A plan of last resort: Choosing who lives and dies if ICUs turn into virus war zones

If hospitals become overwhelmed, doctors will be asked to make impossible 
decisions that in normal times would be anathema to their training.

It’s not quite drawing names from a hat.

But if COVID-19 pushes hospitals to crisis levels, Ontario hospitals have been instructed that, when faced with tie-breaking situations — one empty bed in the ICU, and two, four or more critically sick people with more or less equal chances of surviving competing for it — random selection should be applied.

Each person would be assigned a number. The administrator on call would enter the numbers in a random number generator like random.org, and then click the “generate” button.

“Randomization is efficient when decisions need to be made rapidly,” reads a critical care rationing plan prepared for Ontario hospitals designed to help doctors decide who should get access to beds, intensive care or ventilators in the event of a catastrophic COVID-19 surge. Randomization avoids power struggles between doctors, the document continues. It eliminates explicit or unconscious bias and, critically, reduces the moral and psychological burden of deciding whom, ultimately, wins the bed. Who gets a chance at living.

It may sound dystopian and dehumanized. But far worse than a random number generator would be a human being having to choose, said Dr. Judy Illes, a professor of neurology at the University of British Columbia. “Because the people who have to administer those decisions are hugely at risk for moral distress and trauma.”

Doctors in Canada have never faced critical care rationing. There is no historical precedent. If hospitals become overwhelmed, doctors will be asked to make impossible decisions that in normal times would be anathema to their training.

And while thousands of people aren’t getting the timely care they need — knee surgeries, hip replacements, the start of new experimental drug regimes, because of backlogs when hospitals shut down to all but urgent care — most people in Canada have never had to worry about getting rationed for life-saving care.

Critical care triage protocols, like those now being distributed to Ontario and Quebec hospitals, are formed from lessons learned in battlefields and natural disasters. “But it will be no less heart-wrenching in this situation, and maybe even more so,” because the decisions will be taken in urban hospitals, Illes said, not in fields with grenades going off.

“It’s not a question of will the public cooperate? The public will have no choice,” said Illes, who warns that our autonomy will be eroded if we don’t take better control of the situation.

Nothing is fair about COVID-19, Illes and UBC political science professor Max Cameron wrote in April,

and now, nine months out, aggressive mutations are spreading. Hospitalizations and deaths are increasing. An average of 878 people were being treated in ICUs each day during the past seven days. Health-care workers are frightened, anxious, exhausted. Social distancing is slipping,

Peter Loewen reported this week in Public Policy Forum;

and most Canadians won’t be vaccinated until the end of September. Ten months into the pandemic, “and there are 10 months to go,” wrote Loewen, a political science professor at the University of Toronto. “This is half-time.”

Meanwhile, Ontario surpassed 250,000 confirmed infections, Quebec a breath away from the same grim mark, and while Quebec’s health ministry told the

National Post

Friday the province is still a long way from triggering its ICU prioritization protocol, doctors are nervously looking at the U.K, where a new variant is  turning some hospitals into

“war zones.”

“We want to avoid being patients,” Illes said. “We want to exercise our autonomy to help everyone get through this viral war that we’re in and that we’re not winning right now.”

If people don’t double down on distancing and masking and other precautions, choice will no longer be relevant, she said. “Procedures will take over; protocols will supersede choice. And the focus will be on this public-centred approach, maximizing the most good for the most number of people.”

The Ontario ICU triage protocol, used as a model for triage protocols adopted in Quebec, prioritizes those with the greatest likelihood of survival. (It applies to adults only, not children). People who have a high likelihood of dying within 12 months of the onset of their critical illness would be assigned lower priority for critical care. Doctors would score each person on a “short-term mortality risk assessment,” and across a whole range of different conditions — cancer, heart failure, organ failure, trauma, stroke or severe COVID-19 — ideally before they are intubated, connected to a ventilator. It aims to reduce “preventable deaths to the degree possible” under major surge conditions, with the “least infringement of human rights.” Consultant doctors would be available 24/7 to provide a timely (within the hour) estimate of a person’s survival, “recognizing that such estimates may not be perfect,” but likely more accurate than non-expert judgment. In the final “summary and care plan,” one of two boxes would be checked: the patient will, or will not be offered critical care. Those who don’t meet “prioritization criteria” won’t be abandoned. They’ll receive appropriate medical therapy and/or comfort care.

Most controversially is what is not included in the current plan — a recommendation before the Ontario government that life-support be withdrawn from people already in the ICU whose chances of survival are low, if someone with better prospects is waiting behind them.

