It is the worst-case scenario of the COVID-19 pandemic: so many seriously ill patients that doctors have to decide who gets access to a limited number of intensive-care beds and ventilators.
And who is deprived of the potentially life-saving treatment.
But as the number of Canadians made critically ill by the virus ticks up, some patients or their families are actually foregoing entirely the often-harrowing treatment afforded by ICUs and breathing machines.
A number of elderly patients have died in long-term care homes rather than submit to intensive therapy that might have only made their passing more painful and uncomfortable.
Dying on a ventilator with a viral pneumonia would be an undignified way to go
Physicians, meanwhile, are urging Canadians to consider now whether they would want the full panoply of ICU care should COVID-19 make them severely ill, especially given research showing survivors of such treatment often fare poorly over the long term.
“If someone felt like they were approaching the end of their life, dying on a ventilator with a viral pneumonia would be an undignified way to go,” said Dr. Michael Detsky, a critical care specialist at Toronto’s Mt. Sinai hospital. “I would be very supportive if somebody told me they didn’t want mechanical ventilation should they deteriorate.”
Some doctors are even considering whether to raise a more touchy issue, asking patients or families to consider giving up their chance at a ventilator for someone more likely to survive.
For now, Canada’s ICUs have ample space, especially after the cancellation of elective surgeries at most hospitals, and more ventilators are on order. But there are fears that a surge in coronavirus cases like that in Italy or New York — which is by no means a foregone conclusion in Canada — could swamp the system and even lead to rationing of care.
Guidelines developed recently by the University of Toronto’s critical-care medicine department urge health-care workers to ask COVID-19 patients soon after they’re admitted what goals they have for treatment, given the potential for “rapid deterioration” once laboured breathing and low oxygen levels set in.
Such conversations could have benefits for more than just the patients, say the guidelines.
“Early establishment of goals of care may also reduce unnecessary utilization of limited critical care,” they say.
Statistics on the proportion of Canada’s 130 or so COVID-19 deaths that have occurred outside of hospital or the ICU are hard to come by. But in Ontario, 18 of the 53 deaths have been in long-term care homes, said a Health Ministry spokeswoman late Thursday.
That appears to include one of of the largest outbreaks in the country.
When the first cases of the coronarvirus emerged at Pinecrest Nursing Home in Bobcaygeon, Ont., last month, its medical director, Dr. Michelle Snarr, emailed families to warn they may have to decide whether to send their loved ones to hospital. That would involve going on a ventilator, she said, and a frail nursing-home resident would likely “suffer a great deal” and might not survive the ordeal.
Pinecrest Nursing Home in Bobcaygeon, Ont.
Carlos Osorio/Reuters/File
Snarr could not be reached for comment, but it appears none went the ICU route.
“Under normal times, we would send people to the hospital if that was the family’s wishes, but we knew that was not going to be possible knowing that so many people were going to all get sick at once and also knowing the only way to save a life from COVID is with a ventilator and to put a frail, elderly person on a ventilator, that’s cruel,” she told CTV News.
In Quebec, Micheline Sauriol’s mother died from COVID-19 at a seniors’ home in LaSalle after briefly being taken to Montreal’s Jewish General Hospital and then returned, according to CBC.
Ventilators help people breathe when their lungs cease to function properly and can save lives. But they also have clear negative side effects.
It is routine for critical-care physicians to brief patients, especially elderly people with multiple illnesses, about the travails and uncertain outcomes of going on the machines, said Dr. Gordon Rubenfeld of Toronto’s Sunnybrook Health Sciences Centre.
“It’s not like you’re awake and alert and writing notes to loved ones.”
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With a tube down their throat and often under sedation, they cannot communicate, while the process of inserting the tube and suctioning airways is uncomfortable and painful. Patients are also unable to take care of their own bodily functions or cleaning. Some say they would let staff know when they’ve had enough, but are shocked to learn they’d have no way to indicate that, said Rubenfeld.
“It’s a bit like being in a twilight or in a dream,” he said. “It’s not like you’re awake and alert and writing notes to loved ones … This inability to communicate is one thing that people don’t know and seems to play an important role in their decisions.”
And the research, a lot of it carried out by Canada’s critical-care doctors, indicates that those who make it out of the ICU and a long stint on a ventilator face an unsure future.
Experts call the possible negative effects “post intensive-care syndrome” — a combination of cognitive decline, psychiatric problems like depression and post-traumatic stress and muscular-skeletal weakness.
A striking 2017 paper by Detsky and colleagues looked at about 300 patients in Pennsylvania who had spent at least three days in the ICU and more than 48 hours on ventilation or being infused with a drug for dangerously low blood pressure.
With a median age of 62, half were dead within six months, and just a third were back to their previous health levels, the researchers found.
Informing patients of the risks and benefits of ICU treatment is standard. But if hospitals become overrun with COVID-19 patients, Rubenfeld wonders if doctors should bring altruism into the picture — tell patients who are unlikely to fare well that not going on a ventilator could free up one for someone more likely to benefit.
“I really do believe that a lot of people are altruistic and a lot of people, particularly Canadians, have a really strong sense of community and social justice,” he said. “It may well be the most ethical and humane way to present this to families.”
(Updated 11:20 p.m. April 2 to include Ontario statistics on location of death.)
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
