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
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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?


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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?

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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Any Time, You Can Watch The Agenda with Steve Paikin’s Panel on Disability Discrimination Risks If Life-Saving Critical Medical Care Must Soon Be Rationed – and


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

January 14, 2021

SUMMARY

1. You Can Watch “The Agenda with Steve Paikin’s January 13, 2021 Panel on Critical Care Triage Issues for Patients with Disabilities Any Time

We continue our unbelievably uphill efforts to get the media to cover the immediate and important issue of the danger that patients with disabilities could be subjected to disability discrimination in access to life-saving critical medical care if overloaded hospitals must ration or “triage” critical medical care. The Ford Government still refuses to answer our letters on this issue.
The one and only televised panel discussion devoted to this issue that included disability and bioethics perspectives took place last night on TVO’s The Agenda with Steve Paikin. You can watch this 30 minute discussion any time by going to this link: https://www.youtube.com/watch?v=qkq1NmaXLwk&feature=youtu.be
The panelists were AODA Alliance Chair David Lepofsky, ARCH Disability Law Centre counsel Mariam Shanouda, Dr. James Downar (a member of the Government-appointed external advisory Bioethics Table and an author of the March 28, 2020 critical care triage protocol with which the disability community had strong objections) and Ontario research chair in bioethics Prof. Udo Schuklenk.
As you watch this panel, please remember that as far as we can tell, there is now no protocol in place in Ontario to direct hospitals what to do if critical care must be rationed or triaged. There is some reference during the panel to a current triage “protocol”. As speakers confirmed elsewhere during the panel, and as is also confirmed elsewhere, the Government has not finalized and issued any critical care triage protocol as of now.
We welcome your feedback on this panel. We will have more to say about it in the future. Write us at [email protected]
We respectfully take issue with some of Dr. Downar’s and Prof. Schuklenk’s statements. Because of time limitations, there was not enough opportunity for David Lepofsky or Mariam Shanouda to itemize all of these concerns during the interview. We fully understand that there is a limited amount of information that can be conveyed in such a panel.

2. Canadian Press Publishes a Strong Report on the Critical Care Triage Dangers Posed for People with Disabilities

On January 13, 2021, the Canadian Press’s Liam Casey wrote an excellent article on the same critical care triage issue. So far, we have found that article posted on the websites of the Toronto Star and Global News. We have not yet ascertained if any newspapers included it in their hard copy editions, or if any radio or TV news reports included any of it. We set that report out below.

3. What You Can Do

Please spread the word far and wide about the panel on The Agenda with Steve Paikin, and the CP news story. Post these on social media and your website. Email them to others. Recruit a carrier pigeon to get the word out, if you can. Urge as many people as possible to tell the Ford Government that it should immediately consult directly with the public including people with disabilities, and not just hide behind its external advisory Bioethics Table. The Ford Government should also answer our unanswered letters on this issue, sent last fall.
We thank The Agenda with Steve Paikin and its host and staff for including this panel. We applaud the Canadian Press as well. We urge other news and public affairs programs to follow the commendable examples of The Agenda with Steve Paikin and Canadian Press, and give this issue the coverage that it so urgently deserves.
As of now, there have been 714 days, over 23 months, since the Ford Government received the 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 ground-breaking report. This worsens the festering problems facing patients with disabilities during the COVID-19 pandemic, such as those addressed in this new episode of The Agenda with Steve Paikin. For more background on this issue, check out:

1. The AODA Alliance’s December 21, 2020 news release on the critical care triage issue.

2. The Government’s external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed days ago.

3. The December 3, 2020 open letter to the Ford Government from 64 community organizations, calling for the Government to make public the secret report on critical care triage from the Government-appointed Bioethics Table.

4. The AODA Alliance’s unanswered September 25, 2020 letter, its November 2, 2020 letter, its November 9, 2020 letter, its December 7, 2020 letter, its December 15, 2020 letter and its December 17, 2020 letter to Health Minister Christine Elliott.

5. The August 30, 2020 AODA Alliance submission to the Ford Government’s Bioethics Table, and a captioned online video of the AODA Alliance’s August 31, 2020 oral presentation to the Bioethics Table on disability discrimination concerns in critical care triage.

6. The September 1, 2020 submission and July 20, 2020 submission by the ARCH Disability Law Centre to the Bioethics Table.

7. The November 5, 2020 captioned online speech by AODA Alliance Chair David Lepofsky on the disability rights concerns with Ontario’s critical care triage protocol.

8. 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

January 13, 2021 Toronto Star Online
Originally posted at https://www.thestar.com/news/gta/2021/01/13/medical-staff-need-guidance-on-life-or-death-triage-decision-as-icus-fill-up-experts.html

January 13, 2021 Toronto Star Online

Originally posted at https://www.thestar.com/news/gta/2021/01/13/medical-staff-need-guidance-on-life-or-death-triage-decision-as-icus-fill-up-experts.html

Medical staff need guidance on life-or-death triage decision as ICUs fill up: experts

