{"id":4947,"date":"2020-06-12T18:43:41","date_gmt":"2020-06-12T18:43:41","guid":{"rendered":"https:\/\/tvndy.ca\/?p=4895"},"modified":"2020-11-16T11:27:10","modified_gmt":"2020-11-16T16:27:10","slug":"webcast-archive-quebecs-triage-protocol","status":"publish","type":"post","link":"https:\/\/tvndy.ca\/en\/2020\/06\/webcast-archive-quebecs-triage-protocol\/","title":{"rendered":"Webcast archive: Qu\u00e9bec\u2019s 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>QU\u00c9BEC\u2019S TRIAGE PROTOCOL<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">On <\/span><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-ontario-triage-protocol\/\"><span style=\"font-weight: 400;\">April 17<\/span><\/a><span style=\"font-weight: 400;\"> and <\/span><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-cma-framework-for-ethical-decision-making\/\"><span style=\"font-weight: 400;\">April 24<\/span><\/a><span style=\"font-weight: 400;\">, we reviewed Ontario\u2019s Triage Protocol and the Canadian Medical Association\u2019s 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.\u00a0 Since then we\u2019ve pointed out that the provinces haven\u2019t 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.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Back in April, we saw references to a triage protocol in Qu\u00e9bec, but we were unable to get a copy for review. Last week we learned of a project launched by the <\/span><a href=\"https:\/\/www.sqdi.ca\/en\/\"><span style=\"font-weight: 400;\">Qu\u00e9bec Intellectual Disability Society<\/span><\/a><span style=\"font-weight: 400;\"> called <\/span><a href=\"https:\/\/triage.quebec\/en\/home-english\/\"><span style=\"font-weight: 400;\">Triage.Qu\u00e9bec<\/span><\/a><span style=\"font-weight: 400;\">.\u00a0 Their website:<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">posts the <\/span><a href=\"http:\/\/www.cmq.org\/pdf\/coronavirus\/msss-protocole-national-triage-soins-intensifs-pandemie-def.pdf\"><span style=\"font-weight: 400;\">protocol<\/span><\/a><span style=\"font-weight: 400;\"> online;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">provides a plain language <\/span><a href=\"https:\/\/triage.quebec\/en\/the-protocole__trashed\/the-protocole-in-plain-language\/\"><span style=\"font-weight: 400;\">summary<\/span><\/a><span style=\"font-weight: 400;\">;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">fills in important information that\u2019s missing in the version on the website of the Coll\u00e8ge des M\u00e9decins du Qu\u00e9bec; and\u00a0\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Includes a <\/span><a href=\"https:\/\/triage.quebec\/en\/sign-the-petition\/\"><span style=\"font-weight: 400;\">petition<\/span><\/a><span style=\"font-weight: 400;\"> demanding that the protocol be changed to remove sections that discriminate on the basis of age and disability.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Qu\u00e9bec\u2019s protocol begins with general statements about its purpose and application.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The triage rules apply to all people needing intensive care, whether or not they have COVID-19.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">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.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">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.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">In order to be transparent and trustworthy, the \u201ccriteria must be widely available, clearly documented and accompanied by procedures ensuring accountability.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Not only is the document hard to find, but essential information is missing.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The protocol states \u201cthe triage process for adults &#8230; is based on a set of clinical and additional criteria described in the evaluation form in Appendix B.\u201d But appendix B contains only a blank page under the heading \u201cAppendix B: Intensive Care Triage Form for Adults in a Pandemic Situation.\u201d\u00a0\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The <\/span><a href=\"http:\/\/www.cmq.org\/pdf\/coronavirus\/msss-protocole-national-triage-soins-intensifs-pandemie-def.pdf\"><span style=\"font-weight: 400;\">protocol<\/span><\/a><span style=\"font-weight: 400;\"> presents a flow chart (p. 7) that relies heavily on \u201cinclusion criteria\u201d and \u201cexclusion criteria,\u201d but without listing the criteria themselves.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Fortunately, the Triage.Qu\u00e9bec site provides a <\/span><a href=\"https:\/\/triage.quebec\/en\/the-icu-triage-protocole-in-quebec\/\"><span style=\"font-weight: 400;\">link<\/span><\/a><span style=\"font-weight: 400;\"> to the missing <\/span><a href=\"http:\/\/www.cmq.org\/pdf\/coronavirus\/msss-form-triage-soins-intensifs-pandemie-adultes-def.pdf\"><span style=\"font-weight: 400;\">document<\/span><\/a><span style=\"font-weight: 400;\">.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">To be eligible for intensive care, a person must need invasive breathing assistance or have very low blood pressure (\u201cinclusion criteria\u201d). The protocol recognizes three stages of emergency, depending on how overburdened the hospital system is.\u00a0 In a stage 1 emergency, the protocol would deny intensive care only to people with a very high probability of dying (\u226580%). In a level 2 situation, people with a better than even chance of dying would be excluded.\u00a0 At stage 3, only the 30% with the best chance of surviving would get access to intensive care resources.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Protocol sets forth 12 exclusion criteria. According to the Ministry of health and social services, people who meet <\/span><b>any<\/b><span style=\"font-weight: 400;\"> of these criteria are unlikely to recover from an acute illness or to survive more than a few months. \u201cTo be eligible for intensive care, the person must not meet ANY of the following criteria.