Quebec lays out life-and-death COVID-19 triage guide, but some say province could do more

Hospital beds (www.ctvnews.ca)

Quebec doctors could soon have to make difficult life-and-death decisions for COVID-19 patients and others needing intensive care.

With hospitals reaching a critical stage in the second wave, their staff are starting to be trained on the province’s new advanced triage protocol for deciding who gets care when resources get too tight to treat everybody.

The protocol is a list of criteria for rating critically ill patients to determine who has the best chance of survival and, therefore, who will get access to ICU treatment and life-saving equipment such as ventilators.

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The government has said it will only trigger the protocol once Quebec has reached 200 per cent capacity of ICU beds in the entire province.

Earlier this week, Dr. Lucie Opatrny, Quebec's assistant deputy minister of health, indicated that it’s something that could be needed in a matter of weeks. 

It's an extremely serious, even a historic, move for the province to make, and some argue it shouldn't be needed -- that Quebec should have done, and can still, do more to avoid these kinds of tragic choices.

“It’s totally unacceptable,” said Dr. Paul Saba, a family physician. 

“ICU and intensive care beds are and should always be available to those who need the most intensive care. It goes completely against our model for health care, which is that you provide care for everybody, regardless of who they are, based on their need, and not based on survivability.”

Eugene Bereza, a medical ethicist at the McGill University Health Centre, said the decisions involved really are life-or-death -- some patients would likely die if the protocol is put in place.

“We really need to be very clear on the significance of this," he said.

"This is unprecedented, uncharted territory for us here in Quebec in our generation... We’re now talking about a scenario, if it happens, where people whom we could normally save with ICU, reasonably, we may not be able to save because we can’t help everybody," Bereza said.

"So we’ll prioritize the ones that are most likely to benefit so we can save as many lives as possible. Those we can’t save will die, when they might have lived if it weren’t for this crisis in resources.”

WHO DECIDES, AND HOW?

That choice, however, won’t come down to the doctor who is at the patient’s bedside. The protocol calls for a committee of three people, consisting of two physicians such as an intensivist (a doctor specializing in intensive care) or an emergency-room doctor, along with a third person such as an ethicist. 

“That group would anonymously receive, without patient names or identifiers, prognostication forms and other criteria and they would have to prioritize and inform the teams, literally, who is next,” Bereza said.

“The main reason for (having a separate committee), I think is because a lot of physicians have given us feedback that the burden of that responsibility lying on their shoulders is untenable,” he added.

“You’re asking them to do something that is contrary to what they believe in and are trained to do."

The criteria that would be used to evaluate who gets treatment in the ICU would come down to clinical prognostics. In other words, what is the probability that the patient will benefit from ICU care.

“Patients who are evaluated clinically as having an extremely small chance of benefitting from ICU care would clearly be prioritized much lower than an individual who is clinically evaluated as having a much higher chance of benefitting,” Bereza explained.

The guidelines stress that discriminatory criteria shouldn’t be used, such as whether a person has a disability, has children, or is homeless.

But the triage committee would also look at how long a patient is probably going to have to stay in the ICU. If comparing a patient requiring a one-week stay versus a two-month stay, “we would prioritize the person with one week in the ICU," Bereza said.

"We can then liberate our bed to save more patients."

After these criteria have been considered, there are other indicators the committee would look at, including what is referred to as "life cycle," which Bereza explaines is not exactly about age.

“It’s not like the 67-year-old gets precedent over the 63-year-old," he said.

"What we’re saying is people, the elderly, who have had their life to live, so to speak, will be less prioritized than someone in their twenties, who haven’t had an opportunity to go through those life cycles.”

QUEBEC CAN AVOID THIS, CRITICS SAY 

The provincial government devised the protocol along with a working group that included critical-care doctors, ethicists and lawyers.

Training around the protocol is already underway in some hospitals, and the MUHC says dry-run simulations are being planned at the Royal Victoria Hospital and Montreal General, though neither has been launched yet.

Some, like Saba, reject the idea that this should be necessary right now.

The very possibility of the government having to eventually trigger this triage protocol also angered patient rights advocate Paul Brunet. 

“Section 7 of the Charter of Rights and Freedoms of Canada is to the effect that everyone has the right to live, and to be treated adequately in emergency situations,” he said.

He said the government should have done more, earlier in the pandemic, to prevent ICUs in the province from becoming overwhelmed.

“We think the government was late in preparing itself, postponed a lot of surgeries, exacerbated the situation in the hospitals,” he said.

Saba says the government should be looking into other solutions to increase capacity within the health-care network.

He said he'd like to see the government explore options such as bringing doctors out of retirement, giving medical, nursing and respiratory therapy students provisional diplomas, or redeploying surgeons and other specialist who have experience in ICUs.

The care people receive “should not be based on a score,” he said.

“The sicker you are, the less survivable you are, so actually it’ll end up meaning those who really need ICU care won’t get it," he said, because it will go "only to those who are less sick.”

--With files from CTV’s Matt Grillo

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