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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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.



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Phase 2 of Ontario’s vaccine plan to focus on age, neighbourhood and health conditions in April


The Ontario government says there will be a focus on seniors aged 60 and older, those in other congregate settings, hot spot regions and those who cannot work from home in an updated vaccine rollout plan on Friday.

According to the documents, the vaccine rollout firstly targets death prevention, followed by prevention of illness, hospitalization and ICU admission, and transmission reduction.

The province is currently wrapping up Phase 1, in which those living in long-term care homes, retirement homes, as well as staff and front-line workers were targeted. Over 820,000 doses have been administered and over 269,000 Ontarians have been fully immunized with two shots.

Read more:
Canada approves Johnson & Johnson’s 1-shot COVID-19 vaccine

Officials noted that the plan does not factor in the newly approved Johnson & Johnson shot and additional doses of the Pfizer-BioNTech’s vaccine, which was announced on Friday.

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Health officials said timelines are amendable and may change based on vaccine supply.  There are currently four vaccines approved in Canada: Pfizer, Moderna, AstraZeneca and Johnson & Johnson. The first three require two shots several weeks apart while Johnson & Johnson only requires one.

Retired Gen. Rick Hillier, the head of the province’s vaccine rollout said with the approval of the new vaccines, the hope will be that everyone who wishes to be vaccinated will have at least their first dose by the end of June, or potentially by the first day of summer on June 20.

Phase 2 of Ontario’s three-phase rollout plan will see shots administered based on risk factors including age, neighbourhood, existing health conditions and inability to work from home.

Read more:
Toronto, Peel Region moving to grey lockdown restrictions under Ontario’s COVID-19 framework

This strategy focuses on the 2.5 million Ontarians between the ages of 60 and 79 years old.

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Residents over the age of 80 will be vaccinated first in March, followed by those over 75 years old, over 70 years old, over 65 years old and over 60 years old with the target end date to be done by the beginning of June.


The Phase 2 sequencing provided by the Ontario government.


Ontario government


Health Conditions and Congregate Settings

This strategy focuses on the 2.9 million Ontarians living with health conditions and the 0.2 million Ontarians living in congregate settings. This group will begin to be vaccinated in April.

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Ontarians living with the following health conditions will be vaccinated in Phase 2:

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

Highest-risk (442,000)

  • organ transplant recipients
  • hematopoietic stem cell transplant recipients
  • people with neurological diseases in which respiratory function may be compromised
  • haematological malignancy diagnosed <1 year
  • kidney diseases eGFR<30

High-risk (292,000)

  • Obesity (BMI>40)
  • Other treatments causing immunosuppression
  • intellectual or developmental disabilities

At-risk (2.2 million)

  • immune deficiencies and autoimmune disorders
  • stroke/cerebrovascular disease
  • dementia
  • diabetes
  • liver disease
  • all other cancers
  • respiratory diseases
  • spleen problems
  • heart disease
  • hypertension with end organ damage
  • diagnosis of mental disorder
  • substance use disorders
  • thalassemia
  • pregnancy
  • immunocompromising health conditions
  • other disabilities requiring direct support care in the community.

At-risk staff, essential caregivers and residents in congregate settings will be vaccinated in this category.

  • supportive housing
  • developmental services/intervenor and supported independent living
  • emergency homeless shelters
  • other homeless populations not in shelters
  • mental health and addictions congregate settings
  • homes for special care
  • violence against woman shelters and anti-human trafficking residents
  • children’s residential facilities
  • youth justice facilities
  • indigenous healing and wellness
  • provincial and demonstration schools
  • on-farm temporary foreign workers
  • bail beds and indigenous bail beds
  • adult correctional facilities

Read more:
Coronavirus: Toronto still waiting on vaccine supply boost from province

This strategy focuses on the 900,000 Ontarians living in targeted hot spot regions, who have high rates of death, hospitalizations and transmission. These hot spot regions will still focus on older age groups first. The vaccination process will begin in April and is expected to be completed by the end of May.

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The following 13 public health units will receive up to 920,000 additional vaccine doses to target “historic and ongoing hot spots,” according to the documents.

  • Durham
  • Halton
  • Hamilton
  • Niagara
  • Ottawa
  • Peel
  • Simcoe Muskoka
  • Waterloo
  • Wellington Dufferin Guelph
  • Windsor Guelph
  • Windsor Essex
  • York
  • Toronto
  • South West

Read more:
COVID-19 vaccination booking sites busy in Ontario regions offering shots to oldest seniors

This strategy focuses on the almost 2.5 million Ontarians who cannot work from home amid the pandemic. These residents are broken into two groups and those who fall under this category will be vaccinated at the end of Phase 2 expected to be around June.

The first group contains 730, 000 people:

  • elementary/secondary school staff
  • workers responding to critical events (police, fire, compliance, funeral, special constables)
  • childcare and licensed foster care workers
  • food manufacturing workers
  • agriculture and farm workers

The second group contains 1.4 million people:

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  • high-risk and critical retail workers (grocery and pharmacies)
  • remaining manufacturing labourers
  • social workers
  • courts and justice system workers
  • lower-risk retail workers
  • transportation, warehousing and distribution
  • energy, telecom, water and wastewater management
  • financial services
  • waste management
  • mining, oil and gas workers

Over 400,000 essential caregivers will be vaccinated at the same time (at the end of Phase 2), with the focus being on those who take care of residents living with the highest-risk conditions including organ transplants recipients and hematopoietic stem cell transplant recipients.

Ontario will be launching its online vaccination booking system and call centre on March 15. Certain public health units have launched their own system including in Peel Region and Guelph.


Click to play video 'Ontario pharmacies added to COVID-19 vaccine rollout'







Ontario pharmacies added to COVID-19 vaccine rollout


Ontario pharmacies added to COVID-19 vaccine rollout

The Ontario government said it is also working with all 34 public health units in the province to create mass immunization clinics. According to the document, “it is expected that approximately 80 per cent of total provincial vaccine allocations will be administered through mass immunization clinics during Phase 2 and 3.”

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Vaccinations will also be made available through certain pharmacies and family health centres.

“It is expected that the majority of the first shipment of AstraZeneca in March and in Phase 2 will be supported by the addition of retail pharmacies and primary care,” the documents read.

— With files from The Canadian Press





© 2021 Global News, a division of Corus Entertainment Inc.





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Ontario Human Rights Commission Echoes More Serious Concerns with the Ontario Critical Care Triage Plan – Will the Ford Government Start to Listen This Time?


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/

Ontario Human Rights Commission Echoes More Serious Concerns March 2, 2021

SUMMARY

The pressure on the Ford Government mounts even more to open up, publicly discuss and substantially revise its seriously flawed plans for rationing or triage of critical medical care if the COVID-19 pandemic overloads hospitals. On March 1, 2021, the Ontario Human Rights Commission wrote the Ford Government a strong letter, set out below. It echoes a number of our serious problems with the Ontario critical care triage plan. It specifically references concerns that have been raised by the AODA Alliance and the ARCH Disability Law Centre.

We commend the Ontario Human Rights Commission for this letter. We call on the Ford Government to come out of hiding, and address the serious concerns that we and the Ontario Human Rights Commission are raising.

If there must be a critical care triage plan and protocol, it must be legally valid and constitutional. It is not good enough for anyone to duck our concerns by simply taking the position that a critical care triage plan is needed. That one is needed does not justify its discriminating because of disability contrary to the Ontario Human Rights Code and Charter of Rights, and its failing to provide due process to patients whose very lives are in jeopardy.

There is an urgent need for frontline doctors, being trained to conduct critical care triage, to be alerted to the serious human rights and constitutional violations that they could commit. As the AODA Alliance’s February 25, 2021 report on Ontario’s critical care triage plan reveals, a recent January 23, 2021 webinar for over 1,100 frontline doctors completely failed to alert those trainees to these issues. It misleadingly told those trainees that the Ontario Human Rights Commission was consulted on the development of Ontario’s critical care triage plan, without also alerting them that the Commission (along with community organizations like the AODA Alliance) raised serious human rights objections to that plan. The Commission’s letter, set out below, is yet more proof that such misleading training for critical care triage doctors risks real harm to patients with disabilities.

The Ontario Human Rights Commission’s letter refers to an earlier written submission on critical care triage that the Commission sent the Government-appointed Bioethics Table last December, and to a summary that the Bioethics Table prepared of a consultative roundtable that the Bioethics Table held on December 17, 2020 (in which the AODA Alliance participated). We set that summary out below, as well as the Ontario Human Rights Commission’s written submission that supplemented it, included as an appendix to that summary. We want to give you some information to help you read the summary of the December 17, 2020 roundtable that the Bioethics Table prepared:

1. Several key points that the AODA Alliance raised at that December 17, 2020 roundtable are set out in greater detail in the AODA Alliance’s unanswered December 17, 2020 letter to the Minister of Health.

2. The overwhelming point that came from the community groups at that roundtable made was that they had not had time to prepare for that rushed meeting, but had serious human rights concerns with the critical care framework we were shown. Since then, no such consultation has been held with community groups like the AODA Alliance by the Government, its Bioethics Table or its Ontario Critical Care COVID Command Centre. This is so even though the Government and its proxies and defenders in the medical world repeatedly claim that consultations are ongoing on the Ontario critical care triage plan.

3. As it turns out, we now know that the Ford Government and its Ontario Critical Care COVID Command Centre had already taken important steps towards its critical care triage plan by the time that the December 17, 2020 roundtable was being held. These steps were likely known to the Bioethics Table participants, but were not revealed to the AODA Alliance and other community groups taking part in that discussion.

For more background, check out:

1. The AODA Alliance’s February 25, 2021 report revealing new serious problems with the Ontario critical care triage plan, and its February 26, 2021 news release on that report.

2. The January 13, 2021 Ontario Critical Care Triage Protocol, which the Government has never revealed, and which we believe is only publicly downloadable from the AODA Alliance website.

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

March 1, 2021 Letter from the Ontario Human Rights Commission to the Ontario Government

The Honourable Christine Elliott
Minister of Health
College Park 5th Floor, 777 Bay Street
Toronto, ON M7A 2J3

Dear Minister Elliott:
RE: Follow-up on critical care triage Ongoing human rights concerns and the need for public consultation
I hope this letter finds you well. Thank you for speaking with me in December 2020 and confirming your commitment to human rights and your interest in ensuring that our stakeholders’ concerns are appropriately heard. As you know, since April 2020, the Ontario Human Rights Commission (OHRC) has voiced the importance of respecting human rights when triaging critical care during the pandemic. The OHRC has sought to promote an equity-sensitive approach that is fair, transparent and founded on human rights principles.
Since last year, the OHRC has called on the Government to publicly release and consult with human rights stakeholders on various iterations of the critical care triage protocol and framework. Throughout this time, the OHRC has undertaken all best efforts to support the COVID-19 Bioethics Table in its work to revise a triage framework that respects human rights.
We are writing to highlight certain issues about the most recent triage-related documents that the Ontario Critical Care COVID-19 Command Centre has disseminated to health-care administrators and, once again, to offer our support to your Ministry in hopes of ensuring that the concerns and interests of human rights stakeholders will be heard.
As you know, last December, the OHRC worked collaboratively with the COVID-19 Bioethics Table to facilitate a consultation with human rights stakeholders on the September 11 version of the proposed triage framework document. The Bioethics Table prepared a summary of the meeting and circulated it to participants. The summary also included an appendix prepared by the OHRC summarizing its recommendations for the Bioethics Table and your Ministry’s consideration.
Early this year, the OHRC obtained a copy of the Emergency Standard of Care dated January 13, 2021. We also obtained copies of related supplementary materials on the Emergency Standard of Care:
Template letters to be sent to patients informing them they will not receive critical care and/or that critical care is being withdrawn without their consent
An online short-term mortality risk calculator with digitized clinical tools to assess mortality
Critical Care Services Ontario’s January 23, 2021, webinar and slide deck to help disseminate the Emergency Standard of Care within the sector.
While the OHRC appreciates that the Emergency Standard of Care refers to human rights principles and obligations in its introduction, we remain concerned about the following issues that we raised earlier:
The reliance on a 12-month predicted mortality timeline is excessive and risks discriminatory biases
The use of clinical assessment tools not validated for critical care triage also risks discriminatory bias
The need to account for the human rights duty to accommodate throughout the decision-making process including when assessing a patient’s predicted mortality
The need to ensure the legal right to due process and transparency for triaging decisions, including an effective mechanism for the right to appeal a decision that disproportionately impacts the right to life of vulnerable groups
The need to ensure appropriate human rights training and guidance for healthcare service providers so that they can implement the standard equitably and effectively.
Further, while the OHRC appreciates that the Emergency Standard of Care is intended to be an evergreen document, we are concerned that this document and supplementary materials (including the online short-term mortality risk calculator) are being shared within the health-care sector with potentially discriminatory content and without sufficient public input or consultation. We are also concerned that the previous March 2020 version of the protocol, which was intended to be rescinded in October 2020, may still be in circulation and relied upon by health-care partners, particularly given something to this effect was noted in the above-cited January 23, 2021, webinar regarding emergency/ambulance services.

