILS

April 13, 2021 ARCH Disability Law Centre Letter to the College of Physicians and Surgeons of Ontario

55 University Avenue, 15th Floor
Toronto, Ontario M5J 2H7
www.archdisabilitylaw.ca
(416) 482-8255 (Main) 1 (866) 482-ARCH (2724) (Toll Free)
(416) 482-1254 (TTY) 1 (866) 482-ARCT (2728) (Toll Free)
(416) 482-2981 (FAX) 1 (866) 881-ARCF (2723) (Toll Free)

Sent via email at [email protected] and [email protected] April 13, 2021
Dr. Nancy Whitmore, Registrar and CEO
College of Physicians and Surgeons of Ontario
80 College Street
Toronto, Ontario M5G 2E2

Dear Dr. Whitmore:

Re: Triaging of Critical Care in Ontario

I am writing on behalf of ARCH Disability Law Centre in response to your email correspondence to members of the College of Physicians and Surgeons of Ontario on April 8, 2021, and the College’s subsequent response to the AODA Alliance dated April 12, 2021. ARCH shares the concerns raised by the AODA Alliance in its April 9th and April 13th letters.

We understand and appreciate the context of your correspondence, and the need to respond to the challenging circumstances that this pandemic continues to thrust on our health care service providers including physicians and surgeons. We also understand the need for a plan as this third wave of the pandemic overwhelms hospitals and critical care resources.

Your email correspondence addresses physicians’ obligations regarding the withholding and withdrawing of critical care. You state that the College supports deviation from its policies in following triage frameworks as developed by the command table.

Respectfully, your stated intention to ensure public trust in decision-making is eroded by supporting a critical care triage protocol that has been kept secret, on which there has been no proper public consultation, and which has been subject to serious disability discrimination objections. Disability advocates, and other marginalized communities, have been outspoken for over a year since the first Triage Protocol draft was leaked, identifying serious unlawful discriminatory implications that have persisted and have not yet been remedied. In addition, your correspondence does not clarify that all actions by your members must be taken free from any discrimination. Human rights protections under Ontario’s Human Rights Code and the Canadian Charter of Rights and Freedoms continue to fully apply during a pandemic. It is precisely during times such as these that our human rights protections are most critical. We are concerned that the College’s messaging disregards and dispenses entirely with such human rights concerns, to the serious detriment of Ontario physicians and patients.

Moreover, in considering public interest and protecting the rights of our most vulnerable patients, any messaging by the College that supports a potentially discriminatory framework and contemplates limitations on patients’ rights such as the making of complaints to the College is troubling and inappropriate.

The public looks to the College to objectively and impartially decide any individual complaints against member physicians. It must not pre-decide issues on which it will have to rule. The public must be given confidence that its complaints process is a fair one. The College’s April 8, 2021 email to its members is inconsistent with that obligation, on a topic where the public needs a strong assurance, rather than a cause for concern.

We urge the College to rescind and clarify its message and ensure that its members understand their paramount human rights obligations during this pandemic, and their continued human rights obligations regardless of what triage frameworks are ultimately approved.

Sincerely,
ARCH Disability Law Centre
Robert Lattanzio
Executive Director

cc:
Premier Doug Ford [email protected]
Christine Elliott, Minister of Health [email protected] Helen Angus, Deputy Minister of Health [email protected] Raymond Cho, Minister of Seniors and Accessibility [email protected]
Denise Cole, Deputy Minister for Seniors and Accessibility [email protected]
Mary Bartolomucci, Assistant Deputy Minister for the Accessibility Directorate [email protected]
Todd Smith, Minister of Children, Community and Social Services [email protected]
Janet Menard, Deputy Minister of Children, Community and Social Services [email protected] Ena Chadha, Chief Commissioner, Ontario Human Rights Commission [email protected]
David Lepofsky, Accessibility for Ontarians with Disabilities Act Alliance [email protected]

April 13, 2021 Statement by New Democratic Party on Critical Care Triage

April 13, 2021

Ford’s triage protocol needs public consultation and must respect disability rights

QUEEN’S PARK NDP Leader Andrea Horwath and MPP Joel Harden (Ottawa Centre), the NDP’s critic for Accessibility and Persons with Disabilities, said that as ICUs struggle to provide care for a rising number of people in critical condition, the provincial government must hold open consultations on the triage protocol and remove disability discrimination from it.

We all desperately hope the triage protocol will never have to be triggered, and there is more the provincial government can do to prevent that horrific scenario from playing out in Ontario. But preparing for life-and-death decisions about the lives of people, including people with disabilities, should not be done by the Ford government in secret, said Horwath. It’s time for this government to do the work it should have done months ago, and consult with disability and human rights groups, as well as Ontario families who will bear the consequences of these decisions.

