Introduction

Webcast Archive: Ontario Triage Protocol

This week: we look at Ontario’s triage protocol using a disability discrimination lens, and announce the federal government’s COVID-19 disability advisory group.

Webcast Archive: Ontario Triage Protocol

During the COVID-19 pandemic, we will not present our webcast, due to technical problems caused by heavy internet usage. However we are providing the text as a bulletin to offer up-to-date information about assisted suicide, euthanasia and ending-of-life practices for the disability community.

ONTARIO TRIAGE PROTOCOL

 

  • Governments and health care facilities are coming up with policies for distributing scarce resources during the COVID-19 pandemic.  Even if they don’t say “disabled people are better off dead” many of these policies discriminate against disabled people in less obvious ways.  Disability rights activists have made an evaluation tool which includes six questions to identify policies that discriminate against people with disabilities.  Today we’ll try out the evaluation tool on the Ontario Clinical Triage Protocol to see how it scores on disability discrimination. 
  • The team that wrote the Ontario policy was led by Dr. James Downar, a strong supporter of assisted suicide and euthanasia (AS & E).  Given that background, it’s not surprising that disability rights activists have already criticized the protocol.  In an open letter to Ontario premier Doug Ford and other government officials signed by more than 200 disability groups, activists pointed out that the protocol would exclude people with cognitive disabilities and degenerative diseases from receiving life-saving care if there were a shortage of beds, staff or equipment. The letter says the “protocol must clearly state that clinical judgment must not be informed by bias, stereotypes, or ableism,” and that disabled people should not be given lower priority “based on the supports they receive for daily living.” 
  • The principles that guide the Ontario Triage protocol are:

 

      • Utility: gaining the maximum benefit by giving resources to those who will gain the most benefit (people who are most likely to recover).
      • Proportionality:  the protocol should not have a negative effect on more people than using a “first come, first served” approach.
      • Fairness: “Clinically-relevant criteria should be used first and foremost” (meaning whether a person is likely to  recover from the disease). “Priority should not be given to anyone on the basis of socioeconomic privilege, or political rank.”

 

  • The Ontario protocol describes who would be denied intensive care should shortages become severe, in three stages, depending on how bad the shortage is: 

 

      • A Level 1 shortage would exclude the smallest number of people, those whose chance of dying is more than 80%;
      • A Level 2 shortage would exclude more people, those whose chance of dying is more than 50%;
      • A Level 3 shortage would exclude the largest number of people, those whose chance of dying is over 30%.
  • The exclusion criteria look at whether the person is likely to die from the immediate illness, and whether they have a chance of surviving in the long term (more than a few months). 
  • The guiding principles for avoiding disability discrimination written by disabled activists stand in sharp contrast to the Ontario protocol. 
    • “The lives of people with disabilities are equally worthy and valuable as those of people without disabilities.
    • “People with disabilities must have an equal opportunity to receive life-sustaining treatment.
    • “The fact that an individual with a disability requires support (minimal or extensive) to perform certain activities of daily living is not relevant to a medical analysis of whether that individual can respond to treatment.
    • “Doctors and triage teams must [not make assumptions and use stereotypes] about the worth or quality of the life of a person with a disability in making decisions about medical treatment.
    • “Doctors and triage teams must not assume that they are free from … bias in making critical life and death health care decisions.  … People with disabilities have long experienced discrimination in receiving medical care.
    • “To avoid discrimination, doctors or triage teams must perform a thorough … review of each patient and not assume that any specific diagnosis [can reliably give a] prognosis or [predict] … survival without an analysis of current and best available objective medical evidence and the individual’s ability to respond to treatment.
    • “Doctors and triage teams must not reallocate [give to other people] ventilators of individuals with disabilities who use them in their daily lives.“

Applying the discrimination evaluation tool to the Ontario protocol

  • Does the plan exclude people based on their diagnosis or functional limitation?
    • As noted above, the Ontario protocol mentions specific disabilities, such as cognitive impairments, Parkinson disease, ALS, and cystic fibrosis.  The protocol also refers to “metastatic malignant disease” and “advanced and irreversible immunocompromise” which appears to be another way of saying cancer and AIDS. 
  • Does the plan include quality of life assessments as an allocation criteria?
    • The protocol takes a clinical, neutral tone and does not include phrases like “quality of life.” The tenth exclusion criterion (J) uses scores from the Clinical Frailty Scale, which describes “the fitness or frailty of an older adult” including the person’s ability to perform activities of daily living.  This could be seen as a measure of quality of life, and is directly related to age and disability.
  • Does the plan include long-term survival beyond the acute care episode as an allocation criteria?
    • Yes.  Exclusion criterion 13 (M) is a rating of the person’s “chance of mortality due to their critical illness, or in the near future regardless of their critical illness.”
  • Does the plan permit allocation or re-allocation [of resources] on the basis of anticipated or documented duration of need?
    • Exclusion criterion 9 (L) refers to people who have used a ventilator for at least 14 days who have high “ProVent” scores.  Usually, the ProVent score is calculated based on 21 days of vent usage.  It’s also worth noting that half of the six points in the ProVent score are signs of illness (one each for a low platelet count, and needing vasopressors and dialysis).  The rest relate to the person’s age.  
  • Where the plan incorporates short-term survival probabilities, does it do so in an individualized fashion consistent with available standards of evidence?
    • “In order to be admitted to an ICU bed, a patient must meet one of the inclusion criteria, and must not meet any of the exclusion criteria.” There are two inclusion criteria, related to breathing problems and other symptoms. There are 13 exclusion criteria, described on pages 4-6 of the protocol.
    • The protocol suggests that “clinical judgment” could expand the number of people excluded “as some conditions not listed may also denote a poor prognosis.” Two doctors must agree on the assessment, which is sent for review by the hospital’s triage oversight committee.  This group “should at least include a physician, an ethicist, and a representative from the hospital administration responsible for allocating beds.” 
  • Are there “special” provisions for people who use ventilators? 
    • The protocol does not mention taking ventilators from people who use them daily and “re-allocating” them to others.
  • A couple of other items to note:
    • There are two points in the step-by-step “Triage algorithm” process where the person is asked if they want to do without life-saving care.
    • “If the patient indicates a preference to receive life-sustaining measures in the event of a deterioration, but the [Most Responsible Physician] feels that this is not appropriate given the patient’s medical condition, they should attempt to resolve this discordance as they normally would.”  The protocol doesn’t say how that is supposed to happen.

FEDERAL COVID-19 DISABILITY ADVISORY GROUP

  • The Honourable Carla Qualtrough, Minister of Disability Inclusion has established a disability advisory group on Canada’s “Disability-Inclusive approach” to the COVID-19 pandemic. One member of that advisory group is Dr. Heidi Janz, chair of the Council of Canadians with Disabilities’ Ending-of-life Ethics Committee.
  • The group will “provide advice on the real-time lived experiences of persons with disabilities during this crisis” and will focus on “equality of access to health care and supports; access to information and communications, mental health and social isolation; and employment and income supports,” among others.