An ICU health-care worker shown inside a negative pressure room cares for a COVID-19 patient on a ventilator at the Humber River Hospital during the COVID-19
pandemic in Toronto on Wednesday, December 9, 2020. Hospitals and human rights organizations want Ontario to finalize its plan on who, and how, life or
death decisions for patients will be made if and when the day comes where ICU beds will be full. By Liam Casey The Canadian Press
Wed., Jan. 13, 20213
TORONTO – As intensive care units in Ontario hospitals continue to fill up with COVID-19 patients, the province has yet to finalize a plan on who should get life-saving care when health resources are limited.
The latest COVID-19 projections show the province’s ICUs could reach “gridlock” by mid-to-late February. At that point, health-care workers will have to decide who gets an ICU bed and who doesn’t – a practice known as critical care triage. It’s a heart-wrenching decision doctors in a number of countries with hospitals overwhelmed with COVID-19 patients have had to make.
“It’s really concerning to not know what the plan is and transparency around that would go a long way towards everyone’s ability to prepare and everyone’s mental well-being,” said Dr. Samantha Hill, the president of the Ontario Medical Association, which represents more than 40,000 physicians.
The province has stumbled in its efforts to get the critical care triage ethical framework out to doctors.
Ontario Health sent out a critical care triage protocol on March 28, 2020, but retracted it several months later after an outcry from human rights organizations.
“The first protocol was horrifically discriminatory against patients with disabilities,” said David Lepofsky, the chairman of Accessibility for Ontarians with Disabilities Act Alliance.
One problem with that proposal was the use of a “clinical frailty scale,” or CFS, Lepofsky said. The scale is also part of a proposed framework sent to the government by the Bioethics Table, which advises the province on the health system’s response to COVID-19.
The document – titled “Critical Care Triage during Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario” – lays out how a patient would qualify or be excluded from critical care and was sent to the province in September.
The clinical frailty scale is used as a prognostic tool for progressive illnesses that assesses a patient’s general deterioration over time, the Bioethics Table notes in the document, which was obtained by The Canadian Press.
However, the proposal acknowledges that the CFS “would seem to conflate disability with frailty and hence would contribute to over-triaging of persons with disabilities.”
It further notes that the CFS “illustrates how clinical evidence and experience are not sufficient alone to establish the justifiable use of a clinical tool and calls attention to the embedding of social norms within clinical tools and in their application in practice.”
The Ontario Human Rights Commission has also expressed concern about the recommendation that patients be evaluated for their survival potential over the next 12 months.
Under the Bioethics Table’s proposed protocol, patients would be evaluated and assigned into colour-coded categories based on the predicted percentage of short-term mortality risk over the next year.
There would then be three levels of triage depending on demand and availability of beds. In Level 1 triage, patients who have greater than 20 per cent chance of surviving 12 months should be prioritized. In Level 2, patients with greater than 50 per cent chance of survival in a year should be prioritized and, in Level 3, patients who have a greater than 70 per cent chance of survival should be prioritized.

Ena Chadha, the chief commissioner of the Ontario Human Rights Commission, said the 12-month time period is troubling.
“A doctor can make a decision in the short term: is this person going to survive next week, the next two weeks,” she said.
“But when you start looking at one year…you are going to be infused with discriminatory ideas about the person’s disability and age. Our stakeholders would like to see a much shorter time frame.”
Both Lepofsky and Chadha, along with the Bioethics Table, said there must also be due process an appeal process so that life or death decisions aren’t made by one person.
Another major concern for both Lepofsky and Chadha is the province’s lack of transparency on such an important issue.
“This process is very opaque as to who are the decision-makers, what is the process and where are we at right now?” Chadha said.
“This is distressing for our community stakeholders. They are very worried that their dignity and life is at stake and that when it comes to making decisions about a very horrible death, the health-care decision-makers may not understand the value of their life.”
The Ministry of Health said the Bioethics Table will continue to talk to various stakeholders.
“These conversations are ongoing to ensure that the proposed framework reflects the best available evidence and advice,” said spokesman David Jensen, noting that nothing has been approved by the ministry.




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It’s Time for the Ford Government to Agree to Create a Built Environment Accessibility Standard under Ontario’s Disabilities Act


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/

November 30, 2020

SUMMARY

Today is the first day of our non-partisan grassroots disability accessibility movement’s 27th year in action!!

We call on the Ford Government to immediately take effective action to tackle the many barriers that Ontarians with disabilities continue to face in the built environment. More specifically, we call on the Ford Government to announce that it will develop and enact a comprehensive, strong and effective Built Environment Accessibility Standard under the Accessibility for Ontarians with Disabilities Act. The Government should now post an announcement recruiting people to serve on a Built Environment Standards Development Committee under the AODA. That Committee is needed to consult the public and to make recommendations on what the Built Environment Accessibility Standard should include.

That AODA Standards Development Committee should be free to make whatever recommendations it deems helpful to address any aspect of the built environment. Part of its mandate should be to conduct the long-overdue mandatory review of Ontario’s weak and limited Design of Public Spaces AODA Accessibility Standard. The AODA required that review to begin three years ago. A review of the Design of Public Spaces Accessibility Standard is only a small part of what is now needed.

The Ontario Government typically and wrongly treats the Ontario Building Code and existing AODA accessibility standards as the only legally required benchmark that it must meet in new or significantly renovated buildings. Yet those legal requirements fall far short of what people with disabilities need. A building that is built in full compliance with the Ontario Building Code and with existing AODA accessibility standards need not be fully accessible, and likely will not be fully accessible to people with disabilities. It will not meet the higher accessibility requirements guaranteed to people with disabilities by the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms.

Below we give more background on this issue. To learn even more about the AODA Alliance’s multi-year campaign to get a strong and effective Built Environment Accessibility Standard enacted in Ontario under the AODA, check out the AODA Alliance website’s built environment page.

There have now been 669 days, or 22 months, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has still announced no comprehensive plan of new action to implement that blistering report, including its strong recommendations regarding disability barriers in the built environment. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis, addressed in the new online video we unveiled last week.

MORE DETAILS

1. A Province Still Full of Disability Barriers in the Built Environment

The Accessibility for Ontarians with Disabilities Act requires Ontario to become accessible to people with disabilities by January 1, 2025. This includes ensuring the accessibility of buildings, as well as employment, goods, services and facilities in Ontario. The AODA requires the Ontario Government to enact all the regulations (called accessibility standards) that are needed to ensure that Ontario becomes accessible by 2025.

Only a little over four years is left for Ontario to achieve this legally mandatory goal. Ontario remains far behind schedule for reaching it. One of the areas where Ontario remains far behind is in making the built environment accessible to people with disabilities. Although this AODA Alliance Update focuses on barriers in the built environment, we emphasize that Ontario remains full of many other kinds of disability barriers as well that need to be removed, beyond those in the built environment.

No one could credibly deny that the built environment in Ontario remains replete with too many accessibility barriers. Under the AODA, the Ontario Government must appoint an Independent Review of the AODA’s implementation every three years or so. The two most recent AODA Independent Reviews each found that barriers in the built environment remain a serious problem. This includes the 2014 report of Mayo Moran’s second AODA Independent Review and David Onley’s 2019 third Independent Review of the AODA.