Stakeholders including ARCH Disability Law Centre and the AODA Alliance have expressed serious concerns that the government may act on calls for an emergency order to suspend certain provisions of the Health Care Consent Act, allowing doctors to withdraw patients from critical care without their consent, or that of their families or substitute decision-makers, and without independent oversight.
The OHRC understands that granting doctors such decision-making power is an extraordinary measure and one the Government will not take lightly. The OHRC also understands that your Ministry wishes to ensure that human rights stakeholders concerns are properly considered and understood. In light of this, we cannot overstate that even if the Government does not issue an emergency order, the lack of transparency regarding the status of the Emergency Standard of Care, plans regarding next steps and questions regarding due process are causing grave concern among vulnerable groups. We believe these concerns must be addressed immediately, particularly given the existence of new, highly transmissible variants of COVID-19.
The OHRC believes that now is the time to act to make sure that frameworks and protocols for triage decisions that are consistent with the Ontario Human Rights Code are in place before a potential third wave overwhelms Ontario’s health-care system.
We call on the Government to publicly release and consult human rights stakeholders including the OHRC on the latest versions of the proposed triage framework and the Emergency Standard of Care. There is an urgent need to make sure that vulnerable groups who may be disproportionately affected have an opportunity to share their perspectives while there is still time, and before the proposed triage framework and/or Emergency Standard of Care and related materials are finalized. Sincerely,

Ena Chadha, LL.B., LL.M.
Chief Commissioner

cc: Helen Angus, Deputy Minister, Ministry of Health
Matthew Anderson, President and CEO of Ontario Health Jennifer Gibson, Co-Chair, COVID-19 Bioethics Table
Dr. Andrew Baker, Incident Commander, Ontario Critical Care COVID-19 Command Centre Hon. Doug Downey, Attorney General
David Corbett, Deputy Attorney General, Ministry of the Attorney General OHRC Commissioners

Ontario Government’s Bioethics Table Summary of Its December 17 2020 Roundtable on Critical Care Triage

Stakeholder Roundtable

Critical Care Triage During Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario

Summary Report

Prepared by:
Jennifer Gibson, PhD (Co-Chair, Bioethics Table)
Dianne Godkin, PhD (Co-Chair, Bioethics Table)
21 December 2020

Introduction
On December 17th, the Ontario COVID-19 Bioethics Table (the Bioethics Table) and the Ontario Human Rights Commission (OHRC) co-convened a roundtable with human rights stakeholders (Appendix 1) to review and provide feedback on the Ontario COVID-19 Bioethics Table’s Critical Care Triage During Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario (the Proposed Framework). The Proposed Framework was developed iteratively from March to August 2020 (Appendix 2) and submitted with recommendations for next steps to the Ministry of Health and Ontario Health in September 2020. An earlier version of the framework, which had been developed and released to Ontario hospitals in March 2020, was never implemented and was subsequently rescinded on October 29th.
The roundtable was facilitated by Dr. Kwame McKenzie (CEO, Wellesley Institute). Representatives from the Office of the Minister of Health, the Ministry of Health, Ontario Health and the COVID-19 Ontario Critical Care Command Centre were in attendance as observers. As laid out by Dr. McKenzie, the roundtable aimed to ensure: 1) that all human rights stakeholders were able to share their views on the Proposed Framework; 2) that their concerns were heard by the Ministry, Ontario Health, Critical Care Command Centre representatives and by Bioethics Table members; and 3) that there was clarity on how the Proposed Framework could be improved. Roundtable participants were also provided with links to recent publications on the topic of critical care triage and associated frameworks/protocols in Canada and elsewhere (Appendix 3).

This report provides a high-level summary of key issues and concerns raised by roundtable participants and potential actions identified by roundtable participants to address these issues and concerns. It is not exhaustive of all that was discussed at the roundtable. It is intended to reflect the most urgent issues and concerns around which there was broad agreement among roundtable participants in the immediate context of Wave 2 of the COVID-19 pandemic. The OHRC has also provided an outline of its recommendations (Appendix 4). It was acknowledged by all that there are systemic health inequities that will require long-term solutions that are outside of the scope of critical care triage during a pandemic.

Key Issues/Concerns and Potential Actions

Roundtable participants stressed the paramount importance of a non-discriminatory, equitable, and culturally safe critical care triage approach. COVID-19 has already had a disproportionate negative impact on many of the communities represented by roundtable participants. Pre-existing historical and social inequities in health outcomes and negative experiences of the healthcare system further exacerbate these impacts. Some may experience intersectionality, the cumulative impact of belonging to more than one disadvantaged group (e.g., a racialized person who also has a disability). For Indigenous communities, it is not just a matter of individual survival, but of cultural survival if an Indigenous knowledge keeper becomes ill and dies. Participants raised concerns that there has been limited engagement of disability, older adults, Indigenous, Black and other racialized communities, arguably those who have been most significantly impacted during the pandemic, in all aspects of pandemic planning and that this has resulted in unsatisfactory and unsafe care. The possibility of triage raises significant fears that these historical and social inequities will be magnified if actions are not taken to implement a critical care triage process that is non-discriminatory. Participants were very concerned that they only had one week to review the Proposed Framework and had difficulty understanding some aspects of the document. Consequently, further engagement and stakeholder consultation is required. A general observation of the Proposed Framework raised by participants is that is not sufficiently prescriptive in describing what must be done.

The following Table summarizes the most urgent issues and concerns and potential actions identified by roundtable participants:

1. Human Rights and Non-Discrimination as Legal ObligationsIssue: Roundtable participants need greater assurance that decisions related to critical care triage will be made in alignment with human rights codes and will be non-discriminatory.

Potential actions:
> Articulate non-discrimination/human rights as the primary overarching legal obligation used to guide the critical care triage process.

2. Equity as a Positive ObligationIssue: Although equity is identified as an important ethical principle in the Proposed Framework, roundtable participants emphasized the need for a positive obligation to promote equity and for concreteness and clarity on how equity would actually be enacted in practice. It was recognized that under conditions of great stress during a major surge in demand for critical care, unconscious bias is likely to be activated unless steps are taken to support clinicians in promoting equity.

Potential actions:
> Develop an equity-based checklist tool that healthcare providers must review and consider during the assessment stage of the triage process to help them account for the impact of social determinants of health and pre-existing co-morbidities due to social and historical inequities in the care of their patients.
> Make requirements for accommodations for persons with disabilities or to address communication barriers explicit, including allowing a support person to be present as needed.
> Ensure all who are involved in critical care triage process receive anti-racism, anti-bias (e.g., anti-ageism, anti-ableism), and Indigenous cultural safety training and/or have access to tools and resources (e.g., see checklist above) to minimize the risk of unconscious bias.

3. Legal Framework for Critical Care Triage During a Major Surge Issue: Critical care triage during a major surge would deviate from current legal and regulatory standards, particularly in relation to withdrawal of life-sustaining treatment without consent. Roundtable participants underscored the need for a legal framework to justify the critical care triage approach and to protect both healthcare providers and patients. Any liability protections for healthcare providers should require that they have acted in accordance with this legal framework and with the Ontario Human Rights Code.

Potential actions:
> Develop a legal framework for critical care during a major surge, including key elements of due process.

4. Critical Care Triage Decision-making Process and Clinical Assessment ToolsIssue: Roundtable participants expressed a need for critical care triage decision-making processes and clinical assessment tools to be outlined in greater detail and communicated in a transparent manner to patients and the public. While there was general agreement that for the purposes of triage decisions, clinical assessment should focus on predicted short-term mortality risk, specific concerns were raised about using 12-months as the time frame for predicted short-term mortality and about the validity of the tools for Indigenous persons and other marginalized persons. Roundtable participants also emphasized the need for critical care triage decisions to be transparent.

Potential actions:
> Engage stakeholders in the identification/adaptation of clinical tools to ensure they are culturally appropriate.
> Reduce the duration of short-term predicted mortality risk from 12 months to a lesser time period.
> Include individuals (e.g., community leaders) outside of the medical profession in the implementation of the critical care triage decision-making process (e.g., as supports to patients in clinical decision-making; as members of the Triage Teams described in the Proposed Framework; as members of appeals committees).
> Develop accessible communication tools tailored to the needs of particular groups to foster understanding and trust.

5. Right to AppealIssue: Given the significance of the decision to withhold or withdraw critical care resources from a patient, roundtable participants underscored the need for a timely appeal process as an important safeguard to uphold non-discrimination.

Potential actions:
> Establish an external appeals process by a third party.

6. Development of Interim Protocol for Wave 2Issue: Given the increasing hospitalizations in Wave 2, roundtable participants underscored the urgency of having a non-discriminatory, legally sanctioned, and effective triage protocol in place in the event that there is a major surge in demand for critical care in the coming weeks or months. Absent an interim protocol, roundtable participants acknowledged that clinicians would be left unsupported in the triage decision-making process and Indigenous, Black and other racialized patients and persons with disabilities would be placed at significant risk of harm. The interim protocol would be subject to further revisions and include ongoing engagement and co-development with key stakeholders.

Potential actions:
> Develop an interim protocol in collaboration with human rights stakeholders and critical care providers. The interim protocol could be based on the institutional protocol created by the Ontario COVID-19 Critical Care Command Centre with modifications to reflect where there is broad human rights stakeholder agreement.
> Concurrently, continue stakeholder engagement to address unresolved issues and to advance elements of the Proposed Framework which may require more time to implement. APPENDIX 1: Roundtable Participants

Roundtable Facilitator:
Kwame McKenzie (CEO, Wellesley Institute)

Participants:
Nicole Blackman (Provincial Director, Indigenous Primary Health Care Council)
Avvy Go (Director, Chinese and Southeast Asian Legal Clinic)also provided written submission
James Janeiro (Director, Community Engagement and Policy, Community Living Toronto)
Trudo Lemmens (Professor & Scholl Chair in Health Law and Policy, Faculty of Law, University of Toronto) David Lepofsky (Chair, AODA Alliance)
Caroline Lidstone-Jones (CEO, Indigenous Primary Health Care Council) Roxanne Mykitiuk (Professor, Osgoode Hall Law School, York University) Tracy Odell (President, Citizens with Disabilities)
Mariam Shanouda (Staff Lawyer, ARCH Disability Law Centre)
Jewelles Smith (Past-Chairperson, Council of Canadians with Disabilities)

Observers:
i) Office of the Minister of Health
Emily Beduz (Director, Pandemic Response)
Heather Potter (Director, Issues and Legislative Affairs)

ii) Ministry of Health
Tina Sakr (Team Lead, Priority and Acute Programs)
Jennifer Lee Arseneau (Senior Policy Advisor, Priority and Acute Programs)

iii) Ontario Health
Louise Verity (Strategic Advisor to the CEO)

iv) Ontario COVID-19 Critical Care Command Centre
Andrew Baker (Incident Commander)

v) Ontario Human Rights Commission
Ena Chadha (Chief Commissioner)
Violetta Igneski (Commissioner)
Raj Dhir (Executive Director and Chief Legal Counsel)
Shaheen Azmi (Director, Policy, Education, Monitoring & Outreach) Bryony Halpin (Senior Policy Analyst)
Jeff Poirier (Senior Policy Analyst)
Rita Samson (Senior Policy Analyst)

vi) Ontario COVID-19 Bioethics Table (in attendance)
Jennifer Gibson (Co-Chair; University of Toronto)
Dianne Godkin (Co-Chair; Trillium Health Partners)
Sally Bean (Toronto Region Bioethics Lead and Member; Sunnybrook Health Sciences Centre) Cecile Bensimon (Member; Canadian Medical Association)
Carrie Bernard (Member; William Osler Health System, University of Toronto, McMaster University)
Nicole Blackman (*new member as of Dec 2020; Indigenous Primary Health Care Council)
Paula Chidwick (Central Region Bioethics Lead and Member; William Osler Health System)
James Downar (Member; The Ottawa Hospital, Bruyere Continuing Care, Ottawa Health Research Institute) Lisa Forman (Member; University of Toronto)
Mary Huska (North Region Bioethics Lead and Member; Health Sciences North) Michael Kekewich (East Region Bioethics Lead and Member; The Ottawa Hospital) Stephanie Nixon (Member; University of Toronto)
Nancy Ondrusek (Member; Public Health Ontario)
Lisa Schwartz (Member; McMaster University)
Robert Sibbald (Member; London Health Sciences; Western University) Maxwell Smith (Past Co-Chair and Member; Western University) Randi Zlotnik-Shaul (Member; Sick Kids Hospital)

vii) Students
Veromi Asiradam, JD Student, Osgoode Hall Law School, York University Ya-En Cheng, JD Student, Osgoode Hall Law School, York University

viii) Recorder
Danielle Linnane (Quality Improvement Specialist, Ontario Health)

APPENDIX 2: Development of the Proposed Framework

The Critical Care Triage During Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario (the Proposed Framework) wasdevelopedbased on iterative review of the academic literature and published policy statements on critical care triage in a pandemic, consultation with clinical, legal, and other experts, and feedback from health system stakeholders. The Proposed Framework with recommendations for next steps was submitted to the Ministry of Health and Ontario Health in September 2020.

Development of the Proposed Framework was undertaken in three phases from March to December 2020:

In Phase 1, an initial draft framework was developed in March 2020 in response to an urgent need for the Ontario health system to prepare for the possibility of a major surge in demand for critical care as was being observed in Italy, Spain, and New York State. The initial draft, which was developed without the benefit of consultation with human rights stakeholders, among others, was released to hospitals on March 28 to aid planning. A major surge in demand for critical care was averted in Ontario. This draft framework was not implemented and was formally rescinded on October 29, 2020.