Horwath and Harden said Doug Ford must stop ignoring human rights leaders and over 200 community organizations that wrote to the Ford government over a year ago exposing and denouncing its directions to Ontario hospitals on life-saving critical care that discriminates against people with disabilities. According to the Toronto Star, the Ford government is considering indemnifying critical care physicians from lawsuits which means the government is planning for doctors to have to make life-and-death decisions about allocating care, but is doing so behind closed doors.

“People with disabilities face a higher risk of getting and being severely impacted by COVID-19,” said Harden. “The Ford government must immediately remove disability discrimination from its clinical triage protocol, and respect the human rights of patients with disabilities.”

Toronto Star April 8, 2021

News

Originally posted at https://www.thestar.com/politics/provincial/2021/04/07/premier-doug-ford-instituting-province-wide-stay-at-home-order-expected-to-begin-thursday-sources-say.html

[Premier Doug Ford is vowing to have…]

Rob Ferguson, Robert Benzie and Kristin Rushowy Queen’s Park Bureau
Premier Doug Ford is vowing to have 40 per cent of adults vaccinated against COVID-19 – including essential workers over age 18 in Toronto and Peel Region hot spots – during Ontario’s 28-day stay-at-home order that begins Thursday.

Declaring a third state of emergency in a year, Ford said special education workers across the province and “all education workers in high-risk neighbourhoods in Toronto and Peel” would also begin getting shots during next week’s spring break, with dangerous variants of the virus spreading by the day.

The stay-at-home order, which could be extended, goes to May 6. The premier’s office said Ford’s 40 per cent vaccination target should get enough first doses to hot zones and quell transmission levels there.

“We need to get the vaccines where they will have the greatest impact as quickly as possible,” a sombre Ford said Wednesday, bowing to pressure from health experts and educators for targeted shots in trouble spots where outbreaks have resulted in younger adults being hospitalized at higher rates.

Vaccines will be sent to more hot zones in other municipalities as supplies allow.

“I am pleased with the pivot,” said Dr. Michael Warner, medical director of critical care at Michael Garron Hospital, formerly Toronto East General Hospital. He warned that adults under age 50 in ICUs are now dying at twice the speed of the first and second waves, with one fatality every 2.8 days.

For Toronto and Peel hot spots, Ford said mobile teams and pop-up clinics are being organized to give jabs to anyone over 18 living in highly impacted neighbourhoods.

The trigger for the second stay-at-home order since January was a sudden increase in admissions of critically ill Ontarians to hospital intensive care units above levels that had been predicted in the “worst-case” modelling scenarios, threatening the health-care system, Ford added.

“How we handle the next four weeks, what we do until we start achieving mass immunization, will be the difference between life and death for thousands of people,” he said, brushing aside criticisms that he should have acted sooner on the stay-at-home order given repeated warnings from his science advisers.

“Ford walked us right into this lockdown with eyes wide open,” New Democrat Leader Andrea Horwath told reporters.

“Experts made it clear every step of the way – he was reopening too quickly, taking away public health protections too soon, and implementing half-measures that would not stop the spread.”

With ICU admissions increasing, Health Minister Christine Elliott said the government is trying to boost hospital capacity. It has not yet prepared a cabinet order indemnifying intensive care physicians from liability in making difficult triage decisions as to which patients will get the resources needed to have the best chance to survive, she said.

“We haven’t finalized any of that.”

The province’s science advisers have cautioned the scenario seen last year in New York City and northern Italy, where ICUs were overwhelmed, would become reality in Ontario once patient levels of about 800 are reached in critical care.

The province is at 504 – a record in the pandemic – after a one-third rise in the last week and more admissions expected with the province averaging almost 3,000 new infections a day.

Elliott said many hospitals are at capacity, meaning there is no way for Ontario to vaccinate its way out of the situation and a four-week stay-at-home order is crucial to containing the virus and its highly contagious variants.

“The variants have won this round of the race,” Peel medical officer Dr. Lawrence Loh told a news conference in Brampton. “Close down, vaccinate, and get out of this.”

There were 3,215 new infections reported Wednesday – including 1,095 in Toronto and 596 in Peel – with 17 more deaths bringing the pandemic total to 7,475 fatalities.

The government limited retailers open for in-person shopping mainly to supermarkets, pharmacies, LCBO outlets, and takeout restaurants. Non-essential retailers go back to online sales and curbside pickup. Malls can designate one indoor location for customer pickup of items by appointment.

In a change from a similar order issued to quell the second wave in January, big box stores like Walmart and Costco will be limited to selling essential food, pharmacy, personal and pet care items.

