ICU doctor calls triage protocol 'morally distressing' as province sees continued stress on care units

As intensive care units across the province continue to see a surge in critical care demand due to COVID-19, doctors are being told to prepare to determine who gets a bed — and who doesn't.

The medical director of critical care at Michael Garron Hospital, Dr. Michael Warner, says ICU doctors across the province have been told to prepare to use critical care triage to determine who will receive life-saving care when ICU resources are limited.

"The public needs to understand they're at risk of not getting the care they need," Warner told CBC News on Thursday.

Warner said the province sent out a memo on Wednesday outlining the protocol to prepare ICU physicians to implement triage when instructed by the critical care command centre, although no start date has been given so far.

"I've never been in that position before, I didn't train for that," Warner said. "And that's the position we may be in, in a matter of weeks."

This comes exactly one week after the province began warning hospitals to prepare for the transferal of patients across and out of regions, in a memo dated Jan. 7.

Hospitals that have intensive care space available in Ontario were told to reserve one-third of those beds for transfers from hospitals that have reached ICU capacity.

Warner said implementing this criteria would mean that not every patient today who needs critical care — COVID-19 or not COVID-19 related — will get the critical care if triage comes into effect.

He said doctors will be required to use a checklist of criteria to determine who is most likely to survive their critical illness not only for a week or two but 12 months from then, and allocate critical care accordingly.

"It makes me very uncomfortable, it's morally distressing and it's terrible for patients."

Only two days ago, a mandate from the Ontario critical care table required nine patients to be moved across the province to another ICU to help loadshare the stress on harder-hit hospitals, Warner said.

"Right now if there's a patient that I would normally offer life-support to, instead of offering them life support — if we're in triage — I go through their short-term mortality risk, which is a checklist to determine or 'guesstimate' how likely they're going to be alive 12 months after their critical illness," Warner said.

The memo says the standard of care is based on a document from Sept.11, 2020 titled "Critical Care Triage during Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario," which was updated Jan. 12. and prepared by the Ontario COVID-19 Bioethics Table.

"In the context of a major surge in demand for critical care resources, where the demand actually exceeds the number who can be safely managed with available resources (including ventilators, supplies and trained staff), it is inevitable that some who may have otherwise benefited from critical care will not receive it, and as a result, some will die who would otherwise have lived," the memo points out.

But Ontario has faced major criticism once before, when trying to implement a critical care triage protocol. 

In March of last year, when Ontario Health sent out a triage protocol during the start of the COVID-19 pandemic, it retracted it shortly after following backlash from human rights organizations.

"Given the evolving situation in Ontario hospitals, the health-care system is preparing for if there is a major surge of critically ill patients outstripping critical care resources across the province," Dr. Andrew Baker, head of the Ontario Critical Care COVID-19 Command Centre told CBC News.

"To help the critical care community plan and to ensure a common approach across the system, training information and standardized tools have recently been shared with the critical care sector so they can learn how to quickly operationalize an emergency standard of care for admission to critical care, if ever needed and directed by the Ontario Critical Care COVID Command Centre," he said.

Baker says the emergency standard of care, which fits within the Health Care Consent Act, is not currently in place.

The memo notes that critical care triage for major surge should be considered an option of last resort and to be invoked only when "all existing local and regional critical care resources have been used, all reasonable attempts have been made to move patients to, or resources from areas with greater critical care resource availability, and only for as long as the major surge lasts."

3-level approach to triage

The document outlines a three-level approach to triage: 

• In a level one triage scenario, patients who have a greater than 20 per cent chance of surviving 12 months from the onset of critical illness based on an evaluation of their clinical presentation at the point of triage should be prioritized.

• In a level two triage scenario, patients who have a greater than 50 per cent chance of surviving 12 months from the onset of critical illness should be prioritized. 

• In a level three triage scenario, patients who have a greater than 70 per cent chance of surviving 12 months from the onset of critical illness should be prioritized.

"That's pretty dramatic," Warner said. "That's something Ontarians have never faced and something I hope I never have to use."