It’s a scenario doctors never thought they would have to face and are still desperately trying to avoid.
But there is now planning underway in Quebec and Ontario to prepare for the possibility hospitals may have to make a choice between who gets access to critical care beds when the demand for space exceeds capacity.
“It is contrary to everything that any physician I imagine has ever been taught, certainly that I was ever taught,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre (MUHC).
“Our teaching has always been that our contract … is with the patient in front of us, regardless of what his or her cost will be to the system.”
Quebec is hoping to avoid having to use a triage protocol that would help doctors determine which patients receive care. Such a protocol would be enacted only if the demand for ICU beds across the province is 200 per cent beyond normal capacity.
Like many institutions, Goldberg said the MUHC has already scaled back surgeries and other health-care services in an attempt to avoid being stretched too far.
Staff at Montreal’s Royal Victoria Hospital and Montreal General Hospital will soon begin what Goldberg called “dry runs,” in which a group of three staff will decide if a patient is best suited to receive critical care, or if the bed should be left for someone with a better chance of survival.
“I’m told this happens on the battlefield all the time, but I never saw our medical system as a battlefield,” he said. “And I guess that’s what some of us need to change our perspective on.”
Guidelines to avoid ethical minefields
Quebec developed its own framework after the pandemic struck last March, in consultation with a working group of more than 40 experts, including intensive-care specialists, emergency physicians, nurses, lawyers, ethicists and patients.
The protocol, entitled Prioritization for Access to Intensive Care (Adults) in Context of Extreme Pandemic, totals 63 pages and lays out the criteria that must be considered.
Broadly speaking, doctors are advised to prioritize patients most likely to survive an intensive care hospitalization.
Each patient is assessed based on the medical issues that would likely prevent them from being successfully weaned off a ventilator.
The protocol was revised this summer, after disability advocates raised concerns the criteria was discriminatory. It stipulated, for instance, that those with an advanced and irreversible neuromuscular disease, such as Parkinson’s, would also not be entitled to intensive care in the event there was a shortage of resources.
Ontario, which also risks being overwhelmed with COVID-19 hospital patients, sent out a memo to ICU doctors on Wednesday to prepare to implement triage protocol if necessary.
“I’ve never been in that position before, I didn’t train for that,” said Michael Warner, the medical director of critical care at Toronto’s Michael Garron Hospital. “And that’s the position we may be in, in a matter of weeks.”
The goal for both provinces is to avoid a situation like the one that played out in Italy in the spring, where doctors had to withhold care and equipment in some cases based solely on the age of a patient.
“That was just a crisis situation, with no time to think and no protocol,” Vardit Ravitsky, a bioethicist at the School of Public Health at Université de Montréal.
“That is obviously tragic, but also ethically unacceptable, because age in itself is not a way of telling what your chance of survival is.”
Ravitsky said having a protocol allows doctors to avoid having to make an excruciating decision on their own in the midst of a crisis. It also serves as a safeguard against any form of discrimination, whether intentional or not.
“If two patients arrive and we really run out of beds, and we’ve done everything else that we can to try and move people around, but really at the end of the road, this committee will look at the medical records, medical files and start the clinical evaluation,” she said.
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“Otherwise, you go on to the other criteria, age and health-care provider status,” Ravitsky said, adding that once the decision is made, it would be communicated to the treating physician and the medical team.
She stressed that the treating physician wouldn’t be on the committee, given the difficulty they would have remaining neutral.
“These decisions are heart wrenching and possibly traumatizing for all involved, not just for the family, but for the medical team as well.”
Care risks being compromised before threshold
The latest projections from Quebec’s health research institute, the INESSS, suggest hospitalizations have stabilized somewhat after rising for more than a month.
The institute says Montreal is still at risk of being beyond capacity within three weeks — though it remains a long way from the 200 per cent beyond capacity in intensive care that would trigger the use of a triage protocol.
Still, patient care risks being compromised well below that threshold, in the view of Dr. Paul Warshawsky, the director of adult critical care at Montreal’s Jewish General Hospital.
New York City has one of the most robust health-care systems in the world, said Warshawsky, but patients with COVID-19 only had a 15 per cent chance of survival if they were admitted to the ICU during the first wave.
“The only plausible explanation for that is because the hospitals were completely over capacity,” he said.
Doctors, nurses and respiratory therapists were stretched too thin, and that increased patient mortality.
Although Quebec is far from the levels of COVID-19 New York had, many Montreal-area hospitals are over capacity or inching toward it.
Ordinarily, the JGH’s ICU has 27 beds, but it’s currently caring for 35 patients, half of whom have COVID-19. At the MUHC, there are 56 patients in 61 ICU beds.
Every day, Warshawsky said they evaluate if they can open up more beds with the staffing they have, and he’s already asked his team to avoid assigning non-essential tasks to nurses.
Many COVID-19 patients develop diabetes and require tight control of their blood sugars. But with the pressure on hospitals to continue opening beds, Warshawsky said it now may make more sense to have that nurse care for an extra patient rather than closely monitoring blood sugar levels.
“That has an impact, that’s triage,” he said. “That means that I’m saying I am going to provide a little bit less good care to all these patients and tolerate things I wouldn’t tolerate in ordinary circumstances to be able to try and provide as much care as possible to a larger number of patients.”
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If hospitalizations continue to increase, the province may have no other choice but to enact the protocol and prioritize patients who have the best chance of survival.
Although there are parts of the protocol he admits he isn’t thrilled with, Warshawsky said having a protocol is essential, as the guidelines make sure everyone is following the same criteria so it’s fair and equitable.
“I want to say, for the record, we don’t kill patients. And I really take exception to that term,” he said. “We decide who we’re going to care for and who we’re going to withdraw care from. It’s not us killing the patient, it’s the disease killing the patient.”