Employees who can are asked to work from home and trips outside the home should be for essential reasons only, such as food shopping, medical appointments and exercise.

Close contact with anyone from another household is discouraged.

The changes came six days after the premier announced an Ontario-wide “lockdown” widely panned as inadequate since it just closed restaurant patios, indoor dining and personal services such as hair salons and barber shops that were open in areas outside Toronto and Peel, and not already in lockdown.

Toronto’s public and Catholic schools closed to in-person learning Wednesday, following in the footsteps of Peel Region schools the day before.

Ford rejected pressure from health experts and opposition parties to introduce a sick pay policy so that people with COVID-19 symptoms and without benefits can stay home if ill. Ford said a federal program is available.

The stay-at-home order is a dramatic turnaround from recent weeks, in which Ford allowed non-essential retailers in lockdown zones to open to 25 per cent customer capacity, raised indoor dining capacity limits in bars and restaurants outside lockdown areas and permitted sidewalk patios in Toronto and Peel.

There was also the promise that barber shops, hair and nail salons could open April 12 in Toronto, Peel and other regions elevated to lockdowns, but as infection levels grew across the province those hopes were dashed.

Cases of COVID-19 are up more than 70 per cent in the last two weeks.

London Free Press April 2, 2021

Originally posted at https://lfpress.com/opinion/columnists/baranyai-triage-framework-should-be-debated-if-public-is-to-have-confidence-as-third-wave-rises Baranyai: Triage framework should be debated as COVID’s third wave rises Author of the article: Robin Baranyai Special to Postmedia News A triage nurse waits for patients in the Emergency Department. (File photo)
Under normal circumstances, patient triage is about identifying who should be treated first: who needs resuscitation, and who can wait to have their broken wrist set. It is not a question of whether the patient receives the care they need, but when.

Last March, that assumption was turned on its head. The world watched in horror as Italy’s well-regarded health-care system, with 3.2 hospital beds per 1,000 people (compared to 2.5 in Canada), was overwhelmed.

The case for delaying the second vaccine dose
Faced with too many patients and too few ventilators, doctors were forced to decide on the fly where scant resources should be allocated. All too often, it came down to the patient’s age.

Canadians hope to avoid these unthinkable choices. As they say: Hope for the best, but plan for the worst.

Concerns again were raised this week about Ontario’s emergency standard of care, designed to provide consistent medical guidance on decisions should they become necessary about who receives care, by prioritizing resources for the patients most likely to survive. The protocol includes an online risk calculator for short-term mortality.

The protocol has been shared with Ontario hospitals, though not approved by the Ministry of Health, nor officially made public. The ministry has deflected queries to Jennifer Gibson, director of the University of Toronto’s joint centre for bioethics, and co-chair of the government’s bioethics table, which developed the triage framework.

It’s not shocking there is a protocol for making life-or-death care decisions, should hospital resources be overwhelmed. It would be shocking if there were not.

It is concerning, however, that an updated version of the protocol was brought to light by a disability advocacy group, and not by an open process of consultation, as recommended by both the bioethics table and the Ontario Human Rights Commission.

Under the protocol, two physicians would be involved in treatment decisions. The online tool allows doctors to input data on the severity of comorbid conditions, such as cancer, to help estimate patients’ odds of survival. Those with the best chance of surviving 12 months would be given priority for ICU beds.

The use of a clinical frailty scale (CFS) in risk calculations was flagged by the Accessibility for Ontarians with Disabilities Act (AODA) Alliance. It measures the ability to perform everyday tasks in patients older than 65. While a CFS may reduce the subjectivity of assessments, the AODA Alliance rightly points out, difficulty people with disabilities have with everyday tasks may have nothing to do with their odds of survival.

Similar concerns were raised by disability advocates in Quebec. An expert working group developed an emergency protocol last March, and the province held open consultations. The emergency protocol was revised after hearing from advocacy groups, including the Quebec Intellectual Disability Society.

Quebec’s protocol goes further than Ontario’s, establishing criteria by which patients could be removed from life support, if needed, without their consent. As yet, there is no mechanism in Ontario to prioritize treatment of patients with a higher likelihood of survival over those on life support.

This is deeply uncomfortable territory. It forces us to think about choices we’d rather not make, or have made for us. But if we want continued confidence in our health-care system, people need to know how these decisions could be made.

The hard choices of battlefield medicine may not be theoretical for long. At the height of the second wave in January, the number of COVID-19 patients in Ontario ICUs peaked at 420. As of Monday, there were 390.

The battle here is not only between patient care and system capacity. It is between communication and opacity; transparency and uncertainty. Transparency builds confidence.

[email protected]




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