Ask Ontario Doctors: Making Difficult Decisions During the Pandemic

Doctors are making difficult decisions on behalf of patients every day during the pandemic. Featuring:
Dr. Erin O’Connor: Toronto emergency physician

Dr. Lawrence Loh: Peel Region medical officer of health

Dr. Anju Anand: St. Michael’s Hospital respirologist

Prof. Maxwell Smith: Western University bioethicist and a member of the COVID-19 Bioethics Table.

Dr. Samantha Hill, OMA Past President and St. Michael's Hospital cardiac surgeon

Transcript

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Spotlight on Health - Season 2, Episode 5 - Ask Ontario Doctors: Making Difficult Decisions During the Pandemic

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Voice-over: In this podcast the Ontario Medical Association looks at current health issues that are on everyone’s mind. Spotlight on Health gives you the straight talk. We’re Ontario’s doctors and your health matters to us.

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Dr. Samantha Hill: I'm Dr. Samantha Hill, President of the Ontario Medical Association. We represent more than 43,000 doctors and medical students across the province. This week, we are still seeing thousands of new COVID cases who our hospitals, our ICUs, and our healthcare workers are straining to care for. Too many people are still unable to get vaccinated, and our province is still in lockdown.

Over the last year, physicians too have had to make extremely hard decisions, both personally and professionally. So, we're here today to talk about the difficult decisions that physicians and others in the health care system are making, or worrying that we will have to make, during a public health crisis in which so many lives are at stake.

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Dr. Hill: I'll now take a minute to introduce our guests who will speak firsthand about the difficult decisions they have been confronting throughout the pandemic.

Dr. Lawrence Loh, the Medical Officer of Health for the Region of Peel. Before that, Dr. Loh served at all three levels of government in two provinces.

Professor Maxwell Smith is a bioethicist and an assistant professor at the Faculty of Health Sciences and Rotman Institute of Philosophy at Western University. He also co-directs Health Ethics, Law and Policy Lab. Professor Smith is a member of Ontario's COVID-19 Vaccine Distribution Task Force, Ontario's COVID-19 Bioethics Table, and the Public Health Agency of Canada's Public Health Ethics Consultative Group, as well as the World Health Organization's ethics and COVID-19 Working Group.

Dr. Anju Anand is a respirologist at St. Michael's Hospital in Toronto, who, during the pandemic, has helped lead grassroots outreach and education efforts, and is currently leading and co-leading a nationwide initiative called "This Is Our Shot."

Dr. Erin O'Connor, an emergency medicine physician in Toronto. She completed medical school at Queen's University and residency training in emergency medicine and palliative medicine at the University of Ottawa.

Dr. Loh, will you please start by telling us about your decision making as a public health physician?

Dr. Lawrence Loh: There is certainly the extreme of significant, severe, long-lasting closures and curtailments that bring with them a whole host of health impacts and issues which are often raised by opponents of the measures that have been taken to date. But there is also a recognition — increasing recognition, especially seeing the tragic experiences of other countries around the world — that if you let this virus loose, and you let things spread completely out of control, you will see the exact same impacts along with significant loss of life, significant burdens on hospitals and healthcare systems, and a significant generational trauma that people will always carry with them.

So, to the extent that you're really in a difficult situation, all of the difficulties that we have been experiencing and undergoing have really had, at its root, the fact that we are living through a human health emergency and disaster. And that fundamentally shapes the way I communicate any of our decisions to the public.

It is about making very clear that this is a very difficult time in our community and our country. And what people need to understand is, in the midst of this emergency, which is not unlike any other natural disaster, we can either choose to do something and it will still be very difficult to get through, or we can do nothing and it will be incredibly difficult with the severity that we have seen elsewhere in other jurisdictions.

Dr. Hill: Thank you so much, Dr. Loh. The OMA has often said that you can't have a healthy economy without a healthy population, and that's something that seems to get lost occasionally in the narrative.

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Dr. Hill: Professor Smith, physicians and patients are tasked with difficult decisions every day. Can you speak to us a little bit about the key ethical challenges?

