{"id":4839,"date":"2020-04-17T13:40:33","date_gmt":"2020-04-17T13:40:33","guid":{"rendered":"https:\/\/tvndy.ca\/?p=4839"},"modified":"2020-11-16T11:27:17","modified_gmt":"2020-11-16T16:27:17","slug":"webcast-archive-ontario-triage-protocol","status":"publish","type":"post","link":"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-ontario-triage-protocol\/","title":{"rendered":"Webcast Archive: Ontario Triage Protocol"},"content":{"rendered":"<p>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.<\/p>\n<p><b>ONTARIO TRIAGE PROTOCOL<\/b><\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li><b><span style=\"font-weight: 400;\">Governments and health care facilities are coming up with policies for distributing scarce resources during the COVID-19 pandemic.\u00a0 Even if they don\u2019t say \u201cdisabled people are better off dead\u201d many of these policies discriminate against disabled people in less obvious ways.\u00a0 Disability rights activists have made an <\/span><a href=\"https:\/\/autisticadvocacy.org\/wp-content\/uploads\/2020\/04\/Evaluation-framework-for-crisis-standards-of-care-plans-4.9.20-final.pdf\"><span style=\"font-weight: 400;\">evaluation tool<\/span><\/a><span style=\"font-weight: 400;\"> which includes six questions to identify policies that discriminate against people with disabilities.\u00a0 Today we\u2019ll try out the evaluation tool on the Ontario <\/span><a href=\"https:\/\/www.nosm.ca\/wp-content\/uploads\/2020\/03\/CLINICAL-TRIAGE-PROTOCHOL-MAJOR-SURGE-COVID-19-PANDEMIC-Ontario-Health-March-28-2020.pdf\"><span style=\"font-weight: 400;\">Clinical Triage Protocol<\/span><\/a><span style=\"font-weight: 400;\"> to see how it scores on disability discrimination.\u00a0<\/span><\/b><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-weight: 400;\">The team that wrote the Ontario policy was led by Dr. James Downar, a strong supporter of assisted suicide and euthanasia (AS &amp; E).\u00a0 Given that background, it\u2019s not surprising that disability rights activists have already <\/span><a href=\"https:\/\/archdisabilitylaw.ca\/wp-content\/uploads\/2020\/04\/April-8-2020-Open-Letter-Ontarios-COVID-19-Triage-Protocol-PDF.pdf\"><span style=\"font-weight: 400;\">criticized<\/span><\/a><span style=\"font-weight: 400;\"> the protocol.\u00a0 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 \u201cprotocol must clearly state that clinical judgment must not be informed by bias, stereotypes, or ableism,\u201d and that disabled people should not be given lower priority \u201cbased on the supports they receive for daily living.\u201d\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-weight: 400;\">The principles that guide the Ontario Triage protocol are:<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"font-weight: 400;\"><b>Utility<\/b><span style=\"font-weight: 400;\">: gaining the maximum benefit by giving resources to those who will gain the most benefit (people who are most likely to recover).<\/span><\/li>\n<li style=\"font-weight: 400;\"><b>Proportionality:<\/b><span style=\"font-weight: 400;\">\u00a0 the protocol should not have a negative effect on more people than using a \u201cfirst come, first served\u201d approach.<\/span><\/li>\n<li style=\"font-weight: 400;\"><b>Fairness:<\/b><span style=\"font-weight: 400;\"> \u201cClinically-relevant criteria should be used first and foremost\u201d (meaning whether a person is likely to\u00a0 recover from the disease). \u201cPriority should not be given to anyone on the basis of socioeconomic privilege, or political rank.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><b><span style=\"font-weight: 400;\">The Ontario protocol describes who would be denied intensive care should shortages become severe, in three stages, depending on how bad the shortage is:\u00a0<\/span><\/b><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A Level 1 shortage would exclude the smallest number of people, those whose chance of dying is more than 80%;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A Level 2 shortage would exclude more people, those whose chance of dying is more than 50%;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A Level 3 shortage would exclude the largest number of people, those whose chance of dying is over 30%.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><b><span style=\"font-weight: 400;\">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).\u00a0<\/span><\/b><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The <\/span><a href=\"http:\/\/thearc.org\/wp-content\/uploads\/2020\/04\/Guidance-to-States-Hospitals_FINAL.pdf\"><span style=\"font-weight: 400;\">guiding principles<\/span><\/a><span style=\"font-weight: 400;\"> for avoiding disability discrimination written by disabled activists stand in sharp contrast to the Ontario protocol.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cThe lives of people with disabilities are equally worthy and valuable as those of people without disabilities.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cPeople with disabilities must have an equal opportunity to receive life-sustaining treatment.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cThe 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.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cDoctors 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.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cDoctors and triage teams must not assume that they are free from &#8230; bias in making critical life and death health care decisions.\u00a0 \u2026 People with disabilities have long experienced discrimination in receiving medical care.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cTo avoid discrimination, doctors or triage teams must perform a thorough &#8230; review of each patient and not assume that any specific diagnosis [can reliably give a] prognosis or [predict] &#8230; survival without an analysis of current and best available objective medical evidence and the individual\u2019s ability to respond to treatment.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cDoctors and triage teams must not reallocate [give to other people] ventilators of individuals with disabilities who use them in their daily lives.\u201c<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><b>Applying the discrimination evaluation tool to the Ontario protocol<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Does the plan exclude people based on their diagnosis or functional limitation?<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">As noted above, the Ontario protocol mentions specific disabilities, such as cognitive impairments, Parkinson disease, ALS, and cystic fibrosis.\u00a0 The protocol also refers to \u201cmetastatic malignant disease\u201d and \u201cadvanced and irreversible immunocompromise\u201d which appears to be another way of saying cancer and AIDS.