Ontario officials creating ethical guidelines for hospitals' response to COVID-19 they hope to never have to use

The provincial government and hospital leaders have been working to increase hospitals' capacity to care for COVID-19 patients — but if efforts to flatten the epidemic curve in Ontario fail, there may not be enough ventilators for all of the patients who need machine-supported breathing.

Officials said Friday they are creating a set of ethical guidelines that will determine who would get those ventilators, and who would not, if a worst-case scenario occurs.

They described it at a briefing for the media on the efforts Ontario has taken to increase the number of critical care beds available.

Earlier in the day, Health Minister Christine Elliott had been asked how the province will handle the difficult ethical decisions of who gets what care in a crisis. She said an ethical framework for COVID-19 was being created, but didn't go into details on what it will look like.

"We have an ethicist who is at the command table," she said, referring to the decision-making structure the province has created to respond to the pandemic. "We are building out an ethical framework."

Some of the worst-hit countries, like Spain and Italy, have so far had to make some of those life-and-death decisions as they have grappled with large daily fatality counts and limited health care capacity relative to the size of the problem.

Kevin Smith, president and CEO of the University Health Network, said the effort is being led by Jennifer Gibson, director of the University of Toronto Joint Centre for Bioethics.

He confirmed it will deal with the question of which patients should be put on ventilators if there are not enough for everyone who needs them.

"We hope we're never in a situation like this," Smith said. "But should we find us in the worst-case situation, like Italy and some other jurisdictions have found themselves in, it will be important to determine first whether or not a patient should go on a ventilator and other advanced forms of life support."

Smith said the province is getting information from other parts of the world on what survival rates have been for patients with certain other conditions, or fitting different medical criteria such as oxygen levels.

The criteria wouldn't be based on age, he said, but would take into account comorbidities that tend to come with age, such as lung and heart problems and diabetes, that have been linked with low survival rates of COVID-19 in other countries.

"So, if we ran out of ventilators then that would be a process one would have to consider, not one we wish to go to, and hopefully one we would never get to," Smith said. "But what we don't want to do is leave the frontline clinicians to have to ration care and we won't do that."

The ethical framework would prevent "futile" care, he said.

Hospitals have been delaying non-essential surgeries, including cancer surgeries, to make room for COVID-19 patients and to free up ventilators.

Today, there are a little over 1,300 critical care beds with ventilators now, 400 of them free. There are currently 60 COVID-19 patients in hospital, 43 of whom are in ICU, and of those, 32 are on ventilators.

But should things change, as they're expected to, there should be 3,250 beds with ventilation available in Ontario, including some that would have anesthesia machines to provide ventilation, and the use of Ontario's share of a federal stockpile of ventilators, officials said.

Officials are concerned about the number of beds and the health-care professionals to care for patients, but it's the number of ventilators that is the greatest concern, officials said.

Also, there is some work being done on measures that could, potentially, safely double the capacity of each ventilator, Smith said.

Whether there are enough ventilators comes down to the "arc" of the epidemic curve — whether or not Ontarians comply with the physical distancing guidelines well enough to slow down the spread of the coronavirus, said Smith.

"It's really in the hands of Canadians to make the decision about whether or not this disease goes in exponential rate or in a flattening curve where we can truly meet the needs of each patient," he said.

If Ontarians flatten the curve, the province will have enough beds and ventilators. In the meantime, critical care nurses have been training their colleagues with other specialties, such as surgery, on how to perform the needed care for COVID-19, with supervision, Smith said.

"It all comes back to are we going to see the curve shaped by Canadian's behaviour?" he said.

Flattening the curve also matters because officials expect there will be more ventilators available as time goes on. Efforts are underway to source some from Ontario manufacturers, but they won't be available in time if the epidemic peaks in a matter of weeks rather than months, officials said.

The province is looking at different models for when the peak of the epidemic will arrive, officials said.

In about three to five days, Ontario should know more about whether or not Ontario's physical distancing measures are working, or whether we will follow the worst-case scenario where hospitals are overwhelmed, such as in Italy — but the province does not appear to be on track for that now, said Smith.

"We are preparing for Italy, in case that materializes," said Deputy Minister of Health Helen Angus. "But if Canadians actually self-isolate, as requested, particularly those snowbirds who are coming back to Canada after (the) winter, we will be in much better shape."

Officials are also working on freeing up non-acute beds in hospitals by getting patients out of hospitals who no longer need to be there, referred to as alternate level of care patients. It includes transferring patients to long-term care and paying their co-payments for them if necessary or sending some home with support. Other options being explored include working with private retirement homes and hotels to provide supportive housing for the patients.