TORONTO -- Imagine a scenario where there are two patients with COVID-19 who are having difficulty breathing. They鈥檙e both in desperate need of a ventilator to help them breathe, but the hospital only has one machine available.
One of the patients is a 12-year-old child, while the other one is a 74-year-old doctor.
While some might assume the machine should be given to the younger patient, health-care professionals say it鈥檚 not that simple.
Timothy Christie, a medical ethicist and the regional director of ethics services for Horizon Health Network in New Brunswick, presented this theoretical scenario to demonstrate some of the fraught ethical dilemmas Canadian health-care systems could be faced with should the COVID-19 pandemic overwhelm hospitals.
鈥淲e might be in a situation where we might not have the resources to save someone that we would normally be able to save if we weren鈥檛 in a pandemic situation,鈥 he told CTVNews.ca during a telephone interview from New Brunswick on Friday.
Although this hasn鈥檛 happened yet in Canada, Christie is sharing these hypothetical scenarios with the Horizon Health Network鈥檚 ethics board to explain the potential magnitude of such a problem and to stress the need for health authorities to prepare for it.
Christie cited hard-it areas such as Italy and New York City as examples of places where the sudden outbreak of COVID-19 overwhelmed hospitals and forced frontline workers to ration life-saving resources.
鈥淭hey鈥檙e just hit with a tsunami all at once,鈥 he said. 鈥淭hey鈥檙e making things up as they go, and they're doing the best they can on the front lines.鈥
According to , there have been reports out of Italy describing physicians 鈥渨eeping in the hospital hallways because of the choices they were going to have to make.鈥
LOOMING SHORTAGES
In Canada, provincial governments have been reassuring people they have enough ventilators and intensive care unit (ICU) beds to respond to the current crisis and they鈥檙e in the process of ordering more should the demand require it.
However, according to from the University of Toronto, University Health Network and Sunnybrook Hospital, Ontario could encounter a shortage of ventilators and beds by the end of April.
Even in a best-case scenario, which includes the province adding more than 2,000 beds and 600 ventilators, the models suggest Ontario鈥檚 health-care system would still face a shortage in two months.
The shortage of equipment in Ontario could come even sooner, according to Dionne Aleman, an associate professor of industrial engineering at the University of Toronto who develops models to predict the spread of a virus in a pandemic.
She said that based on the current trajectory of infections and published numbers of ICU and ventilator usage by COVID-19 patients in Ontario, the province could face a shortage in as little as two weeks if nothing else changes.
鈥淭he latest numbers I have seen are that 25 per cent of ventilators are now used by COVID-19 patients, and around 20 per cent of COVID-19 patients end up requiring this advanced care, which is very concerning,鈥 she said in an email to CTVNews.ca on Tuesday.
Aleman said the infection rates and equipment usage rates aren鈥檛 exact, however, because only patients with moderate to severe illness are tested in the first place.
Ontario鈥檚 numbers may not be good news for the rest of the country, either, because the province has a slightly higher number of ventilators in proportion to its population than the national average, Aleman said.
Aleman said the hope is that Canadians will be able to flatten the curve through self-isolation and physical distancing so that hospitals aren鈥檛 overwhelmed all at once and there is enough equipment for everyone.
Dr. David Migneault, an emergency medicine specialist and bioethicist at Vancouver Coastal Health, said he鈥檚 cautiously optimistic that some of Canada鈥檚 early actions will have an effect on the course of the pandemic.
鈥淚'm not ready to celebrate, but I think that we will have an effect of the curve,鈥 he told CTVNews.ca during a telephone interview from Vancouver on Tuesday.
Migneault said this week will be telling to see whether public health measures, such as self-isolation and physical distancing, have made a difference. He also said that health-care providers are already making difficult decisions, including delaying other surgeries, to respond to the outbreak.
鈥淲e are already making difficult choices in order to accommodate the potential of worst choices to come,鈥 he explained.
鈥淲e all hope we're not going to end up in a situation where we have to make these extremely difficult [decisions] where we have to choose between one individual and another one.鈥
WHO LIVES? WHO DIES?
In the hypothetical case of the 74-year-old patient in need of a ventilator, Christie said that person could still live for another 15 to 20 years and that age, alone, should not be the only consideration when health-care workers are faced with these difficult decisions.
In fact, the medical ethicist said there isn鈥檛 going to be one clear set of guidelines outlining what factors will be taken into account to decide who gets to live and who gets to die during a pandemic.
鈥淚 don鈥檛 think there's going to be any formula that everyone鈥檚 going to be able to live with,鈥 he explained.
Importantly, Christie said health-care providers can鈥檛 base their decisions on discriminatory reasons, such as age, race, religion, sex, prejudices, and arbitrary criteria, such as the patient鈥檚 influence or who they know.
Instead, the medical ethicist said it will most likely have to come down to outcomes and who is more likely to survive for longer if they receive the treatment. It鈥檚 a departure for health-care workers who typically consider the patient鈥檚 values and goals.
For example, Christie said doctors may provide ventilation to a terminally ill patient with cancer because that person wants to live long enough to see their daughter get married, even though they know they won鈥檛 be able to cure the disease.
鈥淚n a pandemic, I think we鈥檙e going to be in a situation where if we鈥檙e not going to be able to prevent death for you, regardless of what your life goals are, we might have to give that resource to someone for whom we can get a better outcome,鈥 he said.
Migneault said that health authorities try to be fair to everybody and consistent in the sense that they treat similar situations the same way every time. However, in a health emergency, information can quickly change and Migneault said health-care workers have to be able to adapt on the fly.
鈥淲e say one thing one day and the next day we learn something, say something else so within all that ethical framework, you have to be flexible with it and try to adapt yourself as things move along,鈥 he said.
In the U.S., health authorities across the country are developing strategies with the general principle to provide the most benefit to the greatest number of people and prioritize those with the best chance of recovery.
Dr. Douglas White, from the University of Pittsburgh, has developed during the COVID-19 pandemic. He said categorically excluding groups of people, based on their age or other underlying health issues for example, from receiving care is ethically problematic.
Instead, White recommends that all patients be assigned a priority scale based on a number of factors including their likelihood of surviving hospital discharge and their longer-term survival. He also said individuals who perform tasks vital to the emergency response, such as doctors and nurses, should receive extra points.
In the event of tie in priority scores, White said the younger patient should be given priority because 鈥渢hey have had less opportunity to live through life鈥檚 stages.鈥
While some American hospitals have already adopted White鈥檚 framework, Christie said Canadian health authorities still have time to look at best practises and confer with their ethical committees to develop their own strategies if they鈥檙e faced with supply shortages. He said by planning ahead of time, health authorities can increase their capacity to treat as many patients as they can and prevent frontline health-care workers from having to make these difficult decisions.
鈥淲e鈥檙e doing all that planning now, so that we can delay these tragic choices as much as we can,鈥 he explained.
Part of that planning includes the distribution of personal protective equipment (PPE) to protect health-care workers, Migneault said.
鈥淲e talk a lot about ventilators, but it actually goes way beyond ventilators,鈥 he said. 鈥淵ou can have as many ventilators as you want, but if you don't have the human resources to provide the care, for example, if you don't have the nurses to provide the care, then you're not providing the care.鈥
Migneault said health authorities have to co-ordinate the distribution of resources on a provincial level to ensure hospitals have the supplies they need to respond to the pandemic.
鈥淚t鈥檚 important to pay attention [to] where are the ventilators, who has access to the ventilators, or critical care resources, and you don't want to forget people that may have more challenging access to them,鈥 he said.
With The Canadian Press and The Associated Press