In Phase 2, extensive feedback on the initial draft framework was received in April 2020 through written submissions from diverse organizations and groups. Feedback was sent either directly to the Bioethics Table or to the Ministry of Health or Ontario Health and shared with the Bioethics Table. The Bioethics Table reviewed and considered all feedback and amended the document accordingly. Additional feedback was solicited from bioethics, health law, and clinical experts. An updated draft framework was developed in May 2020 based on new published findings in the literature, policy discussions in the public domain (e.g., policy statements), and written stakeholder feedback.

In Phase 3, the Bioethics Table began meeting with the Ontario Human Rights Commission (OHRC) in May 2020 and undertook an expanded stakeholder consultation process to elicit input from Black and other racialized groups, Indigenous health leaders, older adults, and disability rights experts. A first stakeholder roundtable was co-convened with the OHRC on July 15, 2020. Meetings continued through July and August with disability rights stakeholders and with the Indigenous Bioethics Reference Group of the Indigenous Primary Health Care Council. The Proposed Framework was informed extensively by these stakeholder discussions, an updated review of the literature and policy statements from civil society organizations (e.g., Canadian Association of Retired People), and additional input from health law and clinical experts. In December 2020, the Bioethics Table received approval to convene a second stakeholder roundtable to review and elicit feedback on the Proposed Framework. The roundtable took place on December 17, 2020.

The Proposed Framework documentis a green document within the overall COVID-19 pandemic response in Ontario.The process for developing an approach to critical care triage in the context of a major surge in demand must be sensitive and responsive to changing conditions, emerging evidence, and evolving understanding of the ethical, social, and legal implications of critical care triage for major surge in a pandemic. As such, this document should be subject to regular review and updating as appropriate.

Acknowledgments:

The Bioethics Table would like to acknowledge the substantive feedback, input, and advice of the following organizations through written submissions and/or stakeholder consultations (listed alphabetically):

AODA Alliance
ARCH Disability Law Centre
Black Health Committee, Alliance for Health Communities
Canadian Frailty Network
Canadian Geriatric Society
Canadian Medical Protective Association
Canadian Thoracic Society
Chinese and Southeast Asian Legal Clinic
Citizens with Disabilities Ontario
Clinical, Organization, and Research Ethics (CORE) Network and Provincial COVID-19 Bioethics Community of Practice University of Toronto Joint Centre for Bioethics1 College of Nurses of Ontario
College of Physicians and Surgeons of Ontario
Community Living Toronto
Council of Canadians with Disabilities
COVID-19 Critical Care Command Centre and Provincial Critical Care Table, Ontario Health Indigenous Bioethics Reference Group, Indigenous Primary Health Care Council Muscular Dystrophy Canada
Ontario Hospital Association/HIROC
Ontario Human Rights Commission
Ontario Medical Association

The Bioethics Table has also benefited from the substantive feedback, input, and advice of individual scholars and practitioners with expertise in the following areas:

Clinical Medicine over 20 clinician experts in cancer care, cardiac care, complex continuing care, critical care, emergency medicine, geriatric medicine, neurology, stroke, thoracic medicine Health Equity
Health Law and Human Rights Law

**Please note that these acknowledgments do not signify endorsement of the Proposed Framework.**

APPENDIX 3: Roundtable Documents

The following is a list of recent publications, including government or policy documents, journal articles, and media reports, on the topic of critical care triage and associated frameworks/protocols in Canada and elsewhere. These were pre-circulated to roundtable participants for their information.

Critical Care Triage Frameworks/Protocols from Other Jurisdictions

1. Quebec Critical Care Triage Protocol (Nov 2020 In French)
2. Saskatchewan Health Authority Triage Working Group, Critical Care Resource Allocation Framework (Sept 2020)
3. Joint Commission on Triage Decisions for Severely Ill Patients During the COVID-19 Pandemic (Israel, July 2020)
4. COVID-19 rapid guideline: critical care in adults (UK-NHS, March 2020/updated Sept 2020)

Publicly Available Advocacy/Feedback related to Critical Care Triage

1. ARCH Disability Law Centre
2. AODA Alliance/ARCH Disability Law Centre
3. Ontario Human Rights Commission
4. Société québécoise de la déficience intellectuelle – English translation using Google Translate attached

Journal & Media Articles

1. Nouvelles directives pour l’attribution des respirateurs artificiels (Le Devoir) – English translation using Google Translate attached
2. Following controversy, Quebec revises rules for who gets intensive care treatment if resources are limited (CBC news)
3. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? (American Journal of Bioethics)
4. Disability, Disablism, and COVID-19 Pandemic Triage (Journal of Bioethical Inquiry)
5. What the Chaos in Hospitals Is Doing to Doctors: Politicians’ refusal to admit when hospitals are overwhelmed puts a terrible burden on health-care providers (The Atlantic)
5. Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources (Canadian Geriatrics Journal)
6. Ontario has a world-leading protocol that all provinces and territories should adopt to be truly ready for COVID-19’s second wave (Policy Options)
7. Proceed with caution with Ontario’s critical care triage protocol (Policy Options) APPENDIX 4: OHRC Recommendations

Summary of OHRC Feedback on Triage Framework
December 18, 2020

Interim Framework / Protocol

* The OHRC encourages the Ministry of Health to share the protocolized version of the Triage Framework that was sent to hospitals in Ontario and also make this document available to all stakeholders involved in the consultation.

* Without having seen this document, the OHRC is not in a position to assess whether the protocolized version could be adapted or whether an entirely new document needs to be developed to reflect stakeholder input and serve as an interim protocol. An interim protocol should be short, user friendly and developedwith a view to how it can be used ina crisis until further consultation can happen.

* The interim protocol could continue to evolveas a basis for further consultation on more complex and contentious issues. While not yet sanctioned by legislation or regulation, hospitals would have ready accessto a protocol that is reasonably acceptable to stakeholders if a major surge happens.

* An interim protocol could potentially address issues where there is agreement across stakeholder groups. The issues are, but not limited to:

o Ensure the protocol recognizes that human rights is the primary guiding principle and law in accordance with the primacy clause under section 47 of Ontario’s Human Rights Code (Code)

o Ensure there is a legislative basis for the protocol that will also provide for governance and accountability mechanisms including how to initiate the use of the protocol during a pandemic surge

o Exclude the Clinical Frailty Scale (CFS) and any other clinical assessment factors and tools that are not validated for critical care resource allocation. The Bioethics Table recognizes the CFS was designed and validated to help identify treatment plans and accommodation supports for frail patients, and not for critical care triage. Used as a triage tool, the CFS would likely disproportionately impact Code-protected groups and may be inconsistent with human rights obligations including the duty to accommodate

o Define short-term predicted mortality as the predicted risk of death in the initial weeks, and not twelve months after the onset of critical illness. The Bioethics Table recognizes that relatively little mortality occurs between six and twelve months

o Ensure a fair and efficient appeal mechanism

o Explicitly recognize the legal duty to accommodate including essential support persons / communications / interpreter access, etc.

o Mandate a clear procedure to document decisions that requires evidence-based written reasons. This could include a positive obligation checklist to account for issues of equity and the social determinants of health

o Require socio-demographic data collection to monitor for adverse application of the protocol

o Allow for human rights equity groupsto monitor, and provide feedback on the protocol.

The OHRC also agrees with the Bioethics Table’s recommendations that call on the Ministry of Health and Ontario Health to:

* Issue clear communications that health care providers must disregard and destroy the March 28 version of the protocol

* Circulate theproposed framework, including the clinical assessment factors and tools, for public feedback and independent legal review

* Convene amultidisciplinary panel, including experts in human rights and law to further develop, or refute, the clinical factors and tools identified in the proposed framework

* Engage health care partners to developguidance for implementing the protocolincluding clinical operations, communications, training, patient and clinician supports, data collection and monitoring

* Provide forgovernance and accountability mechanismsincluding responsibility for initiating the protocol, data collection and independent monitoring for adverse consequences

* Sustain equitable COVID-19 prevention efforts to avoid the need to initiate the protocol, and mitigate disproportionate impacts on vulnerable groups

* Meaningfully engage vulnerable groups, including Indigenous communities, Black and racialized communities, persons with disabilities, older persons and others for their perspectives and participation throughout the process to finalize and implement the protocol.

* Provide comprehensive training on the new protocol, including anti-bias education.
1 The CORE Network and the COVID-19 Bioethics Community of Practice comprise practicing bioethicists who work in a variety of health institutions, including hospitals, long term care homes, rehabilitation facilities, community care, and complex continuing care settings. Members have diverse disciplinary expertise (e.g., philosophy, law, anthropology) and clinical professions (e.g., medicine, nursing, social work, occupational therapy). CORE Network members are based in the Greater Toronto/Hamilton Area. The COVID-19 Bioethics Community of Practice draws practicing bioethicists from across the province of Ontario totalling >50 individuals. The University of Toronto Joint for Bioethics provides secretariat support for both the Core Network and the COVID-19 Bioethics Community of Practice.




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Ontario Human Rights Commission Echoes More Serious Concerns with the Ontario Critical Care Triage Plan – Will the Ford Government Start to Listen This Time?


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/

Ontario Human Rights Commission Echoes More Serious Concerns with the Ontario Critical Care Triage Plan – Will the Ford Government Start to Listen This Time?

March 2, 2021

            SUMMARY

The pressure on the Ford Government mounts even more to open up, publicly discuss and substantially revise its seriously flawed plans for rationing or triage of critical medical care if the COVID-19 pandemic overloads hospitals. On March 1, 2021, the Ontario Human Rights Commission wrote the Ford Government a strong letter, set out below. It echoes a number of our serious problems with the Ontario critical care triage plan. It specifically references concerns that have been raised by the AODA Alliance and the ARCH Disability Law Centre.

We commend the Ontario Human Rights Commission for this letter. We call on the Ford Government to come out of hiding, and address the serious concerns that we and the Ontario Human Rights Commission are raising.

If there must be a critical care triage plan and protocol, it must be legally valid and constitutional. It is not good enough for anyone to duck our concerns by simply taking the position that a critical care triage plan is needed. That one is needed does not justify its discriminating because of disability contrary to the Ontario Human Rights Code and Charter of Rights, and its failing to provide due process to patients whose very lives are in jeopardy.

There is an urgent need for frontline doctors, being trained to conduct critical care triage, to be alerted to the serious human rights and constitutional violations that they could commit. As the AODA Alliance’s February 25, 2021 report on Ontario’s critical care triage plan reveals, a recent January 23, 2021 webinar for over 1,100 frontline doctors completely failed to alert those trainees to these issues. It misleadingly told those trainees that the Ontario Human Rights Commission was consulted on the development of Ontario’s critical care triage plan, without also alerting them that the Commission (along with community organizations like the AODA Alliance) raised serious human rights objections to that plan. The Commission’s letter, set out below, is yet more proof that such misleading training for critical care triage doctors risks real harm to patients with disabilities.

The Ontario Human Rights Commission’s letter refers to an earlier written submission on critical care triage that the Commission sent the Government-appointed Bioethics Table last December, and to a summary that the Bioethics Table prepared of a consultative roundtable that the Bioethics Table held on December 17, 2020 (in which the AODA Alliance participated). We set that summary out below, as well as the Ontario Human Rights Commission’s written submission that supplemented it, included as an appendix to that summary. We want to give you some information to help you read the summary of the December 17, 2020 roundtable that the Bioethics Table prepared:

  1. Several key points that the AODA Alliance raised at that December 17, 2020 roundtable are set out in greater detail in the AODA Alliance’s unanswered December 17, 2020 letter to the Minister of Health.
  1. The overwhelming point that came from the community groups at that roundtable made was that they had not had time to prepare for that rushed meeting, but had serious human rights concerns with the critical care framework we were shown. Since then, no such consultation has been held with community groups like the AODA Alliance by the Government, its Bioethics Table or its Ontario Critical Care COVID Command Centre. This is so even though the Government and its proxies and defenders in the medical world repeatedly claim that consultations are ongoing on the Ontario critical care triage plan.
  1. As it turns out, we now know that the Ford Government and its Ontario Critical Care COVID Command Centre had already taken important steps towards its critical care triage plan by the time that the December 17, 2020 roundtable was being held. These steps were likely known to the Bioethics Table participants, but were not revealed to the AODA Alliance and other community groups taking part in that discussion.

For more background, check out:

  1. The AODA Alliance’s February 25, 2021 report revealing new serious problems with the Ontario critical care triage plan, and its February 26, 2021 news release on that report.
  1. The January 13, 2021 Ontario Critical Care Triage Protocol, which the Government has never revealed, and which we believe is only publicly downloadable from the AODA Alliance website.
  1. 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.
  1. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed last month.
  2. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.

            MORE DETAILS

 March 1, 2021 Letter from the Ontario Human Rights Commission to the Ontario Government

The Honourable Christine Elliott

Minister of Health

College Park 5th Floor, 777 Bay Street

Toronto, ON M7A 2J3

Dear Minister Elliott:

RE: Follow-up on critical care triage – Ongoing human rights concerns and the need for public consultation

I hope this letter finds you well. Thank you for speaking with me in December 2020 and confirming your commitment to human rights and your interest in ensuring that our stakeholders’ concerns are appropriately heard. As you know, since April 2020, the Ontario Human Rights Commission (OHRC) has voiced the importance of respecting human rights when triaging critical care during the pandemic. The OHRC has sought to promote an equity-sensitive approach that is fair, transparent and founded on human rights principles.

Since last year, the OHRC has called on the Government to publicly release and consult with human rights stakeholders on various iterations of the critical care triage protocol and framework. Throughout this time, the OHRC has undertaken all best efforts to support the COVID-19 Bioethics Table in its work to revise a triage framework that respects human rights.

