How Doctors in Canada Will Decide Who Will Live and Die if the Pandemic Worsens

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When there is only one ventilator but two patients who need it, how should a doctor decide who is likely to survive?

Ethical doctors across the country strive to help frontline workers answer important questions if the COVID-19 pandemic were to overwhelm hospitals as it did in northern Italy and New York .

“These are not decisions we want to make,” said Dr. Timothy Christie, who convenes an ethics committee to advise on pandemic response policy in New Brunswick.

“The planning that people are doing right now, they are doing their best so that we don’t end up there. “

On Wednesday, Dr. Theresa Tam, Chief Public Health Officer, warned that the Canadian health care system could be flooded in each of the pandemic scenarios in Ottawa. The system is not designed to deal with an outbreak of COVID-19, which could mean dealing with difficult decisions about how to allocate scarce resources, she said.

Since the new coronavirus was first confirmed in Canada, officials from several provinces have developed guides so that doctors do not feel alone in their life and death decisions.

British Columbia’s ethical framework builds on work undertaken during the H1N1 flu epidemic and the Ebola crisis. It addresses specific ethical issues on everything from the distribution of personal protective equipment and ventilators to “making decisions about who will receive rare treatment if this happens,” said Dr. Bonnie Henry last week. , the provincial health worker.

“No doctor or clinician should make this decision alone. “

Officials in Ontario have announced the formation of an “ethics table” chaired by the Joint Center for Bioethics at the University of Toronto.

Alberta is also working on a framework.

“The goal will be to make sure as many patients as possible get the care they need,” said Alberta Health spokesperson Tom McMillan in an email.

In New Brunswick, clinicians will be given a principle to help them make decisions based on their expertise.

Christie’s committee recommends a fundamental change to the underlying principle that doctors use to make treatment decisions if there are not enough hospital beds and ventilators.

“In cases where resources are limited, we would allocate resources to the people for whom we believe to have the best results,” said Christie, who is also regional director of ethics services for Horizon Health Network, the health authority English speaker of the province.

“It is fundamentally different from how we would do it under normal circumstances. “

Under normal circumstances, Christie said that doctors ask patients what their goals are. A terminally ill cancer patient may wish to spend a final Christmas with their family, and treatment plans can be adjusted to help achieve this goal.

COVID-19 could create a scenario where using a fan to keep someone alive for a few more months is at the expense of another person’s life, he said.

The challenge is to determine how you define the results when comparing patients.

“There is a lot of debate about how you define the best outcome. Some people would say that is the amount of life you could live, “said Christie. In other words, choose to save the younger of two patients.

“We reject this approach,” said Christie.

A 20-year-old man and a 55-year-old man both have a “significant” amount of life, so the difference between them is not morally relevant, he said.

Age is not the only factor discussed by the New Brunswick committee, as it considers how to avoid discriminating against someone who develops COVID-19 after all the fans are already in use.

Rather than stocking ventilators for future cases, Christie said they recommend that a new patient be assessed against those already ventilated. If the new patient has a good chance of surviving, doctors could ethically end the treatment of another unresponsive patient, he said.

But an ethical framework will not help doctors who have to choose between two patients with almost identical results.

“In this circumstance, you have an arbitrary decision. It’s going to be tragic, it’s going to be heartbreaking and it’s going to be arbitrary – and there is no ethical principle that can suddenly improve it, “said Christie. “It is no one’s fault. “

Amy Smart, the Canadian press

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