The 

Post

reported this week that Ontario Premier Doug Ford’s government is being asked by its external advisory COVID-19 Bioethics Table to pass an “executive order” that would permit doctors, without the consent of patients or families, to remove breathing tubes, switch off ventilators and withdraw other life-saving care from people who are deteriorating, and where further treatment seems futile, so that someone who otherwise might live can take their place.

Withdrawing treatment from someone who hasn’t consented to it could be argued to be culpable homicide, said disability rights advocate David Lepofsky. “There are huge legal questions here, and they need to be discussed in the open, because we’re talking about possibly taking an active action that could accelerate someone’s death,” he said.

“The government can’t decide on who lives and who dies by a memo, written in secret, with no debate in the legislature.”

Under normal conditions, withdrawing treatment without consent would be an “illegitimate choice,”

Annette Dufner, of the University of Bonn, wrote in the journal Bioethics.

Even in a pandemic, doctors might risk legal charges.

“At the same time, it is by no mean obvious that patients already under treatment in a setting of scarcity have the same moral claim on the respective medical resources they would normally have,” Dufner wrote. When scarce, “the use of resources can, after all, come at the cost of other patients’ lives.”

Any suspension of the consent act would be temporary, said Dr. James Downar, a member of Ontario’s Bioethics Table “And, to be super clear: if there are enough resources for everybody, this never happens.”

Outside the horror of having to choose, even the practicalities of deciding who gets an ICU bed and who should be “discharged” — the dispassionate euphemism for stopping intensive care  — “these kinds of equitable, distributive justice kinds of decisions are very, very complicated,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.

And how will patients, and families, be told that, “by virtue of this decree” you will, or will not, receive life-saving care? “I don’t know how it’s going to be done,” Goldberg said. “No one has ever done this.”

“Families will presumably have heard about this, from the press. But they may not. They may think this is science fiction. They may go to the courts, and I don’t know what the courts are even going to say in this case.”

Goldberg has never had to take community needs, values or resources into consideration when caring for the critically ill. “Never. Zero. When I have discussions with patients and families, my perspective is always deontological,” what’s best for the person lying in that hospital bed. That “duty to the patient” is now being supplanted by a utilitarian view that says we need to rescue the most lives, he said.

“I understand it, intellectually. But from a physician point of view that I was taught all these years, and from my own personal perspective, it’s just anathema.”

He takes comfort that admissions to his hospitals are coming down.  He’s hoping it’s a trend. “The kids went back to school in Quebec yesterday, the high schoolers. The epidemiologists are telling us we may see a blip in 10 days or two weeks if schools really are a reservoir.”

“We’re waiting. We’re not putting our cards away. But we can’t get far enough away from this.”

Triage protocols, medically-guided protocols that are blind to disability, socio-economic status, cultural origin, are the only way to manage and mitigate the moral distress facing the people who will have to enact them, Illes said. “At the end of the day, it is physicians on the frontline in the ICU with blood flowing on the floor who will bear the burden of decision-making.”

“How do we protect families from moral distress? I don’t know. No protocol is going to help anyone to understand that the people who cared for their loved person weren’t able to take the last-mile possible saving procedure,” she said.

“Let’s try to avoid ever going there.”

• Email: skirkey@postmedia.com | Twitter:

Source: National Post Quebec Nordiques

Celebratory selfies by doctors and nurses promote vaccine safety, but are 'demoralizing' for some still waiting

By Ben Huang

As COVID-19 vaccines continue to be administered to frontline health-care workers across Canada, many doctors have been using social media to share photographs of their vaccinations. These began as celebrations of an innovative medical breakthrough during a long and taxing pandemic, but have also become ways for doctors to lead by example and show the public that COVID vaccines are safe.

“I’ve never had people request a photo when they’ve gotten a vaccine before,” says Monika Winnicki, a dermatologist in Toronto who decided to volunteer to administer vaccines at the Sunnybrook Cancer Centre after her grandfather died from COVID-19. “I think it points to how terrible the pandemic has been and what a historic moment it is…. I’ll be very excited and enthusiastic for when my turn comes up.”

Kelly Ogilvie, an emergency doctor in Vancouver and an Ironman triathlete, says she was surprised when her vaccine selfie got more likes than a Facebook post about finishing her Ironman competition.

“I think it speaks to how everyone’s looking forward to the light at the end of the tunnel,” she says.

However, some frontline workers say the social media phenomenon is fuelling anxiety, envy and frustration. Many physicians are still waiting for their turn in what has been a slow national rollout,

criticized

for its fragmentation across, and even within, provinces.