We are writing to highlight certain issues about the most recent triage-related documents that the Ontario Critical Care COVID-19 Command Centre has disseminated to health-care administrators and, once again, to offer our support to your Ministry in hopes of ensuring that the concerns and interests of human rights stakeholders will be heard.

As you know, last December, the OHRC worked collaboratively with the COVID-19 Bioethics Table to facilitate a consultation with human rights stakeholders on the September 11 version of the proposed triage framework document. The Bioethics Table prepared a summary of the meeting and circulated it to participants. The summary also included an appendix prepared by the OHRC summarizing its recommendations for the Bioethics Table and your Ministry’s consideration.

Early this year, the OHRC obtained a copy of the Emergency Standard of Care dated January 13, 2021. We also obtained copies of related supplementary materials on the Emergency Standard of Care:

Template letters to be sent to patients informing them they will not receive critical care and/or that critical care is being withdrawn without their consent

An online short-term mortality risk calculator with digitized clinical tools to assess mortality

Critical Care Services Ontario’s January 23, 2021, webinar and slide deck to help disseminate the Emergency Standard of Care within the sector.

While the OHRC appreciates that the Emergency Standard of Care refers to human rights principles and obligations in its introduction, we remain concerned about the following issues that we raised earlier:

The reliance on a 12-month predicted mortality timeline is excessive and risks discriminatory biases

The use of clinical assessment tools not validated for critical care triage also risks discriminatory bias

The need to account for the human rights duty to accommodate throughout the decision-making process including when assessing a patient’s predicted mortality

The need to ensure the legal right to due process and transparency for triaging decisions, including an effective mechanism for the right to appeal a decision that disproportionately impacts the right to life of vulnerable groups

The need to ensure appropriate human rights training and guidance for healthcare service providers so that they can implement the standard equitably and effectively.

Further, while the OHRC appreciates that the Emergency Standard of Care is intended to be an “evergreen” document, we are concerned that this document and supplementary materials (including the online short-term mortality risk calculator) are being shared within the health-care sector with potentially discriminatory content and without sufficient public input or consultation. We are also concerned that the previous March 2020 version of the protocol, which was intended to be rescinded in October 2020, may still be in circulation and relied upon by health-care partners, particularly given something to this effect was noted in the above-cited January 23, 2021, webinar regarding emergency/ambulance services.

Stakeholders – including ARCH Disability Law Centre and the AODA Alliance – have expressed serious concerns that the government may act on calls for an emergency order to suspend certain provisions of the Health Care Consent Act, allowing doctors to withdraw patients from critical care without their consent, or that of their families or substitute decision-makers, and without independent oversight.

The OHRC understands that granting doctors such decision-making power is an extraordinary measure and one the Government will not take lightly. The OHRC also understands that your Ministry wishes to ensure that human rights stakeholders concerns are properly considered and understood. In light of this, we cannot overstate that even if the Government does not issue an emergency order, the lack of transparency regarding the status of the Emergency Standard of Care, plans regarding next steps and questions regarding due process are causing grave concern among vulnerable groups. We believe these concerns must be addressed immediately, particularly given the existence of new, highly transmissible variants of COVID-19.

The OHRC believes that now is the time to act to make sure that frameworks and protocols for triage decisions that are consistent with the Ontario Human Rights Code are in place before a potential third wave overwhelms Ontario’s health-care system.

We call on the Government to publicly release and consult human rights stakeholders including the OHRC on the latest versions of the proposed triage framework and the Emergency Standard of Care. There is an urgent need to make sure that vulnerable groups who may be disproportionately affected have an opportunity to share their perspectives while there is still time, and before the proposed triage framework and/or Emergency Standard of Care and related materials are finalized.

Sincerely,

Ena Chadha, LL.B., LL.M.

Chief Commissioner

cc:        Helen Angus, Deputy Minister, Ministry of Health

Matthew Anderson, President and CEO of Ontario Health

Jennifer Gibson, Co-Chair, COVID-19 Bioethics Table

Dr. Andrew Baker, Incident Commander, Ontario Critical Care COVID-19 Command Centre

Hon. Doug Downey, Attorney General

David Corbett, Deputy Attorney General, Ministry of the Attorney General

OHRC Commissioners

 Ontario Government’s Bioethics Table Summary of Its December 17 2020 Roundtable on Critical Care Triage

Stakeholder Roundtable

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

Proposed Framework for Ontario

Summary Report

Prepared by:

Jennifer Gibson, PhD (Co-Chair, Bioethics Table)

Dianne Godkin, PhD (Co-Chair, Bioethics Table)

21 December 2020

 

Introduction

On December 17th, the Ontario COVID-19 Bioethics Table (the “Bioethics Table”) and the Ontario Human Rights Commission (OHRC) co-convened a roundtable with human rights stakeholders (Appendix 1) to review and provide feedback on the Ontario COVID-19 Bioethics Table’s Critical Care Triage During Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario (the “Proposed Framework”). The Proposed Framework was developed iteratively from March to August 2020 (Appendix 2) and submitted with recommendations for next steps to the Ministry of Health and Ontario Health in September 2020. An earlier version of the framework, which had been developed and released to Ontario hospitals in March 2020, was never implemented and was subsequently rescinded on October 29th.

The roundtable was facilitated by Dr. Kwame McKenzie (CEO, Wellesley Institute). Representatives from the Office of the Minister of Health, the Ministry of Health, Ontario Health and the COVID-19 Ontario Critical Care Command Centre were in attendance as observers. As laid out by Dr. McKenzie, the roundtable aimed to ensure: 1) that all human rights stakeholders were able to share their views on the Proposed Framework; 2) that their concerns were heard by the Ministry, Ontario Health, Critical Care Command Centre representatives and by Bioethics Table members; and 3) that there was clarity on how the Proposed Framework could be improved. Roundtable participants were also provided with links to recent publications on the topic of critical care triage and associated frameworks/protocols in Canada and elsewhere (Appendix 3).

 

This report provides a high-level summary of key issues and concerns raised by roundtable participants and potential actions identified by roundtable participants to address these issues and concerns. It is not exhaustive of all that was discussed at the roundtable. It is intended to reflect the most urgent issues and concerns around which there was broad agreement among roundtable participants in the immediate context of Wave 2 of the COVID-19 pandemic. The OHRC has also provided an outline of its recommendations (Appendix 4). It was acknowledged by all that there are systemic health inequities that will require long-term solutions that are outside of the scope of critical care triage during a pandemic.

 

Key Issues/Concerns and Potential Actions

Roundtable participants stressed the paramount importance of a non-discriminatory, equitable, and culturally safe critical care triage approach. COVID-19 has already had a disproportionate negative impact on many of the communities represented by roundtable participants. Pre-existing historical and social inequities in health outcomes and negative experiences of the healthcare system further exacerbate these impacts. Some may experience intersectionality, the cumulative impact of belonging to more than one disadvantaged group (e.g., a racialized person who also has a disability). For Indigenous communities, it is not just a matter of individual survival, but of cultural survival if an Indigenous knowledge keeper becomes ill and dies. Participants raised concerns that there has been limited engagement of disability, older adults, Indigenous, Black and other racialized communities, arguably those who have been most significantly impacted during the pandemic, in all aspects of pandemic planning and that this has resulted in unsatisfactory and unsafe care. The possibility of triage raises significant fears that these historical and social inequities will be magnified if actions are not taken to implement a critical care triage process that is non-discriminatory. Participants were very concerned that they only had one week to review the Proposed Framework and had difficulty understanding some aspects of the document. Consequently, further engagement and stakeholder consultation is required. A general observation of the Proposed Framework raised by participants is that is not sufficiently prescriptive in describing what must be done.

The following Table summarizes the most urgent issues and concerns and potential actions identified by roundtable participants:

1.     Human Rights and Non-Discrimination as Legal Obligations
 

Issue: Roundtable participants need greater assurance that decisions related to critical care triage will be made in alignment with human rights codes and will be non-discriminatory.

Potential actions:

Ø  Articulate non-discrimination/human rights as the primary overarching legal obligation used to guide the critical care triage process.

2.     Equity as a Positive Obligation
 

Issue: Although equity is identified as an important ethical principle in the Proposed Framework, roundtable participants emphasized the need for a positive obligation to promote equity and for concreteness and clarity on how equity would actually be enacted in practice. It was recognized that under conditions of great stress during a major surge in demand for critical care, unconscious bias is likely to be activated unless steps are taken to support clinicians in promoting equity.

Potential actions:

Ø  Develop an equity-based checklist tool that healthcare providers must review and consider during the assessment stage of the triage process to help them account for the impact of social determinants of health and pre-existing co-morbidities due to social and historical inequities in the care of their patients.

Ø  Make requirements for accommodations for persons with disabilities or to address communication barriers explicit, including allowing a support person to be present as needed.

Ø  Ensure all who are involved in critical care triage process receive anti-racism, anti-bias (e.g., anti-ageism, anti-ableism), and Indigenous cultural safety training and/or have access to tools and resources (e.g., see checklist above) to minimize the risk of unconscious bias.

3.     Legal Framework for Critical Care Triage During a Major Surge
 

Issue: Critical care triage during a major surge would deviate from current legal and regulatory standards, particularly in relation to withdrawal of life-sustaining treatment without consent. Roundtable participants underscored the need for a legal framework to justify the critical care triage approach and to protect both healthcare providers and patients. Any liability protections for healthcare providers should require that they have acted in accordance with this legal framework and with the Ontario Human Rights Code.

Potential actions:

Ø  Develop a legal framework for critical care during a major surge, including key elements of due process.

4.     Critical Care Triage Decision-making Process and Clinical Assessment Tools
 

Issue: Roundtable participants expressed a need for critical care triage decision-making processes and clinical assessment tools to be outlined in greater detail and communicated in a transparent manner to patients and the public. While there was general agreement that for the purposes of triage decisions, clinical assessment should focus on predicted short-term mortality risk, specific concerns were raised about using 12-months as the time frame for predicted short-term mortality and about the validity of the tools for Indigenous persons and other marginalized persons. Roundtable participants also emphasized the need for critical care triage decisions to be transparent.

Potential actions:

Ø  Engage stakeholders in the identification/adaptation of clinical tools to ensure they are culturally appropriate.

Ø  Reduce the duration of short-term predicted mortality risk from 12 months to a lesser time period.

Ø  Include individuals (e.g., community leaders) outside of the medical profession in the implementation of the critical care triage decision-making process (e.g., as supports to patients in clinical decision-making; as members of the Triage Teams described in the Proposed Framework; as members of appeals committees).

Ø  Develop accessible communication tools tailored to the needs of particular groups to foster understanding and trust.

 

5. Right to Appeal
 

Issue: Given the significance of the decision to withhold or withdraw critical care resources from a patient, roundtable participants underscored the need for a timely appeal process as an important safeguard to uphold non-discrimination.

Potential actions:

Ø  Establish an external appeals process by a third party.

6. Development of Interim Protocol for Wave 2
 

Issue: Given the increasing hospitalizations in Wave 2, roundtable participants underscored the urgency of having a non-discriminatory, legally sanctioned, and effective triage protocol in place in the event that there is a major surge in demand for critical care in the coming weeks or months. Absent an interim protocol, roundtable participants acknowledged that clinicians would be left unsupported in the triage decision-making process and Indigenous, Black and other racialized patients and persons with disabilities would be placed at significant risk of harm. The interim protocol would be subject to further revisions and include ongoing engagement and co-development with key stakeholders.

Potential actions:

Ø  Develop an interim protocol in collaboration with human rights stakeholders and critical care providers. The interim protocol could be based on the institutional protocol created by the Ontario COVID-19 Critical Care Command Centre with modifications to reflect where there is broad human rights stakeholder agreement.

Ø  Concurrently, continue stakeholder engagement to address unresolved issues and to advance elements of the Proposed Framework which may require more time to implement.