\u201d The conditions are:\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Injury or trauma (as measured by the Trauma Injury Severity Score);\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Serious burns (with two aggravating factors);\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Cardiac arrest;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Severe cognitive impairment due to a progressive condition<\/span><span style=\"font-weight: 400;\"> \u2013 <\/span><span style=\"font-weight: 400;\">inability to <\/span><b>independently<\/b><span style=\"font-weight: 400;\"> perform activities of daily living and domestic chores;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Advanced and irreversible neuromuscular disease (such as Parkinson\u2019s, amyotrophic lateral sclerosis (ALS));\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Cancer;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Brain injury or stroke;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Severe organ failure;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Loss of functional capacity according to the Clinical Frailty Score;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Palliative surgery;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Long-term users of mechanical breathing assistance;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Other clinical judgment.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Triage.Qu\u00e9bec website describes the impact of the protocol on autistics, and people with cognitive disabilities and other specific diagnoses.\u00a0 As well, the <\/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 Framework for crisis plans<\/span><\/a><span style=\"font-weight: 400;\"> produced by U.S. disability rights groups in April, shows how Qu\u00e9bec\u2019s protocol may be discriminatory.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The protocol includes categorical exclusions on the basis of diagnosis and functional impairment. Referring to specific conditions (Parkinson\u2019s, ALS) works against the physician\u2019s duty to do an individual assessment of each person\u2019s ability to recover from the illness.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The disability activists also caution against using \u201cbroad functional impairments,\u201d like a \u201ctotal inability to perform activities of daily living independently\u201d or a high score on the <\/span><a href=\"https:\/\/www.cmaj.ca\/content\/cmaj\/173\/5\/489.full.pdf\"><span style=\"font-weight: 400;\">Clinical Frailty Scale<\/span><\/a><span style=\"font-weight: 400;\">.\u00a0 Whether a person with a cognitive disability can independently do activities of daily living is unrelated to their ability to recover from an illness.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">On the plus side, the Qu\u00e9bec protocol does not use quality of life assessments.\u00a0 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\u2019t provided for in the protocol.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">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.\u00a0\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">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 \u201cexclusion criteria\u201d) and claims the protocol will never be put into effect. Such actions are not consistent with the \u201ctransparency and accountability,\u201d called for in the statement of principles, but they are consistent with the policies of the province of Qu\u00e9bec.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">This week, Qu\u00e9bec 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.\u00a0<\/span><\/li>\n<\/ul>\n   ","protected":false},"excerpt":{"rendered":"<div class=\"entry-summary\">\n<div class=\"entry-summary\">\nThis week we track down Qu\u00e9bec&#8217;s elusive triage protocol, uncover the hidden &#8220;exclusion criteria&#8221; and reveal its discriminatory provisions.\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/06\/webcast-archive-quebecs-triage-protocol\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast archive: Qu\u00e9bec\u2019s triage protocol&rdquo;<\/span>&hellip;<\/a><\/div>\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/06\/webcast-archive-quebecs-triage-protocol\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast archive: Qu\u00e9bec\u2019s 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":[784,354,735,511,776,729,95,788,785,741,738,731,739,733,742,805,99,94,727,97,62,740,770,499,96,98,101,468,156,724,373],"class_list":["post-4947","post","type-post","status-publish","format-standard","hentry","category-webcast-archive","tag-assisted-suicide","tag-autonomy","tag-choice","tag-continuous-palliative-sedation","tag-covid","tag-degenerative","tag-dignity","tag-end-of-life","tag-euthanasia","tag-external-pressure","tag-grievous-and-irremediable","tag-hospice","tag-incurable","tag-informed-consent","tag-irreversible-decline","tag-maid","tag-medical-aid-in-dying","tag-medical-assistance-in-dying","tag-nursing-home","tag-pain","tag-palliative-care","tag-quality-of-life","tag-rationing","tag-reasonably-foreseeable","tag-safeguards","tag-suffering","tag-suicide","tag-terminal","tag-triage","tag-ventilator","tag-vulnerable","entry"],"_links":{"self":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4947","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=4947"}],"version-history":[{"count":1,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4947\/revisions"}],"predecessor-version":[{"id":4958,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4947\/revisions\/4958"}],"wp:attachment":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/media?parent=4947"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/categories?post=4947"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/tags?post=4947"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}