Both Independent Reviews called for new Government action under the AODA to address the many persisting disability barriers in the built environment. The Onley Report described Ontario as full of soul-crushing barriers, with progress on accessibility taking place at a glacial pace.

2. Ontario Has No Comprehensive Accessibility Standard Ensuring that the Built Environment Becomes Accessible

Many are shocked to learn that even though it is now over 15 years since the AODA was passed, there is still no Built Environment Accessibility Standard enacted under the AODA to ensure that the built environment in Ontario becomes accessible by 2025.

Over 14 years ago, the Liberal Ontario Government under Premier Dalton McGuinty commendably committed to enact a Built Environment Accessibility Standard under the AODA. Back then, the Government appointed a Built Environment Standards Development Committee under the AODA to make recommendations on what the promised Built Environment Accessibility Standard should include. That Standards Development Committee submitted its final recommendations to the Government by 2010.

In the 2011 Ontario election, Premier McGuinty promised to enact the Built Environment Accessibility Standard promptly. However, to this day, Ontario still does not have an AODA Built Environment Accessibility Standard.

In December 2012, the previous McGuinty Government passed a very weak and limited Design of Public Spaces Accessibility Standard under the AODA. That regulation only addresses a very limited range of disability barriers in the built environment, mainly some that are outside buildings. As for the vital area of disability barriers inside buildings, that Accessibility Standard only addresses some in public service areas, such as counter heights. Further limiting its effectiveness, the Design of Public Spaces Accessibility Standard only deals with preventing the creation of some new barriers. It does not require removal of any existing barriers anywhere in the built environment inside or outside buildings.

As for the many other disability barriers inside buildings, in December 2013, the McGuinty Government passed very limited changes to the weak accessibility provisions in the Ontario Building Code. Even after those changes, the Ontario Building Code still fails to effectively ensure that a building, even a new building, will be barrier-free for people with disabilities. It requires no retrofits of existing buildings that are not undergoing a major renovation, even if accessibility would be readily achievable.

As a result, even if a new building fully complies with the Ontario Building Code and the Design of Public Spaces Accessibility Standard, it can and usually does end up having accessibility barriers designed into it. The AODA Alliance has documented this cruel reality in three widely-viewed captioned online videos. Serious accessibility problems are revealed in the AODA Alliances 2018 vid HYPERLINK “https://youtu.be/za1UptZq82o”eo about new and recently-renovated Toronto area transit stations, its 2017 video about the new Ryerson University Student Learning Centre and its 2016 video about Centennial College’s new Culinary Arts Centre. Each of those videos secured great media coverage.

Yet such barriers in the built environment can expose providers of goods, services, facilities or employment to human rights complaints, alleging disability discrimination. Those organizations that must comply with the Canadian Charter of Rights and Freedoms are also exposed to the possibility of claims that such barriers violate the guarantee of equality without discrimination because of disability in section 15 of the Charter of Rights.

3. The Ontario Government is in Breach of Its AODA Obligations

Within five years after an AODA accessibility standard is enacted, section 9(9) of the AODA requires the Government to appoint a new Standards Development Committee to review that standard. This review is done to see if that accessibility standard is strong enough to ensure accessibility is achieved by 2025.

As explained earlier, the Government enacted the Design of Public Spaces Accessibility Standard in December 2012. The Government was therefore required to appoint a Standards Development Committee to review it by December 2017. Yet no Standards Development Committee has ever been appointed to conduct that mandatory review.

That mandatory deadline was reached and missed three years ago. The previous Liberal Government of Premier Kathleen Wynne is responsible for the first six months of that 3-year violation of the AODA. The Conservative Government is responsible for the other two and a half years of that AODA violation.

We have diligently and repeatedly alerted each successive Government and each accessibility minister well in advance of this obligation. They should not need a volunteer community coalition like the AODA Alliance to tell them of such basic obligations under the AODA. This is especially so since each successive Ontario Government has claimed to be leading the rest of Ontario by its example on accessibility. Such an overt breach of the law is hardly the example by which Ontarians should be led.

4. Meanwhile, The Ford Government Uses Public Money to Create New Disability Barriers

It is bad enough that the Government leaves existing disability barriers in place. It makes this problem worse when the Government allows public money to be used to build new buildings and infrastructure without ensuring that these will be barrier-free for people with disabilities. It will cost much more to later remove those barriers. To use public money to create new disability barriers is a serious misuse of public money.

The Ford Government has not committed to never use public money to create new disability barriers. For example, last summer, amidst the COVID-19 pandemic, the Ford Government announced that it is spending half a billion dollars to build new schools and do major renovations to existing schools. The Government has no measures in place to ensure that those publicly-funded building projects will be barrier-free.

As well, the Government is in the process of building a new major court building in downtown Toronto. The AODA Alliance has raised serious accessibility concerns about that building’s design. The Government has also announced plans to move ahead with a range of other public infrastructure projects, with no assurance that those projects will be fully accessible. The Ontario Government has a disturbing track-record in this context.

5. Promises Made Promises Not Kept

The Government’s failure to effectively address this issue flies in the face of Premier Doug Ford’s written commitments to the AODA Alliance during the 2018 Ontario general election. In his May 15, 2018 letter to the AODA Alliance setting out his party’s election pledges on disability accessibility, Doug Ford wrote, among other things:

Your issues are close to the hearts of our Ontario PC Caucus and Candidates, which is why they will play an outstanding role in shaping policy for the Ontario PC Party to assist Ontarians in need.

Too many Ontarians with disabilities still face barriers when they try to get a job, ride public transit, get an education, use our healthcare system, buy goods or services, or eat in restaurants.

Whether addressing standards for public housing, health care, employment or education, our goal when passing the AODA in 2005 was to help remove the barriers that prevent people with disabilities from participating more fully in their communities.

