'Worst case scenario' critical care triage being considered in Ontario

As COVID-19 cases hit record highs in Ontario, doctors are preparing to make life and death decisions about who will get critical care.

Elizabeth Payne 5 minute read April 11, 2021

As COVID-19 cases hit record highs in Ontario, doctors are preparing to make life and death decisions about who will get critical care.

It is a “worst case scenario” that health officials in Ontario have been preparing for, but have avoided through earlier waves of the pandemic.

This time, with the number of COVID patients in ICU beds at a record high of 542 on Friday morning and rapidly rising, there is growing concern that doctors at some hospitals will be forced to make decisions about who will get limited critical care resources, even with the majority of the most vulnerable frail elderly now vaccinated.

The provincial government is considering enacting the emergency critical care triage protocol and, this week, the College of Physicians and Surgeons of Ontario sent a letter of support to any doctors who may have to make “extraordinary decisions” about which of their patients will be offered critical care resources that are in short supply.

“This is not a theoretical discussion any longer,” said Anthony Dale, president and CEO of the Ontario Hospital Association. “There will be organizations in all probability who unfortunately have to consider using it.”

An emergency triage protocol was developed for the province early on in the pandemic by the Critical Care COVID Command Centre. The provincial government is discussing implementing the protocol, although several officials told this paper that it could be used by hospitals without provincial implementation if the situation requires it.

The protocol has been circulating in hospitals for weeks.

It is aimed at saving the most lives in the most ethical manner possible by creating a standard system to determine which patients are most likely to survive a critical illness. Every assessment, assisted with the aid of an online calculator, is to be repeated by a second physician to ensure accuracy. Human rights are explicitly protected, so that decisions are not made on the basis of sex, age, race, disability, family status, according to its drafters.

Still, the Ontario Human Rights Commission says the protocol contains “potentially discriminatory content” and should not be implemented without public input. The Human Rights Commission also wants assurances that the Health Care Consent Act remains in place where triage is concerned, meaning life-saving treatment can’t be withdrawn without consent — something requested of the government as part of the COVID-19 triage plan.

The authors of the protocol, including Dr. James Downar, head of the division of palliative care at uOttawa, wrote earlier that it would only be used in a “worst-case scenario after reasonable efforts to expand capacity and redistribute resources are exhausted”.

Those efforts are being made now.

On Friday, two days after implementing a stay-at-home order, the province ordered hospitals to stop elective surgeries beginning next week to preserve capacity and staff “in anticipation of an even larger wave of COVID-19 patients coming into intensive care units,” said Dale. Pediatric hospitals and those in the North are exempted.

Hospitals in Ottawa had already slowed non urgent surgeries beginning this week, but the provincial directive goes further bringing all-but-lifesaving surgeries to a temporary halt — the first time this has happened since the first wave of the pandemic.

Late Friday, the government issued two new emergency orders  — effective immediately — to address the capacity crunch many hospitals are facing. Ontario will allow hospitals to transfer patients without their consent and redeploy home-care workers to the facilities as the number of COVID-19 patients in intensive care units hits new highs.

Health Minister Christine Elliott said the third wave had pushed the province’s hospitals to their limits and the government had to act.

“We are taking the steps using these tools in order to get to the point where, as more patients come into hospital with COVID, we will be able to safely care for them,” she said in an interview.

Ontario set new records Friday for both daily cases and the number of COVID-19 patients in intensive care.

Elliott said the province knew it had to go “a step further” in light of the latest data.

The province has been transferring patients between hospitals for months to accommodate a growing number of COVID-19 cases, but those transfers were done with the patient’s permission.

The province will also be able to redeploy dozens of workers from home-care organizations and Ontario Health – the body that oversees the health system – to hospitals during a surge.

Both orders, which will be in effect for at least two weeks, come as Ontario hospitals prepare to start ramping down elective surgeries and non-urgent procedures next week to ensure they have the capacity to treat COVID-19 patients.

Elliott said the orders and the ramping down of elective surgeries could increase ICU capacity by up to 1,000 patient beds.

Many hospitals in the province, including those in Ottawa, were over capacity with a wide range of patients as the third wave began.

There are ongoing talks in Ottawa about moving patients to smaller hospitals in the region to open up space for critically ill patients.

Dale said he hopes the stay-at-home order and the hold on surgeries will give hospitals enough breathing room to deal with growing numbers of younger, sicker patients severely ill in a pandemic that is now driven by more dangerous variants.

But many doctors are preparing themselves to have to make difficult decisions.

“These are extraordinary times. We potentially all might end up out of our comfort zones,” said Perth emergency physician Dr. Alan Drummond, who is chair of public affairs for the Canadian Association of Emergency Physicians.

“I think it is important that we as physicians accept that this is maybe where we are going and to have candid conversations with our patients about what we may be facing.”

Dale called the current situation the “biggest crisis in Ontario’s modern hospital history,” saying postponing surgeries will add to the current backlog of 250,000 surgeries as hospitals try to weather the crisis.

“I don’t think people realize what is about to happen here. You don’t just close down all surgical activity unless you have a powerful reason and I assure you this is extraordinarily serious.”

He added: “The system will mobilize as it always does and will make every effort to provide equitable access to critical care, and other lifesaving care. It will do everything it can.”


— With flies from The Canadian Press