“When we are on the frontlines and seeing, on social media, vaccinations being given to child psychiatrists doing Zoom meetings or doctors on maternity leave…it gives us the message that we’ve been forgotten,” says Alan Drummond, an emergency physician in Perth, Ontario, about an hour southwest of Ottawa.

For Drummond and other doctors outside of major centres, vaccine celebrations on social media are “tiresome” and “demoralizing.”

“I feel like the urban centres are getting covered. I feel like rural Canada is being missed,” says Sarah Giles, a rural family and emergency physician in Kenora, Ont., near the Manitoba border. “Every time I see a friend posting, I’m happy for them but feel incredibly anxious.”

“We were told (a vaccine) is three months away. There is no vaccine rollout where I’m working — no one has received a vaccine,” she says. “I’m just disappointed. My hospital covers several different communities and there are outbreaks and we definitely see COVID-positive patients…. Rural lives matter too.”

Giles, who has also worked with Doctors Without Borders in countries such as Sierra Leone, Pakistan, South Sudan and Myanmar, says she is worried about the effect of vaccine photos on the morale of people in lower-income countries. “My friends in those countries are not posting vaccine selfies,” she says.

Winnicki echoes her: “One of the personal support workers I was vaccinating said her mom who lives in the Philippines was told by her local public-health official that she wouldn’t be getting it

until 2023

.”

In Montreal, where

frustrations have grown

over a slow provincial rollout, Audrey Marcotte, an emergency medicine resident, says: “As selfies continued to show up, the emotions turned a little bit complex. I caught myself in a more envious state, and then feeling guilt around feeling envy.

“It’s never about individuals; it’s more about feeling (the rollout) should be going faster than it is,” she says. “I think it’s a normal feeling. But I think it’s important to acknowledge the feelings of envy and guilt.”

Charlottetown emergency doctor Aleisha Murnaghan has also felt some guilt, but for different reasons. “We haven’t really seen a ton of cases…. My life hasn’t really changed a whole lot in the past year…. I’ve had Thanksgiving and Christmas dinners with my family. Birthday parties have been celebrated.”

Murnaghan has received her second vaccination dose. “I haven’t posted anything for fears of how it would make my deserving colleagues who haven’t gotten theirs yet feel. Seeing their anxiety on social media has made me realize that posting a picture…might not help their morale.”

Still, many doctors argue that the selfies are useful to educate and inspire vaccine-hesitant friends both outside and, surprisingly, inside health care.

Jennifer Chu, an emergency physician at St. Michael’s Hospital in Toronto says, “there’s a lot of mistrust and conspiracy theories around ‘Big Pharma.’ A lot of people also don’t understand how drugs are made and think that the vaccine can’t be safe because it was rolled out so quickly.”

Vaccine hesitancy has been surprisingly prevalent among health-care workers at long-term care facilities. Some Ontario centres have had worker vaccination rates as low as 20 per cent, according to Kashif Pirzada, an emergency doctor in Toronto.

Pirzada has also been working with Canada’s South Asian COVID

Task Force

to target vaccine hesitancy that is prevalent among the country’s South Asian population.

“Usually the same claims will come up, such as that the vaccine will change your DNA, or that it hasn’t been properly tested, or that it contains pork products, which would make it forbidden for Hindus or Muslims,” he says.

Pirzada decided to post a selfie with captions in Hindi and Urdu to combat this false information.

Constance Nasello, chair of the Ontario Society of Obstetrics and Gynaecology, hopes to also see social media used to advocate for vaccinations for

pregnant

women.

“When Ontario Public Health put out its guidelines for vaccinations, they excluded pregnant and lactating women,” Nasello says. The consensus by several societies, including the Society for Obstetricians and Gynaecologists of Canada, is that it should be offered to pregnant women, she says.

Nasello explains that the risks of complications from COVID-19 are high in pregnant women, so vaccination is especially important for them.

“About eight to 11 per cent of pregnant women who acquire COVID-19 will end up sick enough to be admitted to hospital, and two to four per cent end up in ICU with severe complications, including being on a ventilator for weeks to months and long-term effects from COVID.”

Nasello says she’s been using social media with other obstetrician-gynecologists to get the message out there. “Pregnant doctors are posting to show people that they feel it’s safe enough to get it themselves.”

Kavitha Passaperuma, an oncologist in Richmond Hill, Ont., says that, despite the controversy, she thinks physicians should keep sharing selfies to celebrate and promote vaccines.

