Ontario reviewing ethical guidelines for who gets care if COVID-19 cases overwhelm system

Ontario's ministry of health is reviewing ethical guidelines for prioritizing who gets care and who doesn't if the province's healthcare system becomes overwhelmed during the coronavirus pandemic.

The guidelines were developed in collaboration with hospital ethicists from across the province led by the University of Toronto's Joint Centre for Bioethics, according to Alison Thompson, a member of the group advising the ministry on pandemic planning. 

"We know post-SARS, that those decisions created a huge amount of moral distress for clinicians who were forced to make them in the moment," said Thompson. "If [guidelines are] coming from a central authority like the ministry, then everyone's on the same page." 

The U of T professor and public health expert says the guidelines should mean that no matter where you are in the province, you can expect the same care considerations if the system becomes overwhelmed.

So far, healthcare workers in Ontario haven't had to choose who gets access to resources like intensive care beds and ventilators — unlike their counterparts in Italy who are already making those difficult decisions. 

As of Friday, there were 993 confirmed cases of COVID-19 in Ontario, with 18 deaths and eight cases considered resolved. Another 10,074 people were awaiting test results.

The ministry of health says it has enough ventilators to match current needs, but is preparing for increased demand. In addition to more than 1,300 beds with ventilation across the province, the ministry has procured 300 more ventilators to add to more than 200 they have in surplus.

"We intend to have ventilators available to whomever needs them," said Health Minister Christine Elliott at a news conference Friday. 

'There needs to be transparency around this'

Thompson hopes a public conversation about the guidelines takes place long before they're ever needed. 

"There needs to be transparency around this," said Thompson. "This is going to impact many, many people." 

Asked by CBC Toronto if the ethical guidelines will be made public, the ministry would not say. 

So what might guidelines look like in practice? 

The criteria will be designed to maximize the benefits of scarce resources by determining who is a priority in terms of their role in fighting the pandemic and who is most likely to benefit from what's available, according to Thompson. 

For healthcare professionals, that will likely mean being first in line for whatever personal protective equipment is available and any vaccine developed down the line. 

In terms of resources like ventilators, who gets one will come down to whoever is most likely to benefit from using it —not just medical criteria, Thompson says.

Resources would go to those most likely to benefit, survive

"It's not what's the best thing to do for your grandmother," she told CBC Toronto. "It's who is most likely to benefit, and who's most likely to survive within the population as a whole."

A patient's age will never be the sole factor in making ethical decisions, according to Dr. Kevin Smith, President and CEO of the University Health Network. Instead, Smith told reporters Friday that real-time survival rate data will be shared with the province's ethical team to help in prioritizing care.

Whether or not those kinds of difficult decisions will ever need to be made in Ontario depends on the balance between the number of cases, how fast they come and available resources, according to an infectious disease specialist at Mount Sinai Hospital. 

"It's still really too early to know," said Dr. Andrew Morris. "I don't think we have a good idea of how well our mitigation strategies are working."

But Morris is hopeful that public health and hospital leaders have had enough time to plan in order to deal with a surge in cases.