For the Ontario PCs, this remains our goal. Making Ontario fully accessible by 2025 is an important goal under the AODA and it’s one that would be taken seriously by an Ontario PC government

This is why we’re disappointed the current government has not kept its promise with respect to accessibility standards. An Ontario PC government is committed to working with the AODA Alliance to address implementation and enforcement issues when it comes to these standards.

Ontario needs a clear strategy to address AODA standards and the Ontario Building Code’s accessibility provisions. We need Ontario’s design professionals, such as architects, to receive substantially improved professional training on disability and accessibility.

We have written Premier Ford more than once to raise serious concerns about his Government’s failure to act effectively on accessibility issues such as this. He has never agreed to meet with us or to speak on the phone. He deflects all our issues and requests to the Government’s Accessibility Minister Raymond Cho. Minister Cho has never agreed to create a Built Environment Accessibility Standard under the AODA.

6. Ford Government’s Only New Initiative on Accessibility of the Built Environment is a Wasteful Failure

Since taking office in June 2018, the only new initiative to which the Ford Government repeatedly points for disability barriers in the built environment was its controversial spring 2019 announcement that it is diverting 1.3 million dollars over two years to the Rick Hansen Foundation (RHF) to have its so called private accessibility certification program to look at some buildings in Ontario to decide if it would certify them as accessible. The AODA Alliance was never consulted on that decision.

We have strongly opposed this as a very poor use of public money. It will not help the accessibility cause.

The AODA Alliance has made public numerous concerns with the RHF certification process. Neither the Ford Government nor the RHF have publicly disputed the accuracy of our concerns.

For example, an RHF certification does not in fact certify anything. If the RHF gives a building a rating of accessible, it does not mean that that building is in fact accessible.

Those whom the RHF authorizes to conduct these inspections need not have the required expertise to assess a building’s accessibility. The RHF only requires an assessor to take an 8-day course. That course is far too short. Its training contents are quite deficient and problematic.

One and a half years after this Ford Government strategy was launched, there is no evidence that a single building has been thereby made accessible, or that a single barrier in the built environment was rectified. All that the Government may have accomplished is to give an inappropriate public subsidy to the RHF in its effort to break into the Ontario market, in competition with local Ontario-based accessibility consultants having far more expertise in this field.

For example, earlier this year, one could hear RHF advertisements on Toronto radio stations, promoting the RHF certification program. We asked the Ontario Government if these advertisements were directly or indirectly subsidized by the Ontario Government. The Government did not answer this inquiry.

It is not clear to us that the Government and RHF have found enough organizations to take up the offer of a Government-subsidized RHF appraisal. That would make sense, since the RHF assessment of their building’s accessibility is not reliable.

It would have been much more appropriate for the Government to have invested those public funds into the development and enactment of a Built Environment Accessibility Standard under the AODA, and on effectively enforcing the inadequate accessibility requirements that are already on the books.

7. What Have the Opposition Parties Said On Point?

The Ontario NDP committed as follows on November 9, 2020 as part of its housing plan:

“We’ll mandate Universal Design building codes, which are standards that reflect the needs of people of all ages, sizes, abilities and disabilities.”

The Ontario Liberal Party has not announced a platform on this issue since the 2018 election. In her May 14, 2018 letter to the AODA Alliance setting out the Liberal Party’s disability accessibility commitments in the 2018 election, Kathleen Wynne committed to the following:

1. exploring and determining next steps for preventing and removing accessibility barriers in the built environment

2. New and Existing Accessibility Standards

The creation of new standards is a critical element of the Ontario Liberal commitment to an accessible Ontario by 2025. We intend to continue the reviews already underway and continue the work of developing standards in the areas of health care and education. We would welcome advice from these committees on built environment issues and look forward to making the process more open and transparent to ensure all voices are heard without compromising necessary privacy and accountability measures.

Beyond ongoing work, we know that there are barriers in the province that need to be addressed through standards. Earlier this year, former Minister Tracy Machala publicly stated that the standards governing the built environment need to be strengthened to achieve our goal. That’s why she convened a summit on the subject attended by many impacted stakeholders, including the AODA Alliance. We will use the feedback gleaned from this summit and further consultation with stakeholders to determine the best path forward as we track toward the mandated review of the standard. Given the complexity of housing construction, building modification, and renovation, we will also work with builders, developers, architects, and other experts before committing to a path forward on residential housing and retrofits.

Getting to an accessible Ontario requires that we also ensure that the professionals most connected to design and construction know about accessibility. To this end, we will work with regulatory bodies, colleges, universities, and professional organizations to ensure that accessibility is included throughout the process.

Standards for AFPs differ project to project, but all Project Companies are required to comply with all legislation on AFP projects, including the AODA and accessibility requirements in the Ontario Building Code. This is the de facto minimum standard. Issues related to accessibility in AFP projects are therefore related to the content of the standards. On built environment issues specifically, that’s why we have committed to working with stakeholders toward the next review of the standard.

Accessibility in Education

In its May 4, 2018 letter to the AODA Alliance setting out its election pledges on disability accessibility in the 2018 election, the Green Party of Ontario committed:

e) Take Overdue Steps to Ensure the Accessibility of the Built Environment, Including Residential Housing
We support accessibility as an essential component of any new building project or retrofit. Training in accessible design should be a requirement across all licensing and educational institutions in Ontario, and all new building projects should meet standard accessibility requirements before approval. A strategy must be developed both to increase the supply of accessible housing within Ontario and to undertake the retrofitting of existing buildings in order for them to meet accessibility standards.




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It’s Time for the Ford Government to Agree to Create a Built Environment Accessibility Standard under Ontario’s Disabilities Act – AODA Alliance


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/

It’s Time for the Ford Government to Agree to Create a Built Environment Accessibility Standard under Ontario’s Disabilities Act

November 30, 2020

            SUMMARY

Today is the first day of our non-partisan grassroots disability accessibility movement’s 27th year in action!!

We call on the Ford Government to immediately take effective action to tackle the many barriers that Ontarians with disabilities continue to face in the built environment. More specifically, we call on the Ford Government to announce that it will develop and enact a comprehensive, strong and effective Built Environment Accessibility Standard under the Accessibility for Ontarians with Disabilities Act. The Government should now post an announcement recruiting people to serve on a Built Environment Standards Development Committee under the AODA. That Committee is needed to consult the public and to make recommendations on what the Built Environment Accessibility Standard should include.