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Does the plan include quality of life assessments as an allocation criteria?<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The protocol takes a clinical, neutral tone and does not include phrases like \u201cquality of life.\u201d The tenth exclusion criterion (J) uses scores from the <\/span><a href=\"https:\/\/www.dal.ca\/sites\/gmr\/our-tools\/clinical-frailty-scale.html\"><span style=\"font-weight: 400;\">Clinical Frailty Scale<\/span><\/a><span style=\"font-weight: 400;\">, which describes \u201cthe fitness or frailty of an older adult\u201d including the person\u2019s ability to perform activities of daily living.\u00a0 This could be seen as a measure of quality of life, and is directly related to age and disability.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Does the plan include long-term survival beyond the acute care episode as an allocation criteria?<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Yes.\u00a0 Exclusion criterion 13 (M) is a rating of the person\u2019s \u201cchance of mortality due to their critical illness, or in the near future regardless of their critical illness.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Does the plan permit allocation or re-allocation [of resources] on the basis of anticipated or documented duration of need?<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Exclusion criterion 9 (L) refers to people who have used a ventilator for at least 14 days who have high \u201c<\/span><a href=\"https:\/\/www.criticalcareontario.ca\/EN\/Toolbox\/Toolkits\/Long-Term%20Mechanical%20Ventilation%20Toolkit%20for%20Adult%20Acute%20Care%20Providers.pdf\"><span style=\"font-weight: 400;\">ProVent<\/span><\/a><span style=\"font-weight: 400;\">\u201d scores.\u00a0 Usually, the ProVent score is calculated based on 21 days of vent usage.\u00a0 It\u2019s 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).\u00a0 The rest relate to the person\u2019s age.\u00a0\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Where the plan incorporates short-term survival probabilities, does it do so in an individualized fashion consistent with available standards of evidence?<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cIn 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.\u201d 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.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The protocol suggests that \u201cclinical judgment\u201d could expand the number of people excluded \u201cas some conditions not listed may also denote a poor prognosis.\u201d Two doctors must agree on the assessment, which is sent for review by the hospital\u2019s triage oversight committee.\u00a0 This group \u201cshould at least include a physician, an ethicist, and a representative from the hospital administration responsible for allocating beds.\u201d\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Are there \u201cspecial\u201d provisions for people who use ventilators?\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The protocol does not mention taking ventilators from people who use them daily and \u201cre-allocating\u201d them to others.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A couple of other items to note:<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">There are two points in the step-by-step \u201cTriage algorithm\u201d process where the person is asked if they want to do without life-saving care.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cIf 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\u2019s medical condition, they should attempt to resolve this discordance as they normally would.\u201d\u00a0 The protocol doesn\u2019t say how that is supposed to happen.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><b>FEDERAL COVID-19 DISABILITY ADVISORY GROUP<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Honourable Carla Qualtrough, Minister of Disability Inclusion has established a disability <\/span><a href=\"https:\/\/www.canada.ca\/en\/employment-social-development\/news\/2020\/04\/statement-by-minister-qualtrough-on-canadas-disability-inclusive-approach-to-its-covid-19-pandemic-response.html?fbclid=IwAR2nfNHaVMAXpefWfG7STG_o3q3XPDvO1AOLmOEtxB6h-K38JWByWujb4yE\"><span style=\"font-weight: 400;\">advisory group<\/span><\/a><span style=\"font-weight: 400;\"> on Canada\u2019s \u201cDisability-Inclusive approach\u201d to the COVID-19 pandemic. One member of that advisory group is Dr. Heidi Janz, chair of the Council of Canadians with Disabilities\u2019 Ending-of-life Ethics Committee.<\/span><\/li>\n<li style=\"font-weight: 400;\">The group will \u201cprovide advice on the real-time lived experiences of persons with disabilities during this crisis\u201d and will focus on \u201cequality of access to health care and supports; access to information and communications, mental health and social isolation; and employment and income supports,\u201d among others.<\/li>\n<\/ul>\n   ","protected":false},"excerpt":{"rendered":"<div class=\"entry-summary\">\n<div class=\"entry-summary\">\nThis week: we look at Ontario&#8217;s triage protocol using a disability discrimination lens, and announce the federal government&#8217;s COVID-19 disability advisory group.\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-ontario-triage-protocol\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast Archive: Ontario Triage Protocol&rdquo;<\/span>&hellip;<\/a><\/div>\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-ontario-triage-protocol\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast Archive: Ontario Triage Protocol&rdquo;<\/span>&hellip;<\/a><\/div>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[92],"tags":[776,923,731,99,94,727,62,770,101,468,156,724,373],"class_list":["post-4839","post","type-post","status-publish","format-standard","hentry","category-webcast-archive","tag-covid","tag-end-of-life-en-2","tag-hospice","tag-medical-aid-in-dying","tag-medical-assistance-in-dying","tag-nursing-home","tag-palliative-care","tag-rationing","tag-suicide","tag-terminal","tag-triage","tag-ventilator","tag-vulnerable","entry"],"_links":{"self":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4839","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/comments?post=4839"}],"version-history":[{"count":3,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4839\/revisions"}],"predecessor-version":[{"id":4844,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4839\/revisions\/4844"}],"wp:attachment":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/media?parent=4839"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/categories?post=4839"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/tags?post=4839"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}