“I think we have an obligation as medical experts to spread sound medical knowledge and facts to our non-medical friends and family,” she says.

“I think the time to address and remove vaccine hesitancy is now…. As physicians, we are highly mindful of staying in our own lane when it comes to various societal issues. This is our lane.”

Ben Huang is an emergency medicine resident physician in Vancouver and a freelance journalist.

Source: National Post Quebec Nordiques

Scientists unite to save the sweet potato's identity

The sweet potato is the seventh most important crop in the world.

Every Friday, the

Convolvulaceae Network

gathers virtually to discuss all things related to the morning glory family. Taxonomist

Ana Rita Simões

of Royal Botanic Gardens, Kew in the U.K. and researcher

Lauren Eserman

of the Atlanta Botanical Gardens in the U.S. started the seminar series in September 2019 as a space for scientists to share their work.

The group grew organically, from the fewer than 50 people who joined the first Skype call — during which Eserman presented her work on the evolution of storage roots in morning glories — to roughly 150 today. Now held via Zoom to handle the crowd, its fluid membership joins the discussions, seminars and collaborative meetings from nearly 20 countries, including Brazil, China and Mozambique.

“It’s really diverse,” says Simões. “You get anyone from working in very fundamental science — like really theoretical stuff — to people who work in more applied science. So they work directly with farmers of sweet potato, or work in horticulture. It’s been really enriching because everyone brings their bit and then we can help put pieces of the puzzle together. We can help to solve some problems.”

One such problem has to do with saving the sweet potato’s identity.

Convolvulaceae

is a family of roughly 1,880 species and includes the sizable genus

Ipomoea

, 900-species strong. The family’s largest genus,

Ipomoea

encompasses ornamental and weedy morning glory flowers, and the sweet potato — the seventh most important crop in the world.

 A change to the sweet potato’s scientific name would have repercussions for the food industry, conservation and global food security.

Genetic studies, though, have clouded this categorization in showing

Ipomoea

to be made up of two groups, rather than one. In the spirit of improved classification, this enhanced understanding of plant genetics could potentially result in a future name change for the sweet potato. And in this case, there’s much in a name: it could come at a cost to the food industry, conservation and global food security.

On the Friday I joined the Convolvulaceae Network’s weekly seminar, Eserman presented a collaborative proposal to preserve the plant’s scientific name:

Ipomoea batatas

. For their new paper published in the journal

Taxon

, Eserman and Simões brought together a group of 41 sweet potato specialists across 17 nationalities and five continents (including Joanna Rifkin and John Stinchcombe of the University of Toronto’s department of ecology and evolutionary biology) to find a fresh solution to an old problem.

The issue stems from when Swedish botanist Carolus Linnaeus first described the genus

Ipomoea

in 1753, naming not one but 17 species, Simões explains. Every time a new species was described and compared, and found to be similar to any of those 17 species, it could be named

Ipomoea

. The genus has been expanding ever since.

Advances in DNA-based plant classification have shown that

Ipomoea

is made up of two distinct groups: sweet potato and morning glories in the first, larger group (roughly 600 species); and plants native to Africa and Southeast Asia, many of which are threatened in the wild, in the second, smaller group (about 300 species).

These two subsets of

Ipomoea

have been on “basically separate evolutionary trajectories for about 20, 25 million years,” Eserman said in her presentation. “So grouping everything under a single, large

Ipomoea

, you lose some of this evolutionary information.”

 More than 90 million tons of sweet potatoes are produced every year.

Tiger’s footprint (

Ipomoea pes-tigridis

), a plant in the second, smaller group, has been used to define the genus

Ipomoea

since the 1970s. Called the type species, it is especially significant because it represents the genus as a whole. When DNA studies revealed the evolutionary gap, the sweet potato and its morning glory relatives in the first, larger group risked being renamed.

“Basically, all those 600, some of them really economically important, (could) be renamed. All for the sake of sticking to a rule, a very strict rule, that could be changed,” says Simões. “Some people who are more conservative would say, ‘Well, you have to stick to the rules. If someone said in the ‘70s that this is the type species, then you just really have to rename sweet potato and it doesn’t matter.’ What we’ve tried to do is say, actually, no. Let’s try to find a compromise here. Maybe we do have to bend the rules a bit.”

In their proposal — which will be voted on at the 2023 International Botanical Congress in Rio de Janeiro, Brazil — the scientists suggest changing the type species for

Ipomoea

to one closely related to sweet potato.

