Prepared by Osler’s Ethics Quality Improvement Lab, P Chidwick, J Oliver 20MARCH2020 12:00 pm

Ethics Framework

For Health System Preparation

For Major Surge in a Pandemic:

Steps Before Triage

Draft 4, March 20, 2020

Prepared by Osler’s Ethics Quality Improvement Lab, P Chidwick, J Oliver 20MARCH2020 12:00 pm

Ethics Framework for Health System Preparation for Major Surge in a Pandemic:

As you are aware, things are changing rapidly in Ontario in response to the COVID-19 Pandemic. It is possible that at some point health care providers could be faced with very difficult decisions related to resource allocation. If the surge in patients as a result of COVID-19 overwhelms Ontario’s critical care units, there may be more patients who need critical care than there are beds available. If such a situation arises, decisions will have to be made about who accesses these beds and who does not. In order to preserve and promote trust, solidarity, and equity, and to ensure that such decisions are made only when necessary and as a last resort, it is crucially important that Ontario’s health care system confirms that all legal and professional obligations, as well as obligations related to autonomy, and stewardship are currently being met. By meeting these obligations now, we will safeguard our health care professionals from making resource allocation decisions before we would be ethically justified in doing so. Our obligations to future patients require us to carefully evaluate our treatment of current patients. We can do this now.

Prepared by Osler’s Ethics Quality Improvement Lab, P Chidwick, J Oliver 20MARCH2020 12:00 pm

For each patient admission or patient currently in the unit

Is the Standard of Care being followed?

Ensure that the correct substitute decision maker is

identified in case a new proposal is made

Is the current plan in line with the patient s known

wishes, if any? Propose a new plan that is in line with the

standard of care and the patient s known wishes

(if known) or best interests (if no wishes

known)

NOYES

NO

YES

Is the current plan in the patient s best interests?

YES

NO

Ensure the following actions take place throughout:

Consent and Capacity Board mechanisms are accessed wherever appropriate, and process is started as soon as possible

The first correct substitute decision maker is identified and contact information recorded

The next correct substitute decision maker is identified and contact information is recorded

The patient s wishes, values, and beliefs are asked about and documented

All substitute decision makers are provided with information about their role

A person who is incapable, unwilling, or unavailable is not approached as a substitute decision maker

Substitute decision makers are required to provide their decision within a reasonable time, based on the patient s current condition

Redistribution strategies (i.e. decanting, admission) are explored and implemented

CRITICAL CARE UNITS

GOALS

Ensure current ethical, legal, and professional

obligations.

Patients access Rx that they want and can

benefit from, and they do not access Rx they do not want and cannot benefit

from.

Prepared by Osler’s Ethics Quality Improvement Lab, P Chidwick, J Oliver 20MARCH2020 12:00 pm