Introduction

Webcast archive: Québec’s triage protocol

This week we track down Québec's elusive triage protocol, uncover the hidden "exclusion criteria" and reveal its discriminatory provisions.

Webcast archive: Québec’s 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.

QUÉBEC’S TRIAGE PROTOCOL

  • On April 17 and April 24, we reviewed Ontario’s Triage Protocol and the Canadian Medical Association’s Framework for Ethical Decision Making. These documents provide standards and procedures for medical staff to follow during the COVID-19 pandemic if there is not enough life-saving equipment, staff, beds, or other resources to meet the demand.  Since then we’ve pointed out that the provinces haven’t activated these protocols because many elders and disabled people who would need ventilators or intensive care services to recover from the virus are never transferred to hospitals to get those services, and are simply left to die in nursing homes or other institutions. 
  • Back in April, we saw references to a triage protocol in Québec, but we were unable to get a copy for review. Last week we learned of a project launched by the Québec Intellectual Disability Society called Triage.Québec.  Their website:
    • posts the protocol online; 
    • provides a plain language summary
    • fills in important information that’s missing in the version on the website of the Collège des Médecins du Québec; and  
    • Includes a petition demanding that the protocol be changed to remove sections that discriminate on the basis of age and disability.
  • Québec’s protocol begins with general statements about its purpose and application.
    • The triage rules apply to all people needing intensive care, whether or not they have COVID-19.
    • The guiding principles are similar to those we saw in the Ontario protocol, and include such lofty ideas as maximizing benefits, treating everyone fairly, respecting individual freedom, protecting against prejudice, and solidarity.
    • The triage criteria must be simple enough to be evaluated at the bedside, taking into account the available staff and rapidly changing conditions. The triage system should protect medical professionals by creating a uniform decision-making process and giving the most difficult choices to an independent team of triage experts. 
    • In order to be transparent and trustworthy, the “criteria must be widely available, clearly documented and accompanied by procedures ensuring accountability.”
  • Not only is the document hard to find, but essential information is missing.
    • The protocol states “the triage process for adults … is based on a set of clinical and additional criteria described in the evaluation form in Appendix B.” But appendix B contains only a blank page under the heading “Appendix B: Intensive Care Triage Form for Adults in a Pandemic Situation.”  
    • The protocol presents a flow chart (p. 7) that relies heavily on “inclusion criteria” and “exclusion criteria,” but without listing the criteria themselves.
    • Fortunately, the Triage.Québec site provides a link to the missing document
  • To be eligible for intensive care, a person must need invasive breathing assistance or have very low blood pressure (“inclusion criteria”). The protocol recognizes three stages of emergency, depending on how overburdened the hospital system is.  In a stage 1 emergency, the protocol would deny intensive care only to people with a very high probability of dying (≥80%). In a level 2 situation, people with a better than even chance of dying would be excluded.  At stage 3, only the 30% with the best chance of surviving would get access to intensive care resources. 
  • The Protocol sets forth 12 exclusion criteria. According to the Ministry of health and social services, people who meet any of these criteria are unlikely to recover from an acute illness or to survive more than a few months. “To be eligible for intensive care, the person must not meet ANY of the following criteria.” The conditions are: 
    • Injury or trauma (as measured by the Trauma Injury Severity Score); 
    • Serious burns (with two aggravating factors); 
    • Cardiac arrest; 
    • Severe cognitive impairment due to a progressive conditioninability to independently perform activities of daily living and domestic chores;
    • Advanced and irreversible neuromuscular disease (such as Parkinson’s, amyotrophic lateral sclerosis (ALS)); 
    • Cancer;
    • Brain injury or stroke;
    • Severe organ failure;
    • Loss of functional capacity according to the Clinical Frailty Score;
    • Palliative surgery; 
    • Long-term users of mechanical breathing assistance; 
    • Other clinical judgment.
  • The Triage.Québec website describes the impact of the protocol on autistics, and people with cognitive disabilities and other specific diagnoses.  As well, the Evaluation Framework for crisis plans produced by U.S. disability rights groups in April, shows how Québec’s protocol may be discriminatory. 
    • The protocol includes categorical exclusions on the basis of diagnosis and functional impairment. Referring to specific conditions (Parkinson’s, ALS) works against the physician’s duty to do an individual assessment of each person’s ability to recover from the illness. 
    • The disability activists also caution against using “broad functional impairments,” like a “total inability to perform activities of daily living independently” or a high score on the Clinical Frailty Scale.  Whether a person with a cognitive disability can independently do activities of daily living is unrelated to their ability to recover from an illness. 
    • On the plus side, the Québec protocol does not use quality of life assessments.  However it does use long-term survival as an eligibility criteria for access to intensive care, which opens the door to discrimination. A flexible system for figuring survival potential for a disabled person, such as by allowing additional time on a respirator as a reasonable accommodation, isn’t provided for in the protocol.
    • Also, the protocol excludes people who use any kind of breathing machine long-term, such as people with neuromuscular conditions, or even those with sleep apnea.  
  • The triage protocol was created without the input of elders and people with disabilities, who will be most affected by its harmful provisions. Perhaps this is why the Ministry of health and social services has made it difficult for the public to find the document, omits the crucial details (the “exclusion criteria”) and claims the protocol will never be put into effect. Such actions are not consistent with the “transparency and accountability,” called for in the statement of principles, but they are consistent with the policies of the province of Québec.
  • This week, Québec marked the 5,000th death due to COVID-19, 85% of those people lived in institutions. Yet the province clings to the dangerous and obsolete system of warehousing people in nursing homes, rather than giving them funds to pay attendants they choose to help them in their own homes.