They’ve chosen

Ipomoea triloba

, which is a member of the first, larger group encompassing sweet potato and morning glories, and is one of the 17 species Linnaeus originally included in the genus.

“We want to choose a type species for this group

Ipomoea

so that whenever someone wants to describe a new species in this group, they know exactly what to compare it with,” says Simões.

 The scientists are proposing a different type species for Ipomoea: Ipomoea triloba.

With an annual production of roughly 90 million metric tons, a hypothetical name change could be costly to sweet potato breeders, producers and regulators worldwide, Eserman explained in her presentation. Promoting a new scientific name for the sweet potato could lead to communication breakdown between scientists and the agricultural community, not to mention costs passed on to consumers.

From the actual sweet potato roots to products made from them, such as bread, candy, chips, flour, noodles and pectin, all labelling, packaging and documentation would have to be changed. “Anything that you can think of that would involve the name of that species would have to be updated and that’s a cost,” says Simões.

If voted in, this bend in the rules would keep the group with the highest diversity intact while preserving the identity of the economically important sweet potato and aiding conservation efforts for the threatened wild species in the smaller, second group, the scientists say, which can be renamed as science progresses.

“It works both ways. Those species to be renamed, it’s going to be easier to conserve them. And the other species that are closely related to sweet potato, it’s going to be easier to work with them on all these aspects of more applied science towards strategies for food security and fighting effects of climate change,” says Simões, adding that specialists working with the second, smaller group would welcome a change in identity.

“A lot of them are threatened in the wild and they do need conservation action. In Thailand, some of these species are flagships for some protection — they’ve created parks around these species — so the fact that they’re named

Ipomoea

in those countries is actually negative because they’re associated with the crops and the ornamentals … By renaming it something else, it makes it so much easier for our colleagues on the ground to make a case for protecting them because it can be set aside from this other, mostly American, cultivated and more weedy species.”

As a reflection of evolutionary relationships, species names are significant when it comes to future-proofing crops and safeguarding food security. In studying characteristics of the sweet potato, such as disease-resistance, drought tolerance, and starch or water content in roots, researchers would turn to its close relatives to determine if they have similar characteristics and if they would be useful for breeding.

If producers in Uganda, for example, wanted to find an alternative to the sweet potato, which originated in Central and South America, they might try to find other species that are closely related to it. They may turn to the wild relatives of sweet potato, which might be suitable for cultivation and are native to East Africa. But to do that, Simões underscores, you need to know which species are most closely related to sweet potato. And this is especially difficult when you’re dealing with a large genus.

“You want as much genetic diversity as possible. You want people to be growing their own food locally and you want to make sure that whatever they’re growing locally is nutritious enough to solve possible famine due to climate change,” says Simões. “In this case, it just makes it more effective if we can name the species closely related to sweet potato the same … so that the other species that are not related are not included, or not prioritized in those crop studies.”

Communicating the implications of the group’s work, Simões says, is a way of conveying the direct impact taxonomy can have on people’s lives. The approach they’re taking with the Convolvulaceae Network has already had a ripple effect: another group of scientists used it as a model when starting a similar virtual seminar focused on nightshades, called Solanaceae Seminar Online.

Regardless of the outcome of their proposal, Simões sees it as an example of the power of diversity in collaboration and a way to deconstruct the notion that science is somehow removed from the realities of everyday life. She also hopes it, like the Convolvulaceae Network, will encourage other scientists to work together more often.

“Twenty-first century science should be like this: People from different fields getting together discussing solutions. Technology allows it today so there’s really no reason not to do it,” she says. “We also hope that it’s inspiring that science can be a bit more open to society and to understand all these challenges we’re facing ahead — like food security and climate change. We need to be open to understand that at a societal level and work towards fighting those challenges.”

Source: National Post Quebec Nordiques

Inside Alberta's very bad week: A behind-the-scenes look at the killing of Keystone XL

Posters in support of Canadian oil are displayed in Edmonton. Alberta is reeling after U.S. President Joe Biden killed the Keystone XL project on his first day in office.

EDMONTON/CALGARY – The Alberta government’s trade office in Washington, D.C. called home last week with grim tidings: Rumours were circulating the U.S. capital that President Joe Biden was planning to scrap the Keystone XL pipeline on his first day in office.

It set off a wave of alarm. The Alberta government worked through the weekend to prepare its response strategy and a flurry of phone calls were placed between Ottawa, representatives in Washington and to the TC Energy headquarters in Calgary. On Sunday, news outlets reported on a Biden team transition memo that said the death of Keystone XL was coming.