APPENDIX 1: Roundtable Participants

Roundtable Facilitator:

Kwame McKenzie (CEO, Wellesley Institute)

Participants:

Nicole Blackman (Provincial Director, Indigenous Primary Health Care Council)

Avvy Go (Director, Chinese and Southeast Asian Legal Clinic)—also provided written submission

James Janeiro (Director, Community Engagement and Policy, Community Living Toronto)

Trudo Lemmens (Professor & Scholl Chair in Health Law and Policy, Faculty of Law, University of Toronto)

David Lepofsky (Chair, AODA Alliance)

Caroline Lidstone-Jones (CEO, Indigenous Primary Health Care Council)

Roxanne Mykitiuk (Professor, Osgoode Hall Law School, York University)

Tracy Odell (President, Citizens with Disabilities)

Mariam Shanouda (Staff Lawyer, ARCH Disability Law Centre)

Jewelles Smith (Past-Chairperson, Council of Canadians with Disabilities)

Observers:

  1. Office of the Minister of Health

Emily Beduz (Director, Pandemic Response)

Heather Potter (Director, Issues and Legislative Affairs)

  1. Ministry of Health

Tina Sakr (Team Lead, Priority and Acute Programs)

Jennifer Lee Arseneau (Senior Policy Advisor, Priority and Acute Programs)

Louise Verity (Strategic Advisor to the CEO)

  1. Ontario COVID-19 Critical Care Command Centre

Andrew Baker (Incident Commander)

 

  1. Ontario Human Rights Commission

Ena Chadha (Chief Commissioner)

Violetta Igneski (Commissioner)

Raj Dhir (Executive Director and Chief Legal Counsel)

Shaheen Azmi (Director, Policy, Education, Monitoring & Outreach)

Bryony Halpin (Senior Policy Analyst)

Jeff Poirier (Senior Policy Analyst)

Rita Samson (Senior Policy Analyst)

  1. Ontario COVID-19 Bioethics Table (in attendance)

Jennifer Gibson (Co-Chair; University of Toronto)

Dianne Godkin (Co-Chair; Trillium Health Partners)

Sally Bean (Toronto Region Bioethics Lead and Member; Sunnybrook Health Sciences Centre)

Cecile Bensimon (Member; Canadian Medical Association)

Carrie Bernard (Member; William Osler Health System, University of Toronto, McMaster University)

Nicole Blackman (*new member as of Dec 2020; Indigenous Primary Health Care Council)

Paula Chidwick (Central Region Bioethics Lead and Member; William Osler Health System)

James Downar (Member; The Ottawa Hospital, Bruyere Continuing Care, Ottawa Health Research Institute)

Lisa Forman (Member; University of Toronto)

Mary Huska (North Region Bioethics Lead and Member; Health Sciences North)

Michael Kekewich (East Region Bioethics Lead and Member; The Ottawa Hospital)

Stephanie Nixon (Member; University of Toronto)

Nancy Ondrusek (Member; Public Health Ontario)

Lisa Schwartz (Member; McMaster University)

Robert Sibbald (Member; London Health Sciences; Western University)

Maxwell Smith (Past Co-Chair and Member; Western University)

Randi Zlotnik-Shaul (Member; Sick Kids Hospital)

vii) Students

Veromi Asiradam, JD Student, Osgoode Hall Law School, York University

Ya-En Cheng, JD Student, Osgoode Hall Law School, York University

viii) Recorder

Danielle Linnane (Quality Improvement Specialist, Ontario Health)

 

APPENDIX 2: Development of the Proposed Framework

 

The Critical Care Triage During Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario (the “Proposed Framework”) was developed based on iterative review of the academic literature and published policy statements on critical care triage in a pandemic, consultation with clinical, legal, and other experts, and feedback from health system stakeholders. The Proposed Framework with recommendations for next steps was submitted to the Ministry of Health and Ontario Health in September 2020.

 

Development of the Proposed Framework was undertaken in three phases from March to December 2020:

  • In Phase 1, an initial draft framework was developed in March 2020 in response to an urgent need for the Ontario health system to prepare for the possibility of a major surge in demand for critical care as was being observed in Italy, Spain, and New York State. The initial draft, which was developed without the benefit of consultation with human rights stakeholders, among others, was released to hospitals on March 28 to aid planning. A major surge in demand for critical care was averted in Ontario. This draft framework was not implemented and was formally rescinded on October 29, 2020.
  • In Phase 2, extensive feedback on the initial draft framework was received in April 2020 through written submissions from diverse organizations and groups. Feedback was sent either directly to the Bioethics Table or to the Ministry of Health or Ontario Health and shared with the Bioethics Table. The Bioethics Table reviewed and considered all feedback and amended the document accordingly. Additional feedback was solicited from bioethics, health law, and clinical experts. An updated draft framework was developed in May 2020 based on new published findings in the literature, policy discussions in the public domain (e.g., policy statements), and written stakeholder feedback.
  • In Phase 3, the Bioethics Table began meeting with the Ontario Human Rights Commission (OHRC) in May 2020 and undertook an expanded stakeholder consultation process to elicit input from Black and other racialized groups, Indigenous health leaders, older adults, and disability rights experts. A first stakeholder roundtable was co-convened with the OHRC on July 15, 2020. Meetings continued through July and August with disability rights stakeholders and with the Indigenous Bioethics Reference Group of the Indigenous Primary Health Care Council. The Proposed Framework was informed extensively by these stakeholder discussions, an updated review of the literature and policy statements from civil society organizations (e.g., Canadian Association of Retired People), and additional input from health law and clinical experts. In December 2020, the Bioethics Table received approval to convene a second stakeholder roundtable to review and elicit feedback on the Proposed Framework. The roundtable took place on December 17, 2020.

The Proposed Framework document is a green document within the overall COVID-19 pandemic response in Ontario. The process for developing an approach to critical care triage in the context of a major surge in demand must be sensitive and responsive to changing conditions, emerging evidence, and evolving understanding of the ethical, social, and legal implications of critical care triage for major surge in a pandemic. As such, this document should be subject to regular review and updating as appropriate.

Acknowledgments:

The Bioethics Table would like to acknowledge the substantive feedback, input, and advice of the following organizations through written submissions and/or stakeholder consultations (listed alphabetically):

  • AODA Alliance
  • ARCH Disability Law Centre
  • Black Health Committee, Alliance for Health Communities
  • Canadian Frailty Network
  • Canadian Geriatric Society
  • Canadian Medical Protective Association
  • Canadian Thoracic Society
  • Chinese and Southeast Asian Legal Clinic
  • Citizens with Disabilities Ontario
  • Clinical, Organization, and Research Ethics (CORE) Network and Provincial COVID-19 Bioethics Community of Practice – University of Toronto Joint Centre for Bioethics[1]
  • College of Nurses of Ontario
  • College of Physicians and Surgeons of Ontario
  • Community Living Toronto
  • Council of Canadians with Disabilities
  • COVID-19 Critical Care Command Centre and Provincial Critical Care Table, Ontario Health
  • Indigenous Bioethics Reference Group, Indigenous Primary Health Care Council
  • Muscular Dystrophy Canada
  • Ontario Hospital Association/HIROC
  • Ontario Human Rights Commission
  • Ontario Medical Association

The Bioethics Table has also benefited from the substantive feedback, input, and advice of individual scholars and practitioners with expertise in the following areas:

  • Clinical Medicine – over 20 clinician experts in cancer care, cardiac care, complex continuing care, critical care, emergency medicine, geriatric medicine, neurology, stroke, thoracic medicine
  • Health Equity
  • Health Law and Human Rights Law

**Please note that these acknowledgments do not signify endorsement of the Proposed Framework.**

 

APPENDIX 3: Roundtable Documents

The following is a list of recent publications, including government or policy documents, journal articles, and media reports, on the topic of critical care triage and associated frameworks/protocols in Canada and elsewhere. These were pre-circulated to roundtable participants for their information.

 

Critical Care Triage Frameworks/Protocols from Other Jurisdictions

 

  1. Quebec Critical Care Triage Protocol (Nov 2020 – In French)
  2. Saskatchewan Health Authority Triage Working Group, Critical Care Resource Allocation Framework (Sept 2020)
  3. Joint Commission on Triage Decisions for Severely Ill Patients During the COVID-19 Pandemic (Israel, July 2020)
  4. COVID-19 rapid guideline: critical care in adults (UK-NHS, March 2020/updated Sept 2020)

 

Publicly Available Advocacy/Feedback related to Critical Care Triage

 

  1. ARCH Disability Law Centre
  2. AODA Alliance/ARCH Disability Law Centre
  3. Ontario Human Rights Commission
  4. Société québécoise de la déficience intellectuelle – English translation using Google Translate attached

 

Journal & Media Articles

 

  1. Nouvelles directives pour l’attribution des respirateurs artificiels (Le Devoir) – English translation using Google Translate attached
  2. Following controversy, Quebec revises rules for who gets intensive care treatment if resources are limited (CBC news)
  3. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? (American Journal of Bioethics)
  4. Disability, Disablism, and COVID-19 Pandemic Triage (Journal of Bioethical Inquiry)
  5. What the Chaos in Hospitals Is Doing to Doctors: Politicians’ refusal to admit when hospitals are overwhelmed puts a terrible burden on health-care providers (The Atlantic)
  1. Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources (Canadian Geriatrics Journal)
  2. Ontario has a world-leading protocol that all provinces and territories should adopt to be truly ready for COVID-19’s second wave (Policy Options)
  3. Proceed with caution with Ontario’s critical care triage protocol (Policy Options)

APPENDIX 4: OHRC Recommendations

Summary of OHRC Feedback on Triage Framework

December 18, 2020

 

Interim Framework / Protocol

  • The OHRC encourages the Ministry of Health to share the “protocolized” version of the Triage Framework that was sent to hospitals in Ontario and also make this document available to all stakeholders involved in the consultation.
  • Without having seen this document, the OHRC is not in a position to assess whether the protocolized version could be adapted or whether an entirely new document needs to be developed to reflect stakeholder input and serve as an interim protocol. An interim protocol should be short, user friendly and developed with a view to how it can be used in a crisis – until further consultation can happen.
  • The interim protocol could continue to evolve as a basis for further consultation on more complex and contentious issues. While not yet sanctioned by legislation or regulation, hospitals would have ready access to a protocol that is reasonably acceptable to stakeholders if a major surge happens.
  • An interim protocol could potentially address issues where there is agreement across stakeholder groups. The issues are, but not limited to:
    • Ensure the protocol recognizes that human rights is the primary guiding principle and law in accordance with the primacy clause under section 47 of Ontario’s Human Rights Code (Code)
    • Ensure there is a legislative basis for the protocol that will also provide for governance and accountability mechanisms including how to initiate the use of the protocol during a pandemic surge
    • Exclude the Clinical Frailty Scale (CFS) and any other clinical assessment factors and tools that are not validated for critical care resource allocation. The Bioethics Table recognizes the CFS was designed and validated to help identify treatment plans and accommodation supports for frail patients, and not for critical care triage. Used as a triage tool, the CFS would likely disproportionately impact Code-protected groups and may be inconsistent with human rights obligations including the duty to accommodate
    • Define short-term predicted mortality as the predicted risk of death in the initial weeks, and not twelve months after the onset of critical illness. The Bioethics Table recognizes that relatively little mortality occurs between six and twelve months
    • Ensure a fair and efficient appeal mechanism
    • Explicitly recognize the legal duty to accommodate including essential support persons / communications / interpreter access, etc.
    • Mandate a clear procedure to document decisions that requires evidence-based written reasons. This could include a “positive obligation” checklist to account for issues of equity and the social determinants of health
    • Require socio-demographic data collection to monitor for adverse application of the protocol
    • Allow for human rights equity groups to monitor, and provide feedback on the protocol.

The OHRC also agrees with the Bioethics Table’s recommendations that call on the Ministry of Health and Ontario Health to:

  • Issue clear communications that health care providers must disregard and destroy the March 28 version of the protocol
  • Circulate the proposed framework, including the clinical assessment factors and tools, for public feedback and independent legal review
  • Convene a multidisciplinary panel, including experts in human rights and law to further develop, or refute, the clinical factors and tools identified in the proposed framework
  • Engage health care partners to develop guidance for implementing the protocol including clinical operations, communications, training, patient and clinician supports, data collection and monitoring
  • Provide for governance and accountability mechanisms including responsibility for initiating the protocol, data collection and independent monitoring for adverse consequences
  • Sustain equitable COVID-19 prevention efforts to avoid the need to initiate the protocol, and mitigate disproportionate impacts on vulnerable groups
  • Meaningfully engage vulnerable groups, including Indigenous communities, Black and racialized communities, persons with disabilities, older persons and others for their perspectives and participation throughout the process to finalize and implement the protocol.
  • Provide comprehensive training on the new protocol, including anti-bias education.

[1] The CORE Network and the COVID-19 Bioethics Community of Practice comprise practicing bioethicists who work in a variety of health institutions, including hospitals, long term care homes, rehabilitation facilities, community care, and complex continuing care settings. Members have diverse disciplinary expertise (e.g., philosophy, law, anthropology) and clinical professions (e.g., medicine, nursing, social work, occupational therapy). CORE Network members are based in the Greater Toronto/Hamilton Area. The COVID-19 Bioethics Community of Practice draws practicing bioethicists from across the province of Ontario totalling >50 individuals. The University of Toronto Joint for Bioethics provides secretariat support for both the Core Network and the COVID-19 Bioethics Community of Practice.



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Ford Government Acknowledges Ontario Students with Disabilities Face Added Hardships Trying to learn at Home During COVID-19 But Announces No Comprehensive Plan to Remove the Added Disability Barriers that Online Learning Creates for Them


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

May 19, 2020, Toronto: Today, as the first media question at Premier Doug Fords Queens Park COVID-19 briefing, the Toronto Star told the premier that parents of special needs children have told the Star that they are particularly struggling at this time and that the Government needs to take a leading role in making sure that their children are being served during the school shutdown. Since schools are now closed until the end of the school year, the Star asked what the Government is doing to help these families and to ensure that school boards are meeting these students needs. The AODA Alliance commends the Star for raising this issue. We have been pressing the Ford Government on this issue for weeks.

Premier Ford referred the question to Education Minister Stephen Lecce. The Minister commendably stated on behalf of the Government that he absolutely agrees with the premise, … that these families are going to need more support now more than ever to support their children enable them to learn while theyre at home. He said on behalf of the Government that we have great concern about these children He pledged that the Government wants to make sure that all kids with exceptionalities are able to get aheadget the support they need.

It is good, but certainly not news, that the Government has told all school boards to deploy all their special education resources during the shutdown, and that the Government earlier consulted with two provincial advisory committees on this issue. It is not yet possible for us to comment on the Governments amorphous announcement of some sort of two-week summer program aimed at helping orient some students with disabilities, such as those with autism, to a return to school. Todays announcement gave no specifics (such as where this will be offered, or which students or how many students will be eligible for this program.)

However, todays Ministers statement falls far short of the urgent action one-third of a million Ontario students with disabilities immediately need. It is good that the Government now publicly acknowledges that students with disabilities and their families suffer additional burdens with the move to online learning as schools are shut down and that the Government should show leadership. However, The Government has not announced any specific comprehensive plan to remove the added barriers that students with disabilities are facing due to the move to online learning.

