Baranyai: Triage framework should be debated as COVID’s third wave rises
Author of the article: Robin Baranyai
Baranyai: Triage framework should be debated as COVID’s third wave rises | London Free Press (lfpress.com)
Under normal circumstances, patient triage is about identifying who should be treated first: who needs resuscitation, and who can wait to have their broken wrist set. It is not a question of whether the patient receives the care they need, but when.
Last March, that assumption was turned on its head. The world watched in horror as Italy’s well-regarded health-care system, with 3.2 hospital beds per 1,000 people (compared to 2.5 in Canada), was overwhelmed.
Faced with too many patients and too few ventilators, doctors were forced to decide on the fly where scant resources should be allocated. All too often, it came down to the patient’s age.
Canadians hope to avoid these unthinkable choices. As they say: Hope for the best, but plan for the worst.
Concerns again were raised this week about Ontario’s emergency standard of care, designed to provide consistent medical guidance on decisions — should they become necessary — about who receives care, by prioritizing resources for the patients most likely to survive. The protocol includes an online risk calculator for short-term mortality.
The protocol has been shared with Ontario hospitals, though not approved by the Ministry of Health, nor officially made public. The ministry has deflected queries to Jennifer Gibson, director of the University of Toronto’s joint centre for bioethics, and co-chair of the government’s bioethics table, which developed the triage framework.
It’s not shocking there is a protocol for making life-or-death care decisions, should hospital resources be overwhelmed. It would be shocking if there were not.
It is concerning, however, that an updated version of the protocol was brought to light by a disability advocacy group, and not by an open process of consultation, as recommended by both the bioethics table and the Ontario Human Rights Commission.
Under the protocol, two physicians would be involved in treatment decisions. The online tool allows doctors to input data on the severity of comorbid conditions, such as cancer, to help estimate patients’ odds of survival. Those with the best chance of surviving 12 months would be given priority for ICU beds.
The use of a clinical frailty scale (CFS) in risk calculations was flagged by the Accessibility for Ontarians with Disabilities Act (AODA) Alliance. It measures the ability to perform everyday tasks in patients older than 65. While a CFS may reduce the subjectivity of assessments, the AODA Alliance rightly points out, difficulty people with disabilities have with everyday tasks may have nothing to do with their odds of survival.
Similar concerns were raised by disability advocates in Quebec. An expert working group developed an emergency protocol last March, and the province held open consultations. The emergency protocol was revised after hearing from advocacy groups, including the Quebec Intellectual Disability Society.
Quebec’s protocol goes further than Ontario’s, establishing criteria by which patients could be removed from life support, if needed, without their consent. As yet, there is no mechanism in Ontario to prioritize treatment of patients with a higher likelihood of survival over those on life support.
This is deeply uncomfortable territory. It forces us to think about choices we’d rather not make, or have made for us. But if we want continued confidence in our health-care system, people need to know how these decisions could be made.
The hard choices of “battlefield medicine” may not be theoretical for long. At the height of the second wave in January, the number of COVID-19 patients in Ontario ICUs peaked at 420. As of Monday, there were 390.
The battle here is not only between patient care and system capacity. It is between communication and opacity; transparency and uncertainty. Transparency builds confidence.