Prof. Maxwell Smith: It's really hard to succinctly distill exactly what the key ethical challenges are because, really, every element of the pandemic response has an ethical dimension — whether it's whether to lockdown or not, whether it's to offer paid sick leave, and — and how to allocate things like

vaccines. We always need to be thinking about, what do we value, what's equitable, and ultimately, what's the right thing to do?

The biggest ethical challenges probably tend to be the trade-offs that have to be made when we don't have enough of a resource to meet everyone's needs, whether it's vaccines or ICU beds. And if we prioritize one group, we need to think about what other groups will have to wait a little bit longer to get their vaccination.

So, what we need to do is understand what our objectives are with a vaccination program. Is it to prevent overall deaths? Is it to prevent hospitalization? Is it to prevent transmission, or to prevent social and economic deprivation? And we need to ask what risks should be prioritized here and then determine the relative priority of different groups based on those risks.

Another way these difficult trade-offs play out is in the allocation of things like critical care beds and ventilators. If we don't have enough supply then we have to make these difficult decisions. But we also need to make sure that we do that in the fairest way possible and ensure that there are safeguards in place to make sure that certain populations aren't disproportionately disadvantaged by these sorts of decisions that we make, such as persons with disabilities.

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Dr. Hill: Dr. Anand, can you tell us a little bit about what physicians are doing to combat vaccine hesitancy?

Dr. Anju Anand: Vaccine rollout, in general, there's three big things that we've seen that have been very challenging: unpredictability with supply, accessibility, and then issues around hesitancy.

And there's many mixed messages out there — sometimes complicated messages — that Canadians may be overwhelmed with messaging, as well, versus clear, concise messaging. So, that leads to more hesitancy. On top of that, sometimes how vaccines are allocated and honesty around what the challenges are is really important and needed.

Recently, we're having, also, many more Canadians having concerns around what type of vaccine they should get. Everything comes with a risk-benefit ratio, and right now, in most parts of Canada, COVID rates in the community are so great that the small risk of side effects from something like the

AstraZeneca vaccine is greatly outweighed by the benefit of not being hospitalized or dying from COVID.

And we've all had to make difficult decisions in our lives. Physicians and frontline health care workers have had to make them, but everyone in their own way has had to make them and has suffered from COVID, and we want this to end, and there's a lot of negativity and fear.

And if we can look at vaccines as something positive, and a safe space for people to come and address fears and questions with clear messaging and make this sort of a "Team Canada" type approach, I think that that would be one way to help combat and change the hesitancy into confidence.

In general, we're seeing across hospitals all over Canada — and in Ontario and a lot of the hotspot areas — the inequities that existed in many populations that are disproportionately affected with COVID have just been heightened with COVID. And many of those inequities actually also lead to younger patient populations being sick at the moment.

Many younger patients are essential workers and racialized populations that are still going to work because they don't have a work-from-home option. They're living in multi-generational or student housing with many other young co-family members. I think this is where trying to really target individual concerns from populations that are disproportionately affected, and allocating resources — as we were talking about difficult decisions — to have the greatest impact for all Canadians.

“This Is Our Shot,” is a nationwide campaign that a bunch of grassroots organizations have come together, really, to rally all Canadians to try to get their vaccine when it's their turn.

It's aimed at having educational, factual information. We have 27 different languages, FAQs on our website, and we're going to have series of town halls to really encourage all Canadians to come with questions and concerns. Because if we don't get all Canadians on board, then we will not be able to achieve herd immunity, and we won't see this pandemic end.

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Dr. Hill: Dr. O'Connor, I'm going to turn to you next. We know that you are facing some, or worrying about, some difficult decisions potentially for the emergency department.

Dr. Erin O’Connor: The potential of what's called critical care triage for the emergency standard of care and having to make decisions about who will be offered critical care resources and who will not, and I don't think that this is something that any of us in medicine thought we would have to do in Canada, in a situation where we are used to working — we have the privilege of working in a situation where we were very well resourced and we're kind of facing the situation of not being well resourced. And I worry about the effects that this will have on my colleagues.