A senior Alberta government source said there was a “lot of anger” within the premier’s office, given they had been hoping Prime Minister Justin Trudeau — who spoke with Biden in November — was going to at least be able to keep Biden from scuttling the project until further discussions were held, even though he’d promised to kill it in May 2020.

“It felt like a betrayal,” the source said.

The impression that there would be discussions going forward was mistaken. And no one was prepared for the pipeline to be cancelled on Biden’s first day. Kenney placed frantic calls to federal ministers, U.S. congressmen, American labour unions, and, on Tuesday, the day before the inauguration, the premier and James Rajotte, Alberta’s envoy to the United States, had a phone call with Trudeau.

Both asked Trudeau to phone Biden, to speak to him about the project. Rajotte, said the Alberta government source, told Trudeau “union groups told him that only a phone call from Trudeau to Biden could salvage the project.”

“The PM did not acknowledge the request to call,” the source said.

The Prime Minister’s Office declined to comment on the specifics of the phone call between Kenney and Rajotte and Trudeau, and referred the

National Post

to previous statements Trudeau has made about the pipeline.

Kirsten Hillman, Canada’s Ambassador to the United States, was notified of the decision on Tuesday night before the inauguration and executive order signing the next day.

On Wednesday, within hours of being sworn in as president, Biden signed an executive order that revoked the presidential permit Trump had issued for the US$14.4-billion pipeline that would link Alberta’s crude oil production with heavy oil refineries in Texas and Louisiana. Since then, it’s been tools down for thousands of workers, many of them members of massive American labour unions.

That evening, as inauguration celebrations were being held in Washington, Alberta’s premier took to the lectern, calling the decision a “gut punch” and “an insult directed at the United States’s most important ally and trading partner.”

On Thursday, TC Energy served notice of 1,000 layoffs along the pipeline route, Reuters reported.

Given Biden’s campaign promises, the cancellation wasn’t “out of the blue,” said Paul de Jong, president of the Progressive Contractors Association, which represents unionized construction companies that build major infrastructure projects.

“This is an approach that President Biden has been signalling for some time,” de Jong said. His organization supported the pipeline.

Still, within the energy industry, executives were hopeful that a negotiation on the merits of the project was possible.

“Up until the pen hit the paper, there was some hope that there would be some conditions around it or some ability to negotiate and engage,” said Chris Bloomer, president and CEO of the Canadian Energy Pipelines Association, an industry group representing midstream companies — TC Energy is a member.

“I have to believe that the governments, both federally and provincially, engaged in sincere conversations about this and tried to find a way through, but this has evolved to be such a powerful political symbol, that I think that trumped everything.”

A federal government official described the effort to advocate in Washington for the project as a “Team Canada” approach between Alberta and Ottawa. The team attempted to sell the merits of the project: built with union labour, partly owned by Canadian and U.S. Indigenous groups, and powered by renewable energy. It also pitched Canada as being committed to emissions reductions and a carbon tax.

 A depot used to store pipes for TC Energy’s planned Keystone XL oil pipeline in Gascoyne, North Dakota, January 25, 2017.

Throughout last fall, Alberta Energy Minister Sonya Savage, federal Natural Resources Minister Seamus O’Regan, and Rajotte held weekly calls to strategize on how to make the case for Keystone XL in the U.S. halls of power.

The Alberta government had also ramped up its lobbying. Alberta’s trade office in Washington held more than 60 meetings with politicians and staff — mostly Democrats and “Biden influencers.”

In December, Alberta added two Washington lobby firms, JDA Frontline Inc. and Crossroads Strategies, to its roster (a contract with Crestview Strategy was already in place) to press the case for Keystone XL, the Alberta energy sector broadly and other economic issues in Washington.

But the efforts made over the last half of 2020 were too little, too late, sources said. The project was doomed. There were also several missteps during the Trump years that made it less likely the project would survive an incoming Democratic president looking to appease the environmental wing of his party.

“It would have made no difference. I lived all this,” said Dennis McConaghy, a former TC Energy executive who oversaw the Keystone XL pipeline project under the Obama administration before his retirement in 2016. “There was no one you could have hired that was going to change the minds of the people around Biden.”

The “Team Canada” strategy has now taken on a new dimension. Kenney has demanded that Ottawa take a more assertive approach in an attempt to negotiate for Keystone XL and, if that fails, to retaliate with sanctions. Other premiers, it seems, share his concern.