That AODA Standards Development Committee should be free to make whatever recommendations it deems helpful to address any aspect of the built environment. Part of its mandate should be to conduct the long-overdue mandatory review of Ontario’s weak and limited “Design of Public Spaces AODA Accessibility Standard”. The AODA required that review to begin three years ago. A review of the Design of Public Spaces Accessibility Standard is only a small part of what is now needed.

The Ontario Government typically and wrongly treats the Ontario Building Code and existing AODA accessibility standards as the only legally required benchmark that it must meet in new or significantly renovated buildings. Yet those legal requirements fall far short of what people with disabilities need. A building that is built in full compliance with the Ontario Building Code and with existing AODA accessibility standards need not be fully accessible, and likely will not be fully accessible to people with disabilities. It will not meet the higher accessibility requirements guaranteed to people with disabilities by the Ontario Human Rights Code and the Canadian Charter of Rights and Freedoms.

Below we give more background on this issue. To learn even more about the AODA Alliance’s multi-year campaign to get a strong and effective Built Environment Accessibility Standard enacted in Ontario under the AODA, check out the AODA Alliance website’s built environment page.

There have now been 669 days, or 22 months, since the Ford Government received the ground-breaking final report of the Independent Review of the implementation of the Accessibility for Ontarians with Disabilities Act by former Ontario Lieutenant Governor David Onley. The Government has still announced no comprehensive plan of new action to implement that blistering report, including its strong recommendations regarding disability barriers in the built environment. That makes even worse the serious problems facing Ontarians with disabilities during the COVID-19 crisis, addressed in the new online video we unveiled last week.

            MORE DETAILS

 1. A Province Still Full of Disability Barriers in the Built Environment

The Accessibility for Ontarians with Disabilities Act requires Ontario to become accessible to people with disabilities by January 1, 2025. This includes ensuring the accessibility of “buildings”, as well as employment, goods, services and facilities in Ontario. The AODA requires the Ontario Government to enact all the regulations (called accessibility standards) that are needed to ensure that Ontario becomes accessible by 2025.

Only a little over four years is left for Ontario to achieve this legally mandatory goal. Ontario remains far behind schedule for reaching it. One of the areas where Ontario remains far behind is in making the built environment accessible to people with disabilities. Although this AODA Alliance Update focuses on barriers in the built environment, we emphasize that Ontario remains full of many other kinds of disability barriers as well that need to be removed, beyond those in the built environment.

No one could credibly deny that the built environment in Ontario remains replete with too many accessibility barriers. Under the AODA, the Ontario Government must appoint an Independent Review of the AODA’s implementation every three years or so. The two most recent AODA Independent Reviews each found that barriers in the built environment remain a serious problem. This includes the 2014 report of Mayo Moran’s second AODA Independent Review and David Onley’s 2019 third Independent Review of the AODA.

Both Independent Reviews called for new Government action under the AODA to address the many persisting disability barriers in the built environment. The Onley Report described Ontario as full of “soul-crushing barriers”, with progress on accessibility taking place at a “glacial” pace.

 2. Ontario Has No Comprehensive Accessibility Standard Ensuring that the Built Environment Becomes Accessible

Many are shocked to learn that even though it is now over 15 years since the AODA was passed, there is still no Built Environment Accessibility Standard enacted under the AODA to ensure that the built environment in Ontario becomes accessible by 2025.

Over 14 years ago, the Liberal Ontario Government under Premier Dalton McGuinty commendably committed to enact a Built Environment Accessibility Standard under the AODA. Back then, the Government appointed a Built Environment Standards Development Committee under the AODA to make recommendations on what the promised Built Environment Accessibility Standard should include. That Standards Development Committee submitted its final recommendations to the Government by 2010.

In the 2011 Ontario election, Premier McGuinty promised to enact the Built Environment Accessibility Standard “promptly.” However, to this day, Ontario still does not have an AODA Built Environment Accessibility Standard.

In December 2012, the previous McGuinty Government passed a very weak and limited “Design of Public Spaces” Accessibility Standard under the AODA. That regulation only addresses a very limited range of disability barriers in the built environment, mainly some that are outside buildings. As for the vital area of disability barriers inside buildings, that Accessibility Standard only addresses some in public service areas, such as counter heights. Further limiting its effectiveness, the Design of Public Spaces Accessibility Standard only deals with preventing the creation of some new barriers. It does not require removal of any existing barriers anywhere in the built environment inside or outside buildings.

As for the many other disability barriers inside buildings, in December 2013, the McGuinty Government passed very limited changes to the weak accessibility provisions in the Ontario Building Code. Even after those changes, the Ontario Building Code still fails to effectively ensure that a building, even a new building, will be barrier-free for people with disabilities. It requires no retrofits of existing buildings that are not undergoing a major renovation, even if accessibility would be readily achievable.

As a result, even if a new building fully complies with the Ontario Building Code and the Design of Public Spaces Accessibility Standard, it can and usually does end up having accessibility barriers designed into it. The AODA Alliance has documented this cruel reality in three widely-viewed captioned online videos. Serious accessibility problems are revealed in the AODA Alliance‘s 2018 vid HYPERLINK “https://youtu.be/za1UptZq82o”eo about new and recently-renovated Toronto area transit stations, its 2017 video about the new Ryerson University Student Learning Centre and its 2016 video about Centennial College’s new Culinary Arts Centre. Each of those videos secured great media coverage.

Yet such barriers in the built environment can expose providers of goods, services, facilities or employment to human rights complaints, alleging disability discrimination. Those organizations that must comply with the Canadian Charter of Rights and Freedoms are also exposed to the possibility of claims that such barriers violate the guarantee of equality without discrimination because of disability in section 15 of the Charter of Rights.

 3. The Ontario Government is in Breach of Its AODA Obligations

Within five years after an AODA accessibility standard is enacted, section 9(9) of the AODA requires the Government to appoint a new Standards Development Committee to review that standard. This review is done to see if that accessibility standard is strong enough to ensure accessibility is achieved by 2025.