This takes an extreme emotional toll on colleagues, to say I can't offer you something that they would have offered in the past, something that may potentially benefit a patient, that they can't offer.

Those of us on the frontlines realize that we have to allocate resources to those most likely to survive, but I — it's a heartbreaking decision to have to make.

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Dr. Hill: Ontario's doctors are here for you, and they are making the most difficult decisions every day to safeguard your health.

Dr. Loh: When we are moving to address a specific disease, that — whether it is a recognition that the precautions and schools are maybe no longer holding to keep in person learning safe, or maybe that our workplaces are starting to really see further and faster spread of variants — the need for being able to go forward on a decision that is in the best interests of our community that may be at odds with different groups in the community, that may also open, not just myself but certainly my staff who I'm always thinking about, as well as our hospital and healthcare partners, up to abuse or harassment. I think those are all sorts of things that ultimately get weighed into some of those decisions.

Recognizing that they are made in the midst of trying to control this human health emergency, and that they do impact a lot of people and do cause a lot of difficulty, but are ultimately needed in the same way that you would order an evacuation for hurricane or in the same way that you would order people to stay at home that there is an ice storm.

I think the use of those powers is something that we have tried to use judiciously but have had to use in recognition of the unique circumstances our community has weathered through this pandemic.

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Dr. Anand: For me, seeing so many communities disproportionately affected with COVID-19, one of the hardest decisions that I had to make was, in addition to my day job, to really work very hard and put my family aside to try to advocate for people who don't have a voice.

And that doesn't sound like a hard decision, but when everyone's burned out and you have other responsibilities, and I think all Canadians sort of feel that, to sort of put your needs aside to try to help those people who don't have a voice has been something that has been hard but rewarding for me.

But my most difficult decisions are coming.

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Dr. O’Connor: Back in the very beginning, and being someone who was working in the ED with very little information about this virus, the decision about whether I would still come home to my family or whether I should be renting an apartment and not coming home to my toddlers at all because of the fear and of the potential risk that I was exposing them to. Because I certainly wasn't going to stop seeing patients and stop doing my job as an emergency physician. But then the trade-off was, well, what is the cost to my family?

And I think that that's not a unique decision that many health care providers had to make at that time.

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Prof. Smith: As an ethicist, my job is really in an advisory role. Out of the conversations and discussions that I've had play a role in — in making recommendations, I would say the two most difficult: providing proposed framework for critical care triage, one of the most difficult decisions that I think anyone will have to make, and, similarly, identifying populations to be prioritized for vaccination has been really difficult.

We need everyone in this province to be vaccinated at the end of the day. And so no one is without risk. That's part of the — the most difficult decisions that I've had to play a role in.

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Dr. Hill: We are at a place for most health care workers where we've been put in a situation that is high stress, and we have stepped up and we've stepped into that

space in a variety of ways. We have pushed through personal decisions, and we've done all of this from a fortunate place that many Ontarians didn't even have those choices. And we're well aware of that. But we've also carried the burden of consequences of health care decisions on our population.

Physicians, by and large, go into medicine because they want to help people. And, by and large, they — they carry that weight and that toll very personally.

There's going to be a cost to this, and we won't know for sure what it is until the dust settles and people have a chance to stop reacting and start experiencing. And that won't come for most of us until after the third wave tapers off.

Physicians were struggling long before the pandemic got here, with a fair number of us struggling with burnout. And at the end of the pandemic, we're still going to have to catch up on all of that backlog of care, and if physicians and nurses aren't able to do that work, we're going to be in a very challenging position.

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Voice-over: This podcast is brought to you by the Ontario Medical Association. It is produced and edited by Jodi Crawford Productions. This podcast is not intended to provide medical advice for specific situations and is for general educational purposes only. Please consult your doctor if you have symptoms or questions about your health.

For more information, please visit our website at oma.org.

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