It is wrong for the Ford Government to continue to leave it to over 70 school boards to each have to wastefully re-invent the wheel as they struggle with the same recurring disability barriers. It is wrong for the Ford Government to leave over-burdened parents of students with disabilities to have to fight the same battles against these disability barriers, one school board at a time, while isolated at home during the COVID-19crisis.

For example, the Ford Government is not even ensuring that the online platforms that each school board and each school uses to hold virtual classes are fully accessible to students, teachers and parents with disabilities, or even to track which of these platforms are being used. The Government has not announced any plan to fix the significant accessibility barriers in the online learning resources that the Government itself provides to teachers, parents and school boards on its Learn at Home website, such as the TVO online resources that have a series of accessibility problems. It was the AODA Alliance that earlier exposed these accessibility problems.

To help frontline teachers and parents of students with disabilities, the AODA Alliance and Ontario Autism Coalition held a helpful May 4 online virtual town hall to share teaching strategies from experts in teaching students with disabilities, now viewed over 1,300 times. Yet despite our repeatedly asking, weve seen no indication that The Government has taken the simple step of sharing this resource with school boards and encouraging them to watch it, much less has the Government organized similar events to share the creative solutions that frontline teachers and parents are inventing all around Ontario.

The AODA alliance remains ready to assist the government on any and all of these issues.

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

Background Resources
The April 30, 2020 letter from the AODA Alliance to Ontario Education Minister Stephen Lecce, which sets out a list of concrete and constructive requests for action that the AODA Alliance presented to Ontarios Ministry of Education.
The May 4, 2020 virtual town hall on teaching students with disabilities during the COVID-19 crisis, organized by the AODA Alliance and the Ontario Autism Coalition.

The AODA Alliances education web page, that documents its efforts over the past decade to advocate for Ontario’s education system to become fully accessible to students with disabilities
The AODA Alliances COVID-19 web page, setting out our efforts to advocate for governments to meet the urgent needs of people with disabilities during the COVID-19 crisis.
The earlier widely-watched April 7, 2020 virtual public forum by the AODA Alliance and Ontario Autism Coalition on the overall impact of the COVID-19 crisis on 2.6 million Ontarians with disabilities.




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Ford Government Acknowledges Ontario Students with Disabilities Face Added Hardships Trying to learn at Home During COVID-19 But Announces No Comprehensive Plan to Remove the Added Disability Barriers that Online Learning Creates for Them


ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE

NEWS RELEASE – FOR IMMEDIATE RELEASE

Ford Government Acknowledges Ontario Students with Disabilities Face Added Hardships Trying to learn at Home During COVID-19 But Announces No Comprehensive Plan to Remove the Added Disability Barriers that Online Learning Creates for Them

May 19, 2020, Toronto: Today, as the first media question at Premier Doug Ford’s Queen’s Park COVID-19 briefing, the Toronto Star told the premier that parents of special needs children have told the Star that they are particularly struggling at this time and that the Government needs to take a leading role in making sure that their children are being served during the school shutdown. Since schools are now closed until the end of the school year, the Star asked what the Government is doing to help these families and to ensure that school boards are meeting these students’ needs. The AODA Alliance commends the Star for raising this issue. We have been pressing the Ford Government on this issue for weeks.

Premier Ford referred the question to Education Minister Stephen Lecce. The Minister commendably stated on behalf of the Government that he “absolutely agrees with the premise, … that these families are going to need more support now more than ever to support their children enable them to learn while they’re at home.” He said on behalf of the Government that “we have great concern about these children…” He pledged that the Government wants to “make sure that all kids with exceptionalities are able to get ahead…get the support they need.”

It is good, but certainly not news, that the Government has told all school boards to deploy all their special education resources during the shutdown, and that the Government earlier consulted with two provincial advisory committees on this issue. It is not yet possible for us to comment on the Government’s amorphous announcement of some sort of two-week summer program aimed at helping orient some students with disabilities, such as those with autism, to a return to school. Today’s announcement gave no specifics (such as where this will be offered, or which students or how many students will be eligible for this program.)

However, today’s Minister’s statement falls far short of the urgent action one-third of a million Ontario students with disabilities immediately need. It is good that the Government now publicly acknowledges that students with disabilities and their families suffer additional burdens with the move to online learning as schools are shut down and that the Government should show leadership. However, The Government has not announced any specific comprehensive plan to remove the added barriers that students with disabilities are facing due to the move to online learning.

It is wrong for the Ford Government to continue to leave it to over 70 school boards to each have to wastefully re-invent the wheel as they struggle with the same recurring disability barriers. It is wrong for the Ford Government to leave over-burdened parents of students with disabilities to have to fight the same battles against these disability barriers, one school board at a time, while isolated at home during the COVID-19crisis.

For example, the Ford Government is not even ensuring that the online platforms that each school board and each school uses to hold virtual classes are fully accessible to students, teachers and parents with disabilities, or even to track which of these platforms are being used. The Government has not announced any plan to fix the significant accessibility barriers in the online learning resources that the Government itself provides to teachers, parents and school boards on its “Learn at Home” website, such as the TVO online resources that have a series of accessibility problems. It was the AODA Alliance that earlier exposed these accessibility problems.

To help frontline teachers and parents of students with disabilities, the AODA Alliance and Ontario Autism Coalition held a helpful May 4 online virtual town hall to share teaching strategies from experts in teaching students with disabilities, now viewed over 1,300 times. Yet despite our repeatedly asking, we’ve seen no indication that The Government has taken the simple step of sharing this resource with school boards and encouraging them to watch it, much less has the Government organized similar events to share the creative solutions that frontline teachers and parents are inventing all around Ontario.

The AODA alliance remains ready to assist the government on any and all of these issues.

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

Twitter: @aodaalliance

Background Resources

The April 30, 2020 letter from the AODA Alliance to Ontario Education Minister Stephen Lecce, which sets out a list of concrete and constructive requests for action that the AODA Alliance presented to Ontario’s Ministry of Education.

The May 4, 2020 virtual town hall on teaching students with disabilities during the COVID-19 crisis, organized by the AODA Alliance and the Ontario Autism Coalition.

The AODA Alliance’s education web page, that documents its efforts over the past decade to advocate for Ontario’s education system to become fully accessible to students with disabilities

The AODA Alliance’s COVID-19 web page, setting out our efforts to advocate for governments to meet the urgent needs of people with disabilities during the COVID-19 crisis.

The earlier widely-watched April 7, 2020 virtual public forum by the AODA Alliance and Ontario Autism Coalition on the overall impact of the COVID-19 crisis on 2.6 million Ontarians with disabilities.



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City Urged to Think About People With Disabilities in CurbTO Plan to Create Space on Sidewalks


‘Accessibility doesn’t happen by accident,’ says disability rights advocate David Lepofsky CBC News
Posted: May 03, 2020

David Lepofsky, a disability rights advocate, says: ‘The real question that I would ask is: What are they doing to ensure that, in altering this part of the built environment, that the alteration will increase and not decrease accessibility?’

An advocate is urging the City of Toronto to make sure its plan to ease sidewalk crowding takes into consideration the needs of people with disabilities amid COVID-19.

David Lepofsky, chair of the Accessibility for Ontarians with Disabilities Act Alliance, said the new CurbTO program, in which the city will make room for pedestrians and delivery drivers through the creation of “curb lane pedestrian zones” and “temporary parking pickup zones,” is a good one. The alliance is a consumer advocacy group.

Through the program, the city is aiming to enable people on city sidewalks and drivers picking up and dropping goods off to engage in physical distancing to slow the spread of the virus.

But the program will actually make things worse for people with disabilities if city planners fail to think about accessibility for all people, Lepofsky told CBC Toronto on Sunday.

“The real question that I would ask is: What are they doing to ensure that, in altering this part of the built environment, that the alteration will increase and not decrease accessibility?

“In other words, the idea of creating more space for social distancing is obviously important and good. And the fact that they are looking at that is, regardless of disability, good.”

“If they don’t plan for its accessibility, they will likely screw up its accessibility. That’s what we find over and over. Accessibility doesn’t happen by accident. Inaccessibility happens by accident.”

City to make room at ‘hot spots’ or ‘pinch points’

Under the program, the city will make room at “hot spots” or “pinch points” where it is challenging for people to practise physical distancing because of lineups or congestion outside essential businesses.

These areas include sidewalks outside grocery stores, pharmacies, restaurants and community agencies that offer pickup, takeout and delivery services, the city has said.

The city said it will initially target hotspots along 10 busy retail main streets for curb lane installations before the program is expanded to more than 100 locations across Toronto.

Lepofsky said the program raises several issues around accessibility.

For example, if people in a lineup outside a drug store are rerouted onto a curb lane, then it would be difficult for a person using a mobility device, such as wheelchair, scooter or walker, to enter that fenced-off lineup because it would involve stepping down onto the road.

“If they build accessibility in by making sure that the route has level access to get down into the street and so on, that could be an improvement,” he said.

And if, as an additional example, the city sets up a sign outside a drug store indicating where pedestrians should line up, that sign itself could become an obstacle for people who are blind or who have vision loss.

“What kind of prompting will there be to let me know where to go to line up? If they stick a sign on the road or on the sidewalk, which they might want to do, they have now created a new obstacle I could whack into,” he said.

“What are they are going to do to plan for safe navigation?”

In its April 27 news release in which it unveiled the program, the city did not address these concerns. The city has yet to respond to questions posed by CBC Toronto.

Signs, barriers to create additional space, mayor says

Mayor John Tory told reporters at a recent daily news briefing that staff will use signs and barriers to create additional space.

“Each location will have unique conditions that will be assessed carefully by Toronto Public Health and Transportation Services staff to develop the most appropriate solution,” Tory said.

“In some cases, city staff may be able to suggest line-up configurations to the business operator that alleviates crowding concerns. In other cases, a temporary curb lane closure may be the most effective response.”

“Curb lane pedestrian zones” are defined as areas in which pedestrians trying to move past lineups outside essential businesses will have more space.

“Temporary parking pick-up zones” are defined as areas in which drivers delivering food and medicine will be allowed to park for up to 10 minutes near an essential business where they are picking up or dropping off goods.

These zones could be created in areas that are now restricted parking zones.

Physical distancing difficult downtown, councillor says

A downtown councillor, meanwhile, has enlisted the support of residents to propose locations that the city could fix when it expands the program.

Coun. Joe Cressy, who represents Ward 10 Spadina-Fort York, said he is recommending 18 new additional spaces in his ward for “immediate improvements” under the CurbTO program where room could be created to allow people to distance physically during the outbreak.

“Notwithstanding the overarching advice to, where possible, stay at home, we know that in many neighbourhoods, especially in downtown Toronto, there are immediate spaces where it’s not possible to walk on the sidewalk without coming into contact with lots of people,” Cressy said.

His office has worked with local residents, community organizations, businesses and institutions to identify where there are issues around crowding, he said.

“We know that in this dense, crowded city of ours, the overarching message to stay at home works for some, but depending on how busy and crowded the sidewalks are, it doesn’t work for everyone, and that’s why we’re proposing these changes.”

Cressy said to make streets safe and accessible for all requires a “fundamental” redesign of city streets.

He said of CurbTO: “We need to include an accessibility focus around that.”

Original at https://www.cbc.ca/news/canada/toronto/accessibility-curbto-program-disability-rights-david-lepofsky-1.5554034




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Still More Media Reports Reveal Disproportionate Harm to Ontarians with Disabilities Due to the Ontario Government’s Failure to Effectively Plan for Urgent Disability Needs in its COVID-19 Emergency Efforts


and – Federal Government Announces Disability COVID-19 Advisory Panel, So We Offer Our Advice

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

April 23, 2020

SUMMARY

Here are yet more helpful media reports that illustrate how people with disabilities are disproportionately suffering the consequences of the Ontario Governments failure to effectively include the urgent needs of people with disabilities in its emergency COVID-19 planning. Our ongoing advocacy efforts are showing some signs of success, but the battle remains an uphill one. We remain tenacious as we join in that battle!

Below you will find:

* An excellent April 22, 2020 City TV news report by reporter Pam Seatle, on the Ford Governments failure to effectively plan for the COVID-19 needs of Ontarians with disabilities.

* A great April 22, 2020 report on CBC Radio Kitchener Waterloo by reporter Paula Duhatschek on the cruel impact on one individual with disabilities of the Ford Governments unjustified and inexplicable closure of the Adaptive Devices Program during the COVID-19 crisis as a supposedly non-essential program. We commend the individual who brought that issue to CBC.

* An earlier superb April 11, 2020 Canadian Press report by reporter Michelle McQuigge that appeared in a number of media outlets including the Globe and Mail, on the Federal Governments announcement of a federal advisory panel on the impact of COVID-19 on people with disabilities.

We also set out below the Federal Governments actual April 10, 2020 announcement of its federal disability advisory panel on the impact of COVID-19 on people with disabilities. We commend the Federal Government for Accessibility Minister Carla Qualtroughs acknowledging:

We recognize that some groups of Canadians are significantly and disproportionately impacted by this pandemic, in particular Canadians with disabilities. For some persons with disabilities, underlying medical conditions put them at greater risk of serious complications related to COVID-19. Others face discrimination and barriers in accessing information, social services, and health care. For others, the need for self-isolation and physical distancing create additional challenges.

