The Saskatchewan Health Authority (SHA) is planning to form triage committees that would decide who gets life-saving treatment if COVID-19 floods the health system with too many severely ill patients.
The committees would apply a range of factors to ration scarce equipment, including ventilators that allow patients to breathe. They would decide when to withdraw that treatment to save more lives.
According to Dr. Susan Shaw, the SHA’s chief medical officer, the factors would include age, frailty, chronic illness, likelihood of recovery and the patient’s pre-expressed wishes.
The scale of the pandemic in Saskatchewan will play an overarching role in framing those decisions. Shaw hopes current restrictions and public efforts to slow the spread of the virus will spare the committees from ever making the hardest choices.
“We have to plan for the worst and strive for the best,” said Shaw.
There are 332 invasive ventilators province-wide, and 118 non-invasive ventilators. If demand outpaces that supply, some patients would keep breathing while others would go onto palliative care. Those hard choices would quite literally mean life or death.
Shaw said it’s important for the SHA to be transparent about the ethical framework that will guide those decisions. A document has already been circulated with the SHA’s emergency operations committee and its executive leadership team. It will be released to the public this week.
The goal is simple to state, but difficult to accept.
“Really, what we’re looking at is how do we make decisions collectively that save the most lives, and the most life years,” said Shaw.
That means age would play a role. Imagine two patients, one 55 years old and one 75 years old, but otherwise identical in every way. Both need invasive ventilation to breathe. But there is only one ventilator left. Shaw acknowledged that the younger patient would be intubated. The other would not.
Beyond the importance of saving more lives, Shaw framed it in terms of giving everyone an equal opportunity to “live through the various phases of life.”
“If someone has already had the opportunity to live through more years of life than a younger person, that’s how that principle applies,” said Shaw. “But again, that’s only if all the factors are equal.”
Factors are rarely equal. Shaw denied that such a system is inherently discriminatory or ageist, since age is considered alongside other patient-level circumstances to arrive at a decision.
“We don’t have age as an independent factor,” she said. “It’s age and frailty, age and chronic illness. It’s not an isolated factor. It’s never considered by itself.”
Shaw mentioned several chronic illnesses that could play a role, including severe heart, liver or lung disease. Data suggests that patients with multiple chronic conditions are the most likely to die from COVID-19.
The triage committees would continuously assess the condition of patients on ventilators to look for new problems, like organ failure. In a worst case scenario, Shaw said, that could mean removing someone who’s doing poorly to give another a better chance at life.
Shaw acknowledged that losing ventilation would generally mean death. But she emphasized, in the strongest terms, that care would never stop. It would only change. In most cases, it would become palliative care.
“It’s so important that we never stop caring, but with different goals,” she said. “We would never abandon a patient.”
The committees would spare bedside physicians from having to make heartbreaking choices about their own patients. Consisting of other physicians and ethicists, they would make what Shaw called on “objective” assessment that weighs both the patient’s chance of survival and what’s best for society as a whole.
“It’s actually about fairly and equitably and transparently applying ethical principles to societal benefit, to everybody, in a fair way,” said Shaw.
Families would be informed about choices, according to Shaw. They would then be able to raise concerns with the treating physician, who could appeal to a different ethics committee.
But in a condition of scarcity, Shaw said the role of families would be “more limited” than in ordinary circumstances.
Committees would also consider a patient’s pre-expressed wishes. That could come in the form of an advanced care directive. Shaw said everyone should have conversations with their loved ones about what kind of care they would want. COVID-19 only makes that more urgent.
“Start to have a conversation about what’s most important to me, what are my values, what am I interested in accepting,” she advised.
Shaw is herself an ICU doctor, working at Royal University and St. Paul’s hospitals in Saskatoon. She has treated patients with “potential COVID-19.” The team she works with is “united” and “prepared,” she said, with enough ventilators and ICU beds for current demand.
The surge hasn’t come. The ICU isn’t even as busy as usual, according to Shaw, with fewer motor vehicle collisions. She hopes it will stay that way.
“If the public measures work in terms of social distancing, self-isolation, excellence in hand hygiene, all of the things that we are now knowing to be the right thing to do, then I don’t think we’re going to be in this situation,” Shaw said of the rationing measures.
“I can’t guarantee you that,” she added, “and none of us can.”