As explained earlier, the Government enacted the Design of Public Spaces Accessibility Standard in December 2012. The Government was therefore required to appoint a Standards Development Committee to review it by December 2017. Yet no Standards Development Committee has ever been appointed to conduct that mandatory review.

That mandatory deadline was reached and missed three years ago. The previous Liberal Government of Premier Kathleen Wynne is responsible for the first six months of that 3-year violation of the AODA. The Conservative Government is responsible for the other two and a half years of that AODA violation.

We have diligently and repeatedly alerted each successive Government and each accessibility minister well in advance of this obligation. They should not need a volunteer community coalition like the AODA Alliance to tell them of such basic obligations under the AODA. This is especially so since each successive Ontario Government has claimed to be leading the rest of Ontario by its example on accessibility. Such an overt breach of the law is hardly the example by which Ontarians should be led.

 4. Meanwhile, The Ford Government Uses Public Money to Create New Disability Barriers

It is bad enough that the Government leaves existing disability barriers in place. It makes this problem worse when the Government allows public money to be used to build new buildings and infrastructure without ensuring that these will be barrier-free for people with disabilities. It will cost much more to later remove those barriers. To use public money to create new disability barriers is a serious misuse of public money.

The Ford Government has not committed to never use public money to create new disability barriers. For example, last summer, amidst the COVID-19 pandemic, the Ford Government announced that it is spending half a billion dollars to build new schools and do major renovations to existing schools. The Government has no measures in place to ensure that those publicly-funded building projects will be barrier-free.

As well, the Government is in the process of building a new major court building in downtown Toronto. The AODA Alliance has raised serious accessibility concerns about that building’s design. The Government has also announced plans to move ahead with a range of other public infrastructure projects, with no assurance that those projects will be fully accessible. The Ontario Government has a disturbing track-record in this context.

 5. Promises Made – Promises Not Kept

The Government’s failure to effectively address this issue flies in the face of Premier Doug Ford’s written commitments to the AODA Alliance during the 2018 Ontario general election. In his May 15, 2018 letter to the AODA Alliance setting out his party’s election pledges on disability accessibility, Doug Ford wrote, among other things:

“Your issues are close to the hearts of our Ontario PC Caucus and Candidates, which is why they will play an outstanding role in shaping policy for the Ontario PC Party to assist Ontarians in need.

Too many Ontarians with disabilities still face barriers when they try to get a job, ride public transit, get an education, use our healthcare system, buy goods or services, or eat in restaurants.

Whether addressing standards for public housing, health care, employment or education, our goal when passing the AODA in 2005 was to help remove the barriers that prevent people with disabilities from participating more fully in their communities.

For the Ontario PCs, this remains our goal. Making Ontario fully accessible by 2025 is an important goal under the AODA and it’s one that would be taken seriously by an Ontario PC government…

…This is why we’re disappointed the current government has not kept its promise with respect to accessibility standards. An Ontario PC government is committed to working with the AODA Alliance to address implementation and enforcement issues when it comes to these standards.

Ontario needs a clear strategy to address AODA standards and the Ontario Building Code’s accessibility provisions. We need Ontario’s design professionals, such as architects, to receive substantially improved professional training on disability and accessibility.”

We have written Premier Ford more than once to raise serious concerns about his Government’s failure to act effectively on accessibility issues such as this. He has never agreed to meet with us or to speak on the phone. He deflects all our issues and requests to the Government’s Accessibility Minister Raymond Cho. Minister Cho has never agreed to create a Built Environment Accessibility Standard under the AODA.

 6. Ford Government’s Only New Initiative on Accessibility of the Built Environment is a Wasteful Failure

Since taking office in June 2018, the only new initiative to which the Ford Government repeatedly points for disability barriers in the built environment was its controversial spring 2019 announcement that it is diverting 1.3 million dollars over two years to the Rick Hansen Foundation (RHF) to have its so called “private accessibility certification program” to look at some buildings in Ontario to decide if it would “certify” them as accessible. The AODA Alliance was never consulted on that decision.

We have strongly opposed this as a very poor use of public money. It will not help the accessibility cause.

The AODA Alliance has made public numerous concerns with the RHF “certification” process. Neither the Ford Government nor the RHF have publicly disputed the accuracy of our concerns.

For example, an RHF “certification” does not in fact certify anything. If the RHF gives a building a rating of “accessible”, it does not mean that that building is in fact accessible.

Those whom the RHF authorizes to conduct these inspections need not have the required expertise to assess a building’s accessibility. The RHF only requires an assessor to take an 8-day course. That course is far too short. Its training contents are quite deficient and problematic.

One and a half years after this Ford Government strategy was launched, there is no evidence that a single building has been thereby made accessible, or that a single barrier in the built environment was rectified. All that the Government may have accomplished is to give an inappropriate public subsidy to the RHF in its effort to break into the Ontario market, in competition with local Ontario-based accessibility consultants having far more expertise in this field.

For example, earlier this year, one could hear RHF advertisements on Toronto radio stations, promoting the RHF “certification” program. We asked the Ontario Government if these advertisements were directly or indirectly subsidized by the Ontario Government. The Government did not answer this inquiry.

It is not clear to us that the Government and RHF have found enough organizations to take up the offer of a Government-subsidized RHF appraisal. That would make sense, since the RHF assessment of their building’s accessibility is not reliable.

It would have been much more appropriate for the Government to have invested those public funds into the development and enactment of a Built Environment Accessibility Standard under the AODA, and on effectively enforcing the inadequate accessibility requirements that are already on the books.

 7. What Have the Opposition Parties Said On Point?

The Ontario NDP committed as follows on November 9, 2020 as part of its housing plan:

“We’ll mandate Universal Design building codes, which are standards that reflect the needs of people of all ages, sizes, abilities and disabilities.”

