Healthcare resources are finite. This hard truth has never been felt more keenly than in this pandemic. Thousands of people are now at home waiting for their cancer or cardiac or other surgeries that have been cancelled because there are not enough resources to care for them as well as the surge of COVID patients now flooding into hospitals. We already know that delays in treatment due to the pandemic are resulting in preventable deaths and illness.

In situations where resources are limited, the process of choosing who gets care becomes of paramount importance. Hospitals are making hard decisions every day about which surgeries are most urgent, using clinical evidence to allocate scarce beds based on the principle of saving lives and reducing illness.

Critical care is also a finite life-saving resource.  If hospitals become overwhelmed with critically ill patients we must have a fair, evidence-based and principled process for deciding who gets critical care. That is why the Ontario Critical Care COVID Command Centre has issued an emergency standard of care to assist bedside doctors in triaging patients for critical care admission. Based on broad consultation with experts in medicine, bioethics and human rights, this protocol is designed to allocate critical care resources to save the most lives possible while adhering to rigorous ethical principles.

Triage will impact every critically ill person, whether or not they have COVID. If three patients present to the emergency room—one was injured in a motor vehicle accident, one has complications from pancreatic cancer, and one has heart failure—there must be a system to decide which patient will be given the last critical care bed available. There are essentially four options for making this decision.

One would be a passive first-come, first-served approach, where everyone receives critical care until all beds are full, and then everyone else is turned away. While this may work for concert or sporting event tickets, in healthcare this model risks many preventable deaths as people with a poor chance of survival (who are likely to die even with critical care) receive care because they arrived earlier, while others with a very good chance of survival may die because they arrived later. This model is also inequitable, disadvantaging those with poor access to healthcare and transportation (such as remote communities).

A second option would be to randomly allocate intensive care beds using a lottery. This would likely also lead to a number of preventable deaths because some people who are likely to die anyway might be “lucky” enough to receive critical care, whereas others with a better likelihood of recovering may be “unlucky.” Surely the reason we have a healthcare system and clinical expertise is to have survival rates that are better than random chance.

A third option is to leave it up to the discretion of individual doctors at the bedside to decide who gets access to critical care. This has several downsides: it would introduce inconsistencies in decision-making; unconscious biases could cause specific groups to be disadvantaged; and it would contribute to moral injury, PTSD and burnout amongst clinicians if they are forced to bear this moral responsibility alone.

The fourth option is to adopt a standardized provincial triage protocol that allocates critical care resources based on explicit criteria informed by medical evidence. Triage protocols are commonly used in other situations, such as mass casualty events, in the hope of saving the most lives, while ensuring equity, consistency and transparency, and mitigating the moral burden on clinicians.

Given these options, the Critical Care COVID Command Centre, which is charged by Ontario Health with managing critical care capacity and implementing best practices in response to the pandemic, has developed a critical care triage protocol for the province. It would only be used in a worst-case scenario after reasonable efforts to expand capacity and redistribute resources are exhausted. This protocol has been reviewed and endorsed by experts in medicine, ethics and law, and was used as the model for triage protocols adopted in other jurisdictions such as Quebec and Israel.

The intention of this triage protocol is to provide a standard of care to help bedside doctors make the right decisions to save the most lives, using a process that is informed by the principles of: protecting human rights, non-discrimination, equity, proportionality, beneficence, respect for autonomy, accountability and fairness.

This protocol balances these principles in the following way:

• Ideally, all patients who could benefit from critical care would receive it, but patients with the best chance of survival would be offered critical care first in order to save the most lives
• Every patient who becomes critically ill will be assessed using a standardized mortality risk tool, which helps doctors determine which patients are most likely to survive a critical illness. This allows people with different illnesses to be compared on equal terms.
• Every assessment of mortality risk is repeated by a second physician, to ensure accuracy
• Human rights are explicitly protected; decisions are based purely on mortality risk, and not on prohibited grounds like sex, age, race, family status, disability, etc. Nobody would be denied access to critical care because of a disability. Mortality risk is the only criterion used for prioritization.
• Every hospital would create a triage review committee to do quality assurance and monitor how the triage protocol is being used.

If this triage protocol is triggered in the event of a major surge of critically illness, a patient who is admitted to hospital can expect that they will be asked about their goals and wishes. Many patients may wish to focus care on comfort and may not want ICU care. If a patient wishes to have ICU care, their doctor will complete a standardized assessment of their risk of mortality if they become critically ill. This assessment is based on their underlying conditions that may put them at higher risk of death. All patients will receive medical care and symptom management, even if they are not prioritized for critical care.

Healthcare providers and leaders are trying to tackle one of the most challenging ethical problems imaginable—who does and does not get access to potentially lifesaving critical care—with no historical precedent, and in real time. There are no easy answers, and regardless of the approach we use, some people will die who might have survived in non-pandemic times. In this situation, a systematic, standardized, principled and evidence-based approach to allocating these healthcare resources in a consistent way across the province provides the best way to avoid preventable deaths while safeguarding the psychological wellbeing of bedside clinicians, protecting human rights, and ensuring equitable access to care for all Ontarians.

Let us be clear — nobody wants this, but a triage process that makes decisions based on clear principles and clinical criteria is far better than the alternatives.

Dr. Andrew Baker, Critical Care Physician and Incident Commander Ontario Critical Care COVID Command Centre. Dr. Andrea Frolic (PhD), Director, Program for Ethics and Care Ecologies (PEaCE), Hamilton Health Sciences; Assistant Professor, Department of Family Medicine, McMaster University. Dr. James Downar, Head, Division of Palliative Care, University of Ottawa; Department of Critical Care, The Ottawa Hospital.