On a Thursday evening phone call with Trudeau, Quebec Premier François Legault, Ontario Premier Doug Ford, and Saskatchewan Premier Scott Moe all expressed dismay, said an Alberta government source with knowledge of the call. Canada meekly accepting the death of KXL sets an alarming precedent for the country, which faces the possibility of the Biden administration also invoking Buy American provisions in federal projects.

The Alberta source told the

National Post

that Kenney had made this case to Trudeau on the Tuesday phone call, and that Trudeau agreed, and said that would be his message in the coming days to Biden. He was to speak with the new president on Friday.

“The PM’s rather muted response the next day seemed to very much contradict both publicly and to us privately about how Keystone was a top priority. It told us all we needed to know about where we stood,” the source said.

Wednesday marked the third time a U.S. president has killed the project, which was first proposed in 2008 and has spent more than a decade in regulatory reviews and endless litigation.

Former U.S. president Barack Obama vetoed Keystone back in 2012 and, after the company re-applied for permits at the president’s own invitation, denied the project permits again in 2015.

A senior company source, who has since left TC Energy, but who has direct knowledge of the matter, said the U.S. administration gave the company, then called TransCanada Corp., one hour’s notice of the impending cancellation at that time. The company’s then-president and CEO Russ Girling looked liked he was in shock after getting notice of the veto in 2012, the source said.

 Premier Jason Kenney speaks in Calgary on January 20, 2021, regarding the cancellation of  the Keystone XL pipeline.

But the source said the company made strategic mistakes in its third attempt to get the project built after former U.S. president Donald Trump signed an executive order reviving the pipeline on Jan. 24, 2017. They did not communicate the merits of the project assertively with opponents, and most importantly, did not leverage relationships with major U.S. trade unions.

“They (trade unions) were the only ones that could have put enough pressure on the Democrats to stop this from happening,” the person said, noting that labour marches in Washington or other demonstrations of support had been effective in garnering support for the project in the past.

And, for years, TC Energy had only one government-relations contact in Washington, D.C., meaning the company was understaffed in the very place where it most needed support for its key growth project.

TC Energy did not respond to requests for comment. The company has already announced it will take a sizeable charge on its balance sheet as a result of the cancellation.

Research from BMO Capital Markets shows that TC Energy had spent US$1.7 billion on the project up to the end of September 2020, but $720 million of that was contributed by investments from the government of Alberta.

For the Alberta government, the project has long been a must-build, as it would have connected North America’s largest heavy oil formation, the oilsands, with the world’s largest concentration of heavy oil refineries on the U.S. Gulf Coast.

The province first began discussing the possibility of a loan guarantee for the Keystone XL project in June 2019 in an effort to drive the project forward. In the end, the province invested $1.5 billion directly in the project to give itself an ownership stake and also to finance 80 per cent of the first year of construction. It also agreed to a $6 billion loan guarantee that would have been used for construction costs this year.

The opposition New Democrats have called for a release of all the details contained in the contracts between the government and the pipeline giant.

The governing UCP, meanwhile, has been pressing Ottawa to do more. On Thursday evening, Kenney sent a letter to Trudeau expressing his concerns about the cancellation of the project and called upon “the government of Canada to press the U.S. Administration to compensate TC Energy, and the Government of Alberta” for the money spent on the project.

Now, the Alberta government and TC Energy are left with a pipe to nowhere. Parts of the line are built through Alberta and Saskatchewan as well as across the Saskatchewan/Montana border.

McConaghy, the former TC Energy executive, said the business case for Keystone XL is actually expected to strengthen in the coming years in the U.S., because refineries in Texas and Louisiana are designed to process heavy crude, and the output from other sources, like Venezuela and Mexico, are declining.

But, the business case aside, what could spell the final death — or another rebirth — is who is in the Oval Office four years from now.

“It think it’s most likely that this project is over at least as long as Joe Biden is president,” McConaghy said.

— With files from John Ivison

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Source: National Post Quebec Nordiques

Trudeau refuses to apologize or take any responsibility for decision to nominate Julie Payette as governor general

Prime Minister Justin Trudeau holds a press conference at Rideau Cottage in Ottawa on Friday, Jan. 22, 2021.

OTTAWA – Prime Minister Justin Trudeau refused to apologize or acknowledge any responsibility for his decision to nominate now former Governor General Julie Payette,

who resigned Thursday

after a report found she helped create a “toxic” work environment at Rideau Hall.

During a press conference on Friday, Trudeau dodged repeated questions from reporters about his responsibility in the disastrous and unprecedented end to Payette’s tenure as Governor General, as well as the adequacy of the vetting process that failed to note similar issues she caused at previous workplaces.