The Ontario Liberal Party has not announced a platform on this issue since the 2018 election. In her May 14, 2018 letter to the AODA Alliance setting out the Liberal Party’s disability accessibility commitments in the 2018 election, Kathleen Wynne committed to the following:

  1. “exploring and determining next steps for preventing and removing accessibility barriers in the built environment”
  1. “New and Existing Accessibility Standards

The creation of new standards is a critical element of the Ontario Liberal commitment to an accessible Ontario by 2025. We intend to continue the reviews already underway and continue the work of developing standards in the areas of health care and education. We would welcome advice from these committees on built environment issues and look forward to making the process more open and transparent to ensure all voices are heard without compromising necessary privacy and accountability measures.

Beyond ongoing work, we know that there are barriers in the province that need to be addressed through standards. Earlier this year, former Minister Tracy Machala publicly stated that the standards governing the built environment need to be strengthened to achieve our goal. That’s why she convened a summit on the subject attended by many impacted stakeholders, including the AODA Alliance. We will use the feedback gleaned from this summit and further consultation with stakeholders to determine the best path forward as we track toward the mandated review of the standard. Given the complexity of housing construction, building modification, and renovation, we will also work with builders, developers, architects, and other experts before committing to a path forward on residential housing and retrofits.

Getting to an accessible Ontario requires that we also ensure that the professionals most connected to design and construction know about accessibility. To this end, we will work with regulatory bodies, colleges, universities, and professional organizations to ensure that accessibility is included throughout the process.

Standards for AFPs differ project to project, but all Project Companies are required to comply with all legislation on AFP projects, including the AODA and accessibility requirements in the Ontario Building Code. This is the de facto minimum standard. Issues related to accessibility in AFP projects are therefore related to the content of the standards. On built environment issues specifically, that’s why we have committed to working with stakeholders toward the next review of the standard.”

“Accessibility in Education”

In its May 4, 2018 letter to the AODA Alliance setting out its election pledges on disability accessibility in the 2018 election, the Green Party of Ontario committed:

“e) Take Overdue Steps to Ensure the Accessibility of the Built Environment, Including Residential Housing

We support accessibility as an essential component of any new building project or retrofit. Training in accessible design should be a requirement across all licensing and educational institutions in Ontario, and all new building projects should meet standard accessibility requirements before approval. A strategy must be developed both to increase the supply of accessible housing within Ontario and to undertake the retrofitting of existing buildings in order for them to meet accessibility standards.”



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On Friday, August 21, 2020 at 11 AM Eastern Time, Watch “Preparing for School Re-Opening — Action Tips for Parents of Students with Disabilities” – A Virtual Town Hall Organized by the Ontario Autism Coalition and the Accessibility for Ontarians with Disabilities Act Alliance


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/

On Friday, August 21, 2020 at 11 AM Eastern Time, Watch “Preparing for School Re-Opening — Action Tips for Parents of Students with Disabilities” — A Virtual Town Hall Organized by the Ontario Autism Coalition and the Accessibility for Ontarians with Disabilities Act Alliance

August 19, 2020

Like all parents, parents of a third of a million students with disabilities in Ontario are very anxious about the re-opening of schools next month. Will their children be safe? Will their disability-related needs be accommodated?

So much remains uncertain and worrisome about school re-opening during the COVID-19 pandemic. In the face of that, the AODA Alliance and the Ontario Autism Coalition would like to offer parents some practical action tips on how to get ready for school re-opening. We don’t have all the answers, but we want to offer what we can.

On Friday, August 21, at 11 AM Eastern time, log onto the Ontario Autism Coalition’s Youtube channel at https://www.youtube.com/c/OntarioAutismCoalition/. The link to watch this one-hour virtual town hall will appear at or just before 11 AM.

This event will feature a conversation between three speakers, all experts in advocacy for students with disabilities:

  1. Laura Kirby-McIntosh. She is a high school teacher and president of the Ontario Autism Coalition. Among her many advocacy activities, last year she sat on the Ontario Government’s panel giving advice on reforming the Ontario Autism Program.
  1. David Lepofsky. He is a retired lawyer, a part-time visiting professor at the Osgoode Hall Law School, and chair of the AODA Alliance. He is also a member and past chair of the Special Education Advisory Committee of the Toronto District School Board. He is also a member of the Government-appointed K-12 Education Standards Development Committee, and a member of its COVID-19 subcommittee.
  1. Robert Lattanzio. He is a lawyer and executive director of the ARCH Disability Law Centre. He and ARCH have done extensive work providing legal advice and representation to students with disabilities and their families.

Thanks is extended to the ARCH Disability Law Centre, which is providing American Sign Language interpretation and real time captioning for this event. After the event is concluded, it will be permanently available for viewing on Youtube.

This is the third in a series of virtual town halls that the Ontario Autism Coalition and the AODA Alliance have provided to address the needs of people with disabilities during the COVID-19 crisis. Taken together, the first two virtual town halls have been viewed thousands of times.

Please spread the word about this event. Post this announcement on your social media feeds. Encourage as many as possible to log on to this virtual Town Hall.

For more background check out:

* The first OAC/ AODA Alliance virtual town hall, held on April 7, 2020 surveying the major issues facing people with disabilities during the COVID-19 crisis.

* The second OAC/AODA Alliance virtual town hall, held on May 4, 2020, exploring strategies for teaching students with disabilities during distance learning.

* The Ontario Autism Coalition web page, setting out its advocacy efforts for people with autism.

* The AODA Alliance’s COVID-19 web page, describing its advocacy efforts during the COVID-19 pandemic.

* The ARCH Disability Law Centre’s website.

If you have questions that you would like the panel to address, send them in advance to [email protected]



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On Friday, August 21, 2020 at 11 AM Eastern Time, Watch ?Preparing for School Re-Opening


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/

Action Tips for Parents of Students with Disabilities” A Virtual Town Hall Organized by the Ontario Autism Coalition and the Accessibility for Ontarians with Disabilities Act Alliance

August 19, 2020

Like all parents, parents of a third of a million students with disabilities in Ontario are very anxious about the re-opening of schools next month. Will their children be safe? Will their disability-related needs be accommodated?

