The Worst Case: Critical Care Triage in Ontario

As the third wave continues to put more Ontarians into hospitals and ICUs, it is now conceivable that we could soon be faced with a worst-case scenario: invoking Ontario’s Critical Care Triage protocol.

Everyone in Ontario needs to understand what this means. We are all one illness or accident away from being at its mercy. The setting in which Critical Care Triage would be invoked is when there are literally not enough ICU beds, ventilators, staff, etc., to look after patients with ICU-level needs. Some will go without critical care, possibly dying when they wouldn’t have otherwise. We saw this unfold in Italy last year.

The Critical Care Triage protocol is used to decide who gets ICU care and who doesn’t. Its purpose is to minimize death, by prioritizing those most likely to live. The protocol will apply to patients who may require ICU-level care AND going to ICU is in keeping with their personal goals-of-care AND the Ontario Critical Care COVID-19 Command Centre (O5C) has invoked a level of triage required.

The current tactics being employed to avoid this include transferring patients from hospitals with saturated ICUs and wards to those with lower occupancies, cancelling elective surgeries to free up ward beds, as well as attempts to quickly expand the number of ICU beds at individual hospitals. Increasing capacity and spreading around the burden of care across the province will hopefully buy us enough time for vaccines and other public health measures to slow down new cases. If this is not enough, the protocol comes into play. Here’s how it works:

  1. O5C invokes a triage level that hospitals MUST follow (this decision is made centrally by the Ministry). At level 1, patients with a >80% risk of mortality will be deprioritized to receive critical care. At level 2, patients with a >50% risk of mortality will be deprioritized. At level 3, patients with a >30% risk of mortality will be deprioritized.
  2. Once hospitals know the level of triage from O5C, physicians will assess their patient’s eligibility for ICU. First, the patients goals-of-care and wishes will be discussed (as they are routinely during hospital admissions every day). If receiving critical care is within a patient’s goals-of-care AND their medical condition is such that they are likely to require it, their mortality risk is assessed.
  3. The patient’s most responsible physician (MRP) then uses the Short Term Mortality Risk (STMR) tool. I recommend you click the link and take a look. The STMR is based on several validated scoring systems that predict someone’s risk of dying in a particular situation. The output of the STMR is a percentage risk of dying within the next 12 months. This number is then used to determine the patient’s eligibility for ICU according to the triage level from step 1. For example, if your STMR score is 40%, you would be eligible for ICU at triage levels 1 and 2, but not 3. (It is important to note that the validated scores used to calculate the STMR were not derived to be used in aggregate for this purpose).
  4. To limit the possibility of bias, a second physician (ideally an ICU specialist), will also calculate the STMR, as there is some subjective wiggle room when using the scoring tools. Any disagreement between the two assessments will be resolved by using the lower of the two scores (i.e. the more generous estimate).
  5. If two or more patients have the same score, and there aren’t enough beds to accommodate them, a randomization process is then applied (using a random number generator) to decide who gets care and who does not. This step would be completed by an administrator so as to remove the onus and possible conflict-of-interest of the decision from the physicians who made the assessments.

Were you to become critically ill, this is how your eligibility to receive critical care would be determined. Now, I have a couple of comments.

First, the Critical Care Triage protocol, itself, is well-crafted and ethical, so long as you view it through the narrow lens of minimizing death as the main objective. It is solely based on assessment of mortality risk, using validated scoring tools. It is, I think, as objective as it can be. There are no value-judgements. It is NOT based on demographics (age, race, gender, etc.) or an assessment of how worthy one person’s life is compared to another’s. The authors have emphasized the principle of non-discrimination. However, as recently as March 2021, the Ontario Human Rights Commission is not satisfied. Inform yourself. Make your own judgement.

Next, the protocol creates two scenarios for physicians that, under ordinary circumstances, would be considered malpractice or even criminal. Some patients will have treatment withheld, without consent, that we know could save their life. Outside of Critical Care Triage, this could be negligence, depending on what is considered the standard of care at the time. The other possible scenario is withdrawing life-sustaining treatment, without consent, from one patient (where said treatment is considered futile) to free up capacity for another patient who may be more likely to benefit. This sort of withdrawal of treatment has been tested at the level of the Supreme Court and has been ruled illegal.

The College of Physicians and Surgeons of Ontario (CPSO) has offered their support for physicians to act against the CPSO’s own policies in order to carry out the Critical Care Triage protocol, if invoked by the Ministry. This is a truly incredible circumstance, one that is destined to lead to moral injury for physicians, like myself, who will be tasked with following protocols downloaded from a central authority.

You need to know about this, because it could affect you or someone you love. You need to know that it is completely unreasonable that we are currently in a situation where we are scrambling to create ICU space to avoid this worst-case scenario. This capacity could have been set up months ago. You need to know that, while the protocol itself may seem ethical, the circumstances that lead to its possible use are not. You need to know that your physicians and other health care providers will be forced into situations where we would be complicit with what we have always been told is malpractice. You need to know that all of this is the product of our democracy. You need to know that, when this is over, we have a lot of rebuilding to do. Going back to “normal” will never be good enough.