“Everyone deserves a safe and secure workplace, and that includes people who work hard in the Governor General’s team. That is something that I take very seriously,” Trudeau began in French during a prepared statement.

“Yesterday, I accepted the Governor General’s resignation. This morning, I had a phone conversation with Her Majesty the Queen and I informed her that the Chief Justice of the Supreme Court would fulfil the duties of the Governor General on an interim basis.”

Speaking to National Post about Payette’s resignation, Daniel Béland, director of the McGill Institute for the Study of Canada, said responsibility for the unprecedented moment fell squarely on the prime minister’s shoulders.

“This is very bad for Justin Trudeau because Julie Payette was his choice. She was not vetted properly, and this once again calls his judgment into question. You cannot repair nor undo this. This is a major stain on the reputation of Justin Trudeau and it’s not good for the Liberal government at all,” Béland said.

Since her nomination in July 2017, Payette’s time as Governor General has been filled with controversy. Media reports have detailed questionable spending projects at Rideau Hall, Payette’s clashes with her security team, as well as her role in creating a “toxic” work climate for employees working for Rideau Hall.

Payette’s workplace issues also predate her time as Governor General. In August, National Post reported that her harsh management style had also created issues with staff when she ran the Montreal Science Centre until 2016.

Payette said in her resignation statement Thursday that no formal complaints or official grievances were ever filed against her during her tenure.

“There were so many red flags that were documented, including harassment allegations about Ms. Payette prior to her being named Governor General. So prime minister, where does the buck stop? Where does the responsibility lie for this?” a reporter asked Trudeau.

“Obviously, the vetting process that was in place was followed, but obviously we’re going to also look at ways we can strengthen and improve the vetting process for high-level appointments,” Trudeau responded.

In another series of questions less than 24 hours since Payette’s resignation, reporters asked the prime minister if he felt the need to apologize to Rideau Hall workers who had allegedly suffered through the toxic and verbally abusive work climate for years.

Those allegations are contained in a yet-unreleased independent report submitted to the government in recent weeks that sources say is “damning” towards Payette and her top bureaucrat, Assunta di Lorenzo.

“I think as a government, we’ve demonstrated time and time again how important it is to create workplaces that are free and safe from harassment and in which people can do their important jobs in safety and security,” Trudeau said.

“That is why we consider that we needed to accept the resignation of Julie Payette, given the concerns that were raised. The work that has been done by people working at Rideau Hall over the past years has always been exceptional … and as we saw, sometimes in very difficult situations,” the prime minister continued, stopping short of apologizing.

 Julie Payette watches as Prime Minister Justin Trudeau bows to her before his speech in the Senate chamber during her installation ceremony as Gvernor General, in Ottawa on Monday, Oct. 2, 2017.

During his weekly Friday press conference, the prime minister said that there was a “rigorous” vetting process that led to Payette’s nomination, but did not provide any details.

He also said that his office would be assessing if there were ways to better vet the next candidate for governor general..

“We’re going to also look at ways we can strengthen and improve the vetting process for high level appointments,” Trudeau said.

Since Payette’s resignation, opposition parties have requested that the Liberals recreate a non-partisan appointments committee that would oversee future nominations. Trudeau disbanded a similar committee before he appointed Payette in 2017.

Trudeau did not comment on that request Friday, though he promised that her replacement would be announced “in due course.”

Payette’s downfall comes a little more than three years after she entered the office to great fanfare, a female astronaut and renowned scientist with a sterling resume. But her tenure was plagued by controversy after controversy, and sources with deep experience in Rideau Hall have told the Post they feel she was poorly vetted from the start for a position that requires sensitive diplomacy and attention to often arcane ceremonial detail.

– With files from Brian Platt

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Source: National Post Quebec Nordiques

Canadians who travel outside Canada could be stranded abroad, Trudeau warns

Prime Minister Justin Trudeau holds a news conference at Rideau Cottage in Ottawa, January 22, 2021.

OTTAWA – Prime Minister Justin Trudeau warned Friday that anyone travelling outside Canada could face considerable trouble getting back home, as new evidence suggests some COVID-19 variants are both more transmissible and more deadly.

“No one should be taking a vacation abroad right now. If you’ve got one planned, cancel it. Don’t book a trip for spring break,” Trudeau said outside of Rideau Cottage. “We could be bringing in new measures that significantly impede your ability to return to Canada at any given moment without warning.”

The government has had travel advisories warning against any non-essential travel since the beginning of the pandemic, but some Canadians have not heeded that call. Trudeau said people should also avoid any unnecessary