We first learned of the Federal Governments plans in this regard at the same time as did the public when it was publicly announced. It is good that the Federal Government has recognized the disproportionate impact of COVID-19 on people with disabilities. However, as we noted in the April 11, 2020 Canadian Press article by reporter Michelle McQuigge, 95% of the problems people with disabilities face in this crisis are within provincial responsibility, and are not the responsibility of the Federal Government.

It is very important for the Federal and provincial governments across Canada to also directly reach out to, hear from and follow the advice of anyone with the best front-line experience with the impact of COVID-19 on the grassroots disability community. That would include, for example, the ten experts that were interviewed on the April 7, 2020 virtual public forum on COVID-19 and people with disabilities organized by the AODA Alliance and the Ontario Autism Coalition.

In the federal sphere, we offer these recommendations:

* The Federal Government pledged in the fall 2019 federal election that it would apply a disability lens to all its decisions. Beyond creating a new advisory panel, it is important for the Federal Government to let us and the entire public know what it is doing and has done since this crisis began to apply that disability lens to all its decisions in the COVID-19 crisis.

* The new federal disability advisory group should itself watch the April 7, 2020 virtual public forum on COVID-19 and disability, and advocate for the recommendations made there.

* The Federal Government should immediately make public the work of its new federal disability advisory group, when it is meeting, what it is recommending, and what actions the Federal Government is taking as a result to protect people with disabilities during this crisis. Openness and transparency by our governments is especially important during a crisis like this one.

We are not recommending that the Ford Government create a similar advisory panel. It would take the Government too long to set it up, and risk being a distraction. Instead, the Ford Government should immediately reach out to the grassroots disability community to learn about the hardships they are facing during this crisis. The Ford Government should also recognize, as has the Federal Government, the disproportionate impact of COVID-19 on people with disabilities. As we have been urging for weeks, the Ford Government should quickly develop and make public a comprehensive plan of action to meet the urgent needs of people with disabilities as part of its emergency COVID-19 planning.

Our non-partisan campaign is substantially fortified when individuals bring to the media their personal stories about the hardships and barriers they are facing during the COVID-19 crisis due to their disability. The AODA Alliance remains ready and willing to provide broader comments to the media on these issues, as we do in the stories set out below. To help you with this, you can get more background, check out and widely share:

* The guest column by AODA Alliance Chair David Lepofsky in the April 20, 2020 online Toronto Star, which summarizes our major COVID disability issues in one place.

* The widely viewed April 7, 2020 online Virtual Public Forum on what Government Must Do to Meet the Urgent Needs of People with Disabilities During the COVID crisis.

* The AODA Alliances April 14, 2020 Discussion Paper on Ensuring that Medical Triage or Rationing of Health Care Services During the COVID-19 Crisis Does Not Discriminate Against Patients with Disabilities.

* Action tips on how to help ensure that patients with disabilities dont face discrimination in access to critical health care.

* The April 8, 2020 open letter to Premier Ford, organized by the ARCH Disability Law Centre, voicing concerns about the Ontario Governments protocol for rationing medical care during the COVID crisis.

* The AODA Alliances March 25, 2020 letter to Premier Ford, which has gone unanswered.

There have been an inexcusable 448 days since the Ford Government received the groundbreaking 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 worse the problems facing Ontarians with disabilities during the COVID-19 crisis.

There have been 29 days since we wrote Ontario Premier Doug Ford on March 25, 2020 to urge specific action to address the urgent needs of Ontarians with disabilities during the COVID-19 crisis. He has not answered. The ordeal facing Ontarians with disabilities during the COVID-19 crisis is worsened by that delay.

We are sending you more AODA Alliance Updates than usual because of the influx of important news that is important to people with disabilities during the COVID-19 crisis. We are doing our best to stay on top of the rapidly changing events, and to effectively advocate for efforts so that people with disabilities are equally served by government emergency COVID-19 planning.

MORE DETAILS

City News April 22, 2020

Originally posted at https://toronto.citynews.ca/2020/04/22/advocates-say-coronavirus-planning-leaves-out-people-with-disabilities/

Advocates say coronavirus planning leaves out people with disabilities BY PAM SEATLE AND DILSHAD BURMANPOSTED APR 22, 2020

Summary
Disabilities advocates say their community has been overlooked in the government’s COVID-19 planning

NDP Leader Andrea Horwath is calling on the province to provide in-home testing for people with disabilities

No plans have been announced but Minister of Health Christine Elliott says those with disabilities will be accommodated

As the country continues to wage battle against the novel coronavirus, vulnerable populations have been highlighted repeatedly including seniors, those with compromised immune systems, and more recently, those living in low-income neighbourhoods.

While there is no doubt all of those groups are particularly susceptible to COVID-19, disabilities advocates say their community is also a large and highly vulnerable group that has been entirely overlooked by the government in many areas.

People with disabilities in Ontario number at 2.5 million. [They] are facing, really, a triple whammy during this COVID crisis, beyond what everybody else is facing, says David Lepofsky, chair of the Accessibility for Ontarians with Disabilities Act Alliance (AODA).

Lepofsky says the problem includes the following issues:

* People with disabilities are disproportionately prone to contracting COVID-19 and also likely to suffer its most severe medical impacts
* A combination of government neglect and failure to plan is making them even more prone to getting COVID-19 than they already are
* If they do get the disease and have to visit a hospital, they face serious existing accessibility barriers in the healthcare system

The solution is as clear as it is obvious as it is missing. We need the Premier and the Government of Ontario to say we gotta plan. We gotta include in our emergency planning for COVID, specific plans to meet the urgent needs of people with disabilities, who are among the most vulnerable, says Lepofsky.

NDP Leader Andrea Horwath is also calling on the Ford government to address the needs of Ontarians with disabilities.

They are worried and concerned that theyve been left behind, says Horwath.

She says there is no plan to ensure that people with disabilities will get tested if they begin to show symptoms of COVID-19 and there are concerns in the community that they will not have access to testing like everybody else.

Weve asked the government to put in place a plan to have testing available for those folks that would include ensuring that they can get tested at home, says Horwath, adding that this would help mitigate the issues of barriers to transit and navigating public spaces for those with mobility issues.

Lets not leave these folks out. Lets do some proactive testing, lets get to people in their homes and lets give them the peace of mind that others are able to get by having mobility and being able to go out to testing centres and get that testing done.

However, testing and care are not the only ways in which Lepofsky says people with disabilities are falling through the cracks.

He adds that thousands of children with disabilities are being left behind as the government implements online learning which is not accessible to many such students. Plus, he says people with disabilities who live independently at home but still need assistance, are being overlooked as well.

Wendy Porch, the head of the Centre for Independent Living in Toronto, manages a program for about a thousand Ontarians who live independently but need assistance with daily tasks such as eating, getting washed and dressed.

She agrees with Lepofsky and says the people she works with have been ignored.

The folks that we work with have not been considered a priority in any of the priority populations that weve seen defined, she says. There has been no particular guidance thats been released around people with disabilities living at home.

In addition, she says when the issue is raised with authorities, they are told theyre just not there yet.

Theres no attention paid to this population at this point, says Porch.

Making matters arguably worse is that those who care for people with disabilities at home are not receiving any government assistance with personal protective equipment (PPE), despite being essential workers with close physical contact with clients.

Our program is not a medically oriented program, but the people who receive these supports at home, they see the same personal support workers that work in long-term care facilities and theyre certainly at risk. But because theyre at home, it seems as though theyve fallen through the cracks, she says. Because we were named as an essential service, if we could be included in the kind of supply chain relationships that exist between the Ministry of Health and some of these suppliers [of PPE], that would go a long way towards solving this problem for our folks.

In addition to these worries, Lepofsky says one of his biggest concerns is what he calls the provinces secret plans on how patients will be prioritized should critical equipment such as respirators fall into short supply. He says the governments plans to ration critical medical care if such a situation were to arise leaves out those with disabilities.

In an open letter, the province responded to such concerns saying all will be treated equally.

We believe that a human life cannot be valued differently. As such, Ontario Health has been asked to consult with the Ontario Human Rights Commission, as well as human rights and key community experts, to make certain that any medical protocols that may be required during this outbreak do not disproportionately affect vulnerable groups, including people with disabilities, older persons, Indigenous communities and racialized people, they said

Health Minister Christine Elliott was asked about the issue at the provinces daily briefing on Wednesday. She said the government is willing to accommodate everybody.

If people need to be tested, we can take the testing to them, especially people with disabilities who maybe have significant mobility challenges, she said. We want to make sure, if they need to be tested, that they will be tested and if they need care that they will receive the care that they need, including hospital admissions or if theyre doing self-isolation making sure that they have the supplies and equipment and assistance that they need.

At this time, the province has not yet put forth a definitive plan for at-home testing and care.

CBC News Kitchener Waterloo April 22, 2020

Originally posted at https://www.cbc.ca/news/canada/kitchener-waterloo/man-stuck-hours-daily-on-floor-while-province-closes-assistive-devices-office-1.5540041

Man stuck hours daily on floor while province closes Assistive Devices office
Michael Wilson says wheelchair broke while awaiting a replacement, then COVID-19 hit Paula Duhatschek

A Kitchener man has spent nearly a month stuck in his apartmentafter his wheelchair fell apart and a replacement has been delayed.

Meanwhile, the province has shuttered its Assisted Devices Program office, which helps people access funds to pay for their wheelchairs and other mobility devices.

Michael Wilson, who has cerebral palsy and uses a wheelchair to get around, receivesa replacement every five years, paid for through the province’s program.

This year, he says he was due for a new wheelchairbut that the process was delayed after the province initially rejected his applicationand he had to file an appeal.

Wilson was still using his old wheelchair on March 24 when he left his apartment to stock up on essentials.The motor and wheel fell offmid-trip, he says. Without a functional wheelchair, Wilson been unable to venture out for grocery or banking trips, and has mostly been eating delivery pizza. He also can’t comfortably change positions or move himself around his apartment.

“It’s awkward,” he said.

Office not processing applications
Although the province pays mostof the cost of devices provided through the Assisted Devices Program, it’s up to individual vendors to supply them. Corrinne Cave, who is witha localhome care company working with Wilson, said she couldn’t comment on individual cases for privacy reasons. But she saysher business’soperations have been complicated by the fact that the program office was closed due to COVID-19 and is no longer answering the phone or processing new funding applications.

“We’re trying to figure out a balance on how to get these [devices] to people who do need it” while also considering what costs they can absorb, she said.

France Gélinas, NDP health critic and Nickel Belt MPP, told CBC News that vendors and people with disabilities have been left in a tough position following the closure of the office. She saystheprogram itself has long been due for an upgrade, so that people who need new wheelchairs and other devices can get them based on need rather than “arbitrary” rules.

For the time being, Gelinas saysthe office should at least have someone around topick up the phone. “Right now, to not even be able to talk to them I don’t understand it,” Gelinas told CBC News.

“It is disrespectful, it is causing a lot of real hardship to people who often have severe disabilities,depend on those wheelchairs, to anything else to live their lives, and now they’re stuck.”

Pandemic creates urgency
Ontario disability advocate David Lepofsky agrees. He saysassistive devices are even more important during the COVID-19 pandemic, now people have been told to physically distanceand can’t ask their friends and neighbours for extra help.

“The first thing [the province] should do is immediately re-open the assistive devices program and declare it essential,” said Lepofsky. “The second thing they should do is essentially do a short-term surge to try to clear the backlog that will have now been created.”

Province ‘evaluating options’
A spokesperson for Health Minister Christine Elliott said the province couldn’t comment on individual cases. She said vendors will still receive payments based on historical invoicesand can dispense and repair devices for clients who are eligible. “We’re currently evaluating options to provide greater continuity of services under the assisted devices program during the COVID-19 pandemic,” the statement said.

He says they should replace wheelchairs more frequently, before safety becomes an issue. He thinks the programshould also be more cautious about rejecting applications and requiring appeals for needed devices like wheelchairs, especially when it comes to situations like his.

As of Monday, Wilson was still without a wheelchair. But after CBC News contacted the vendor and province about his story, Wilson was told his wheelchair would be delivered Wednesday. When it arrives, he says,he looks forward to finishing up the errands he started back in March.

The Globe and Mail April 11, 2020

Originally posted at https://www.theglobeandmail.com/canada/article-federal-government-names-group-to-ensure-disabled-canadians-included-2/ Federal government names group to ensure disabled Canadians included in COVID-19 response MICHELLE MCQUIGGE THE CANADIAN PRESS

Employment, Workforce Development and Disability Inclusion Minister Carla Qualtrough speaks during a news conference in Ottawa, Thursday March 26, 2020.

Qualtrough did not elaborate on specific systemic barriers in place, but members of Canadas disabled community have been sounding alarms since the beginning of the outbreak. THE CANADIAN PRESS figure

The COVID-19 pandemic takes a particularly heavy toll on Canadians with disabilities and more efforts are needed to ensure theyre included in national efforts to respond to the crisis, the minister overseeing accessibility issues said Friday as she appointed an advisory group to take on the task.

Disability Inclusion Minister Carla Qualtrough said disabled residents have been sounding alarms about a host of concerns related to the outbreak, which has already killed at least 550 Canadians and sickened a minimum of 22,000 others. In a statement announcing the advisory group, Qualtrough said greater efforts are needed to ensure disabled voices are heard during a troubling time.

For some persons with disabilities, underlying medical conditions put them at greater risk of serious complications related to COVID-19, Ms. Qualtrough said in the statement. Others face discrimination and barriers in accessing information, social services and health care. For others, the need for self-isolation and physical distancing create additional challenges.

