June 3, 2020

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Grim new protocols will force doctors to make unthinkable choices

Opinion

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Provincial officials are developing a new triage protocol to help doctors decide who gets critical care and who could be denied life-saving treatment if hospitals become overwhelmed with COVID-19 patients.

It’s a stark and terrifying proposition.

But with cases continuing to rise (and knowing the kind of rationing of critical care that occurred in countries like Italy), Manitoba officials have no choice but to prepare for a worst-case scenario,

"Like other jurisdictions, Manitoba is developing an ethical framework to help determine the criteria and decision-making processes for allocating resources during COVID-19, including critical care," a spokesperson for Shared Health Manitoba stated in an email to the Free Press. "Discussions continue amongst clinical leadership and ethicists."

No further details have been released by the province on how those decisions would be made, what criteria would be used, or how much would be made public.

In some jurisdictions, in the event of a shortage of ventilators, a patient could be taken off a machine, which is then used for someone with a better chance of recovery. (Claudio Furlan / LaPresse files)

In some jurisdictions, in the event of a shortage of ventilators, a patient could be taken off a machine, which is then used for someone with a better chance of recovery. (Claudio Furlan / LaPresse files)

But other jurisdictions, including Ontario and many U.S. states, have developed protocols to guide front-line staff on how to make the gut-wrenching decision of denying critical care to one patient in favour of another. In the event of a shortage of mechanical ventilators, for example, it could mean taking one patient off a machine and giving it to someone who has a better chance of recovery.

Protocols differ between jurisdictions. Most consider not only the age of patients, but also whether they have other medical conditions — organ failure, for example — that could reduce their chance of a full recovery. Some use a points system that assess patients based on various factors.

The goal is to save as many patients as possible, but it's also to give preference to those with a greater chance of living a longer life. Age isn't the only determining factor. But it can be a tiebreaker. If two people had the same chance of recovery, it’s likely the younger patient would get preference.

It’s a brutal scenario, and one Canadian health-care workers are not accustomed to. There are times when doctors have to make tough decisions, in consultation with families, about whether to proceed with life-saving care in some complicated cases. But having to choose between who lives and who dies because of a shortage of supplies or equipment is unheard of in Canadian hospitals.

Manitoba is still a long way off from having to confront such a nightmare. Occupancy rates for both medical beds and intensive-care spots in hospitals are still hovering between 70 and 75 per cent. Winnipeg has 82 ICU beds. Brandon has five. The province is also expanding hospital space for lower-acuity patients to free up more capacity at Health Sciences Centre, and St. Boniface and Grace hospitals, Winnipeg’s three acute-care facilities. As of Tuesday, there were only five patients in the isolated COVID-19 units at those three facilities.

There were 12 COVID-19 patients in hospital, including six in intensive care. That’s up from the two to four on most days late last month.

Occupancy rates for medical beds and intensive-care spots in hospitals are hovering between 70 and 75 per cent. Winnipeg has 82 ICU beds. Brandon has five. (John Woods / Winnipeg Free Press files)

Occupancy rates for medical beds and intensive-care spots in hospitals are hovering between 70 and 75 per cent. Winnipeg has 82 ICU beds. Brandon has five. (John Woods / Winnipeg Free Press files)

Meanwhile, Manitoba has 270 ventilators — which some critically ill COVID-19 patients need to help them breathe — with 16 more on order. Is it enough? No one knows.

What we do know is the more closely Manitobans follow physical-distancing rules and maintain good hand hygiene, the less likely doctors will have to make these unthinkable choices.

Ignoring physical-distancing rules — as some people are still doing — not only puts front-line staff at risk, it could make the difference between having to use the new protocol or not.

"When you get into large groups and (you’re) not following this advice, you’re putting yourself and other Manitobans at risk," Dr. Brent Roussin, Manitoba’s chief public health officer said Monday.

"This is serious; this is, right now, life and death for Manitobans."

Hopefully, the new triage protocol will never be used. But since governments still have no idea how bad this pandemic will be, no matter what their internal modelling may suggest, it is a possibility.

The greatest determining factor, beyond aggressive testing and contact tracing, will be the behaviour of the public over the next few weeks.

tom.brodbeck@freepress.mb.ca

Tom Brodbeck

Tom Brodbeck
Columnist

Tom has been covering Manitoba politics since the early 1990s and joined the Winnipeg Free Press news team in 2019.

Read full biography

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