Please get vaccinated when you can. Please assess your personal risk and adhere to masking and physical distancing. Please share your views on lockdowns and other oppressive public health interventions with your MPPs. And please check in with your family, friends, neighbours just to say, “Hey, I appreciate you. We will get through this together.”

Be well.

Why lockdowns feel amoral

The government has issued another “stay-at-home order” in Ontario. In my view, it is excessive, overly restrictive, and will result in more harm than good. Today, I am mostly interested in how government imposed restrictions make us feel.

When you have an immediately intense feeling about something, positive or negative, your intuition gives you an indication of value-congruency. If you are disgusted or angry or feel dread, it’s because the subject is at odds with your values; your moral framework is being tested. This is a time to get curious. Our values need to be examined. They don’t always work in our favour. The path to well-being requires that we understand our own values and moral frameworks as we design our lives and plan our actions.

The best resource on understanding morality is Jonathan Haidt’s Moral Foundations Theory. Haidt outlines six moral foundations, or, to use his metaphor, tastebuds. Everyone has all six, but with different sensitivities, giving each of us a unique moral palette. I will now explain why lockdowns, as a policy intervention, are narrowly based on the “care/harm” foundation, while violating all others. Anyone in support of lockdowns, is literally suppressing the majority of their moral palette.

Care/Harm: This is simple. In the pandemic, people might get COVID, go to hospital, and die. Numbers are rising. This is scary. We want the harm to stop. We see no other alternatives. We feel like people will be safest at home. Therefore, lockdown. This, of course, ignores all of the untold harm that occurs from lockdowns including mental illness, abuse, loss of education, loss of jobs and businesses, not seeking medical care for non-COVID illness, etc.

Fairness: Lockdowns disproportionally adversely effect people of lower socioeconomic status and congregant living settings. They do not have big homes, big backyards, proximity to green space. This group is also more likely to work in low-paying “essential services” or precarious jobs and will continue to be exposed.

Loyalty: By locking down an entire population, there is no loyalty to be felt by any group. We are all lumped together. Regardless if you have already had COVID, are vaccinated, have to look after loved ones, are able to make your own risk assessment, you are being told it doesn’t matter. It’s easier to paint you all with the same brush. For those of us who disagree with our own colleagues about the call for lockdowns, there is also betrayal of loyalty within groups.

Authority: A very small group of people are now clearly able to dictate how millions of us may live. The decision-making of this group is being called into question. It is clear that these restrictions are not supported by a huge chunk of the population. But this does not matter. There is no democratic opportunity here. Subversion will occur.

Sanctity/Purity: The pandemic has sullied everything. Fear-based reporting and decisions by government would have us believe that nothing is clean, everyone is a potential carrier of disease. Lockdowns cement that this is the perspective of our leaders.

Liberty: It is clear that lockdowns are oppressive. Nothing more needs to be said here.

This is a brief overview, but you get the idea. Lockdowns are not good policy, especially not at this stage when vaccine supplies are increasing and additional strategies exist, including emergency expansion of hospital resources (government would have you believe this number is fixed, boggling the minds of those of us on the front lines).

My hope is that anyone reading this takes some time to think about your “gut” feeling and how it relates to your values and moral palette. Doing so will allow you to test your opinions and ensure your response is in line with what you actually care about.

Be well.

This is it. This is what we get.

In times of struggle our minds rebel. We think things should be different and lament them not meeting our expectations. We ruminate on the past, wondering why we didn’t see this coming, or at least prepare for it. We look to the future and see nothing but a bleak horizon, with little hope. We do everything we can to not pay attention to what is now. This is human nature.

It doesn’t have to be so. When faced with adversity we get to decide, for ourselves, how we respond. This is the freedom and beauty of what we can be capable of, if we allow ourselves. Sometimes all it takes is a simple reminder, “This is it.”

These three words remind us, in the moment, that this is what we get. We can let our worries and unrealistic expectations go. We really can. They are not serving us. These words remind us that, right now, no one owes us anything. But we owe it to ourselves and everyone else to do our best with what we have. 

For the health care workers, remember that you can only be in one place at a time, doing what you can for the patient in front of you. Yes, there are others, many others. You’ll get there, when you can, with the help of your dedicated brothers and sisters in care. It may not be ideal, or up to your normal standard, but this is it. You are there because of your deep love for your fellow human beings. You are the embodiment of the human condition. Stay present, practice your craft the best way you can, stay safe, we will endure this challenge before us.  

After all, this is it. This is what we get.

Be well.

You can’t control everything. That’s OK.

We all like to be in control. We wonder why people don’t see things our way. We feel it’s unfair when the world seems to be against us. The problem here is not someone or something else, it’s us. 

The stoic philosophers, like Marcus Aurelius and Epictetus, wrote about the dichotomy of control. Essentially, they direct us to focus only on things that we can control, while accepting things outside of our control as fate. 

COVID-19 is a global pandemic. Most of what’s happening is entirely out of our individual control, but the news cycle, showing death and despair, commands us to worry endlessly. This is not useful and does not help us feel well or productive. 

What each of us can control right now (and always) is our responsible action for society. Choosing to isolate ourselves, only venturing out for essential items, heeding the advice of our top health officials. This is our duty now. It’s not hard. And, although we may feel confined or frustrated, there will be a tremendous sense of meaning in our small contributions, for the good of us all.  

Be well.