As we continue to address the COVID-19 outbreak, our priority will remain helping persons with disabilities maintain their health, safety, and dignity.

Ms. Qualtrough did not elaborate on specific systemic barriers in place, but members of Canadas disabled community have been sounding alarms since the beginning of the outbreak.

Early public-health messages and briefings at all levels of government often failed to include accessibility measures, such as sign language interpreters for the deaf or simplified messaging for those with intellectual disabilities.

Since then, more concerns have been raised about access to overtaxed health-care resources, the availability of educational supports for disabled students, and the greater vulnerability of those living in confined settings such as prisons, homeless shelters and long-term care institutions. At one assisted living facility in Markham, Ont., the executive director confirmed an outbreak had infected 10 of 42 residents and two staff members. Shelley Brillinger said news of the outbreak prompted the rest of the staff at Participation House to walk off the job, leaving residents without the care they need.

Our residents are the most vulnerable in society, she said. They dont have a voice, and my message would be its our responsibility to speak up for those who cant speak for themselves and ensure that they have the care that they deserve.

The 11-member advisory group, consisting of academics and organization leaders spanning a range of physical and intellectual disabilities, has been tasked
with apprising the government of the barriers their communities face and ensuring their needs are adequately addressed.

Committee member Bonnie Brayton, executive director of the DisAbled Womens Network Canada, said the issues before the group are matters of equality and fundamental access to human rights.

She said the proliferation of the novel coronavirus has laid bear many systemic issues that dogged the community for decades, but have taken on increased urgency as the disease continues to spread.

What the COVID-19 pandemic has shown us is that the question of equality rights for people with disabilities apparently is still on the table in the legal system, in the health system, and I think in the soul of Canadians, Ms. Brayton said in a telephone interview. Its the last piece of our really becoming the country we need to become in terms of human rights.

Other advocates welcomed the federal governments recognition of the need for action, but expressed reservations about the impact such a move could have. David Lepofsky, founder of the Accessibility for Ontarians with Disabilities Act Alliance and a long-time crusader for accessibility rights, said federal governments do not have jurisdiction over most of the programs with the greatest impact on the lives of disabled residents.

Only provincial governments can take 95 per cent of the action people with disabilities desperately need to avert the disproportionate hardships that the COVID-19 crisis inflicts on them, including the horrifying risk that their disability could be used as a reason to deny them medical services during rationing, he said. Were disproportionately vulnerable to get this disease, to suffer its harshest impacts and then to slam into serious barriers in our health care system.

Robert Lattanzio, Executive Director of the Arch Disability Law Centre, shared Mr. Lepofskys concern. He said there is currently no uniform approach to disability inclusion during the COVID-19 crisis. While he applauded the federal government for acknowledging as much, he expressed hope that the advisory group would continually seek input from those without seats at the government table. The disproportionate impact of this pandemic on persons with disabilities is undisputed, but it is playing out very differently across different provinces, territories, cities, and towns, Mr. Lattanzio said. We need voices from people with disabilities who are on the ground and who understand the complexity and nuances of what is actually happening. April 10, 2020 Announcement by Federal Accessibility Minister Carla Qualtrough

Originally posted at https://www.canada.ca/en/employment-social-development/news/2020/04/statement-by-minister-qualtrough-on-canadas-disability-inclusive-approach-to-its-covid-19-pandemic-response.html Statement by Minister Qualtrough on Canadas Disability-Inclusive approach to its COVID-19 pandemic response From: Employment and Social Development Canada

April 10, 2020 Gatineau, Quebec Employment and Social Development Canada

The Honourable Carla Qualtrough, Minister of Employment, Workforce Development and Disability Inclusion, today issued the following statement:

From the onset of the outbreak of COVID-19, the Government of Canada has taken significant steps to curb the spread of this virus and to reduce its impacts on the health of Canadians and our economy.

We recognize that some groups of Canadians are significantly and disproportionately impacted by this pandemic, in particular Canadians with disabilities. For some persons with disabilities, underlying medical conditions put them at greater risk of serious complications related to COVID-19. Others face discrimination and barriers in accessing information, social services, and health care. For others, the need for self-isolation and physical distancing create additional challenges.

As we continue to address the COVID-19 outbreak, our priority will remain helping persons with disabilities maintain their health, safety, and dignity. This includes through more formal communication channels and touch points with the disability community.

To this end, we are establishing the COVID-19 Disability Advisory Group, comprised of experts in disability inclusion. This Group will provide advice on the real-time lived experiences of persons with disabilities during this crisis; disability-specific issues, challenges and systemic gaps; and strategies, measures and steps to be taken. Areas of particular focus will be equality of access to health care and supports; access to information and communications, mental health and social isolation; and employment and income supports.

From the onset, our Government has worked hard to ensure that the interests and needs of persons with a disability are being taken into consideration in our decisions and measures adopted in response to COVID-19. We have put a disability lens on decision-making and have been consulting national disability organizations and other stakeholders. We are also working with other levels of government. We are making strides on accessibility of public announcements and Government of Canada communications.

But we know that there is much more to do.

We have heard the concerns expressed by individuals and organizations for persons with disabilities, as well as their recommendations for ensuring a disability-inclusive approach to this pandemic.

Rest assured that as we support Canadians through this crisis, our Government is unequivocal in our commitment to the rights of every citizen and the value of every life, including the right to equal access to medical treatment and care. This is in keeping with our Governments commitment to nothing without us, and in line with the principles and objectives of the United Nations Convention on the Rights of Persons with Disabilities and the Accessible Canada Act.

April 10, 2020 Federal Government Backgrounder

Originally posted at https://www.canada.ca/en/employment-social-development/news/2020/04/backgrounder–covid-19-disability-advisory-group.html

Canada.ca Employment and Social Development Canada

Backgrounder : COVID-19 Disability Advisory Group
From: Employment and Social Development Canada

Backgrounder

During this time of public health and economic crisis, in the spirit of Nothing Without Us and the Accessible Canada Act, and in recognition of Canadas domestic and international human rights obligations, the Government of Canada is committed to ensuring that it considers, respects and incorporates the interests and needs of persons with disabilities into its decision-making and pandemic response.

Persons with disabilities face unique and heightened challenges and vulnerabilities in a time of pandemic, including equality of access to health care and supports, access to information and communications, mental health and social isolation and employment and income supports. Additional vigilance is also required to protect the human rights of persons with disabilities during these times. This necessitates a disability inclusive approach to Government decision-making and action.

The Government of Canada is taking immediate, significant and decisive action by announcing the establishment of the COVID-19 Disability Advisory Group (CDAG). The CDAG will advise the Minister on the real-time lived experiences of persons with disabilities during this crisis on disability-specific issues, challenges and systemic gaps and on strategies, measures and steps to be taken.

Co-chaired by Minister Qualtrough, the Advisory Group will be comprised of individual experts from the disability community:

Co-Chair: Al Etmanski, is a writer, community organizer and social entrepreneur. He was welcomed into the world of disability in 1978 when his daughter was born. He led the closure of institutions, segregated schools, and sheltered workshops in BC, founded Canadas first Family Support Institute, and initiated the precedent setting right-to-treatment court case for Stephen Dawson. In 1989, he co-founded Planned Lifetime Advocacy Network (PLAN) with his wife Vickie Cammack. PLAN lobbied into existence the Registered Disability Savings Plan. Mr. Etmanski sparked a national conversation about belonging, and was instrumental in establishing a grass roots alternative to legal guardianship and expanding the legal definition of capacity. His last book, Impact: 6 Patterns to Spread Your Social Innovation is a national bestseller. His forthcoming book is The Power of Disability: 10 Lessons for Surviving, Thriving and Changing the World. He blogs at aletmanski.com.

Bill Adair, Executive Director, Spinal Cord Injury Canada. Mr. Adair offers a depth of provincial and national experience in the spinal cord rehabilitation field. As a former Ontario government employee, national task force leader and Director of the National Patient Services Program with the Canadian Cancer Society, he has nearly three decades of expertise in non-profit management and strategic leadership. Prior to joining Spinal Cord Injury Ontario, he was Director of the National Patient Services Program with the Canadian Cancer Society for 13 years. His involvement in providing services to people with disabilities includes serving as the Director of the International Year for Disabled Persons, the Executive Director of a national task force that designed a system to coordinate cancer control efforts throughout Canada, and the Founding Executive Director of Wellspring.

Neil Belanger, Executive Director of the British Columbia Aboriginal Network on Disability Society (BCANDS). Mr. Belanger has over 30 years of experience working within in Canadas Indigenous and non-Indigenous disability and health sectors. Since 2013, BCANDS has been the recipient of eight provincial, national and international awards, the most recent being the Zero Project International Award presented to the Society in Vienna, in February 2019. He also serves in a variety of disability related advisory roles, some of which include: Canada Posts Accessibility Advisory Committee; Ministers Advisory Forum on Poverty Reduction; Ministers Council on Employment and Accessibility; Ministers Registered Disability Savings Plan Action Group and Board Member with Inclusion BC. He is a member of the Lax Se el (Frog Clan) of the Gitxsan First Nation and resides in Victoria with his wife and two children.

Diane Bergeron, President, CNIB Guide Dogs and Vice President, International Affairs.As President of CNIB Guide Dogs, Ms. Bergeron brings lived experience to the position. As a guide dog handler for more than 35 years, she raises her voice to challenge stigma and support equal rights. In addition, as vice president of International Affairs for the CNIB Foundation, she is actively engaged in regional, national and international initiatives that enable people impacted by blindness to live the lives they choose. Before joining CNIB, Ms. Bergeron held senior roles with the Government of Alberta and the City of Edmonton.

Bonnie Brayton, A recognized leader in both the feminist and disability movements, Ms. Brayton has been the National Executive Director of the DisAbled Womens Network (DAWN) of Canada since May 2007. In this role, she has proven herself as a formidable advocate for women with disabilities here in Canada and internationally. During her tenure with DAWN Canada, Ms. Brayton has worked diligently to highlight key issues that impact the lives of women and girls with disabilities. Since 2016, Ms. Brayton has served as a member of the Federal Department of Women and Gender Equality (WAGE, formerly known as Status of Women Canada), Ministers Advisory Council on Gender-Based Violence. She also presents regularly to Parliamentary and Senate Committees, at public consultations and has represented women and girls with disabilities in both Canadian and International spheres.
Krista Carr, Executive Vice-President, Canadian Association for Community Living (CACL). Ms. Carr was previously the Executive Director of the New Brunswick Association for Community Living (NBACL). She had been working with the NBACL for 21 years, the last 16 as Executive Director. She also holds a Bachelor of Business Administration in Marketing from the University of New Brunswick.

Maureen Haan: Ms. Haan has been the President & CEO of the Canadian Council on Rehabilitation and Work (CCRW) since 2012. CCRW is the only national organization with the sole vision of equitable and meaningful employment for people with disabilities, in operation for over 40 years. Under her leadership, CCRW has seen an increase in direct program service throughout Canada, as well as a more transparent, stream-lining of understanding the business case of hiring a person with a disability. She has been very active in the cross-disability sector, currently focusing on employment issues. Ms. Haan has been involved with numerous committees and groups that increase awareness of and access for the disability sector and the Deaf community, including involvement with civil society on the United Nations Convention on the Rights of Persons with Disabilities; and co-development and leadership of the pan-Canadian Strategy on Disability and Work.

Hélène Hébert, President, Réseau québécois pour l’inclusion sociale des personnes sourdes et malentendantes (REQIS). Ms. Hébert is the president of Reqis, a provincial organization defending the collective rights and promoting the interests of deaf and hard of hearing individuals. Its mission is also to contribute to the development and influence of its members through networking and knowledge exchange. She is also a member of VoirDire, a bi-monthly publication serving the deaf population of Quebec since 1983.

Dr. Heidi Janz, University of Alberta, Assistant Adjunct Professor with the John Dossetor Health Ethics Centre. Dr. Janz specializes in the field of Disability Ethics and has been affiliated with the John Dossetor Health Ethics Centre since 2006. She was previously the Curriculum Coordinator for an emerging Certificate Program in Disability Ethics in the Faculty of Rehabilitation Medicine at the University of Alberta. In her other life, Dr. Janz is a writer and playwright. Dr. Janz is also Chair of the End-of-life ethics committee for the Council of Canadians with Disabilities (CCD).

Rabia Khedr, CEO, Disability Empowerment Equality Network Support Services and Executive Director, Muslim Council of Peel. Rabia is a community leader who helps others with issues of fairness and justice that affect persons with disabilities, women and diverse communities. She was recently the Commissioner for the Ontario Human Rights Commission. Ms. Khedr created the Canadian Alliance on Race and Disability, which represents persons with disabilities and organizations at local, provincial and national meetings. She is also a member of the Mississauga Accessibility Advisory Committee. She is a motivational speaker and documentary commentator and has been awarded many awards, including a Queen Elizabeth II Diamond Jubilee Medal.

Dr. Michael Prince, Lansdowne Professor of Social Policy at the University of Victoria. He teaches courses on public sector governance and public policy analysis in the School of Public Administration and the School of Public Health and Social Policy. As a policy consultant, Dr. Prince has been an advisor to various federal, provincial, territorial, and municipal government agencies; four Royal commissions; and, to a number of parliamentary committees federally and provincially. An active volunteer, Dr. Prince has been a board member of a community health clinic, a legal aid society, a hospital society and hospital foundation, the BC Association for Community Living, and the social policy committee of the Council of Canadians with Disabilities.




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