So much remains uncertain and worrisome about school re-opening during the COVID-19 pandemic. In the face of that, the AODA Alliance and the Ontario Autism Coalition would like to offer parents some practical action tips on how to get ready for school re-opening. We don’t have all the answers, but we want to offer what we can.

On Friday, August 21, at 11 AM Eastern time, log onto the Ontario Autism Coalition’s Youtube channel at https://www.youtube.com/c/OntarioAutismCoalition/. The link to watch this one-hour virtual town hall will appear at or just before 11 AM.

This event will feature a conversation between three speakers, all experts in advocacy for students with disabilities:

1. Laura Kirby-McIntosh. She is a high school teacher and president of the Ontario Autism Coalition. Among her many advocacy activities, last year she sat on the Ontario Government’s panel giving advice on reforming the Ontario Autism Program.

2. David Lepofsky. He is a retired lawyer, a part-time visiting professor at the Osgoode Hall Law School, and chair of the AODA Alliance. He is also a member and past chair of the Special Education Advisory Committee of the Toronto District School Board. He is also a member of the Government-appointed K-12 Education Standards Development Committee, and a member of its COVID-19 subcommittee.

3. Robert Lattanzio. He is a lawyer and executive director of the ARCH Disability Law Centre. He and ARCH have done extensive work providing legal advice and representation to students with disabilities and their families.

Thanks is extended to the ARCH Disability Law Centre, which is providing American Sign Language interpretation and real time captioning for this event. After the event is concluded, it will be permanently available for viewing on Youtube.

This is the third in a series of virtual town halls that the Ontario Autism Coalition and the AODA Alliance have provided to address the needs of people with disabilities during the COVID-19 crisis. Taken together, the first two virtual town halls have been viewed thousands of times.

Please spread the word about this event. Post this announcement on your social media feeds. Encourage as many as possible to log on to this virtual Town Hall.

For more background check out:

* The first OAC/ AODA Alliance virtual town hall, held on April 7, 2020 surveying the major issues facing people with disabilities during the COVID-19 crisis.

* The second OAC/AODA Alliance virtual town hall, held on May 4, 2020, exploring strategies for teaching students with disabilities during distance learning.

* The Ontario Autism Coalition web page, setting out its advocacy efforts for people with autism.

* The AODA Alliance’s COVID-19 web page, describing its advocacy efforts during the COVID-19 pandemic.

* The ARCH Disability Law Centre’s website.

If you have questions that you would like the panel to address, send them in advance to [email protected]




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Log In Tuesday, April 7, 2020 from 10 to 11:30 AM Eastern Time for an Important Virtual Public Forum on What Government Must Do During the COVID-19 Crisis to Protect the Urgent Needs of Ontarians with Disabilities Convened by the AODA Alliance and the Ontario Autism Coalition


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/

SUMMARY

On Tuesday morning, April 7, 2020, from 10 to 11:30 am, please use your computer, smart phone or tablet to virtually attend the virtual public forum that the AODA Alliance and Ontario Autism Coalition are jointly organizing and hosting. We will talk to leading experts on the additional barriers and hardships that over 2.6 million Ontarians with disabilities are now facing during the COVID-19 crisis. We will offer the Government constructive ideas on what should be done in the face of these additional hardships. Hosting and moderating the discussion will be OAC President Laura Kirby-McIntosh and AODA Alliance Chair David Lepofsky.

The link to watch our public forum is https://www.youtube.com/c/OntarioAutismCoalition

We appreciate very much that the Ontario Autism Coalition will provide captioning for this event. We will announce more when we can. This event is being organized by volunteers in an incredible rush, given the rapidly changing events that are swirling around us all.

Please spread the word about our April 7, 2020 virtual public forum, by social media, email and any other way you can. Email us with ideas on what we should discuss. Tell us in advance about the barriers you are facing. Please understand that we cannot answer all those emails. However, we will do our best to cover as many of them as we can in our discussion with the panelists during this virtual public forum. Send your ideas to [email protected]

We invite the Ontario Government to assign a senior representative to take part in our public forum and to speak for a few minutes. We would welcome a chance to hear what they are doing, and to have a discussion with them. We invite all levels of government to watch our public forum and to draw on the ideas that will be shared there for emergency COVID-19 planning.

The new Twitter hashtag to use in the lead-up to this virtual public forum, during it, and afterwards is: #DisabilityUrgent

MORE DETAILS

Two weeks ago, on March 20, 2020, we released an especially-important AODA Alliance Update on the COVID-19 crisis and its impact on people with disabilities. We showed how this crisis is having a disproportionate impact on people with disabilities. We identified a number of important areas where governments need to act now, as part of its emergency planning, to address these issues. We called on governments to consult openly with people with disabilities for ideas on what to do. We offered our help.

Five days later, on March 25, 2020 we wrote Premier Ford directly with this message. We offered more specific ideas for action.

Since then, we have not heard back from the Ontario Premier, the Premier’s office, the Ministry of Health, the Ministry of Education, the Ministry of Colleges and Universities, the Ministry of Community and Social Services, or indeed, from any of the line Ontario ministries that are working on key parts of the Ontario Government’s crisis planning. We have similarly not heard back from the Federal Government.

We have had a few exchanges with the Ministry of Accessibility, where we have pressed the need for the actions we seek. We appreciate any help that that ministry can give. However, that small ministry is not responsible for direct planning and implementation in the key areas where action is needed. We have no idea to what extent, if any, they are influencing the Government’s actual plans on the front lines.

We deeply appreciate that governments at all levels are scrambling to deal with this crisis, and are working around the clock. They are dealing with some things with which they’ve never before dealt. We most certainly cut them a huge amount of slack. However, we also know that unless their emergency planning includes effective measures for the urgent needs of people with disabilities, those needs will once again too often be left behind. We also know that the maxim that government often endorse in this area is no more important than now: “Nothing about us without us!” Voices of the grassroots disability community are indispensable at this crucial time.

It is great that the Government now has American Sign Language at its recent news briefings, and that yesterday it announced emergency funding for mental health services. The Government has not told us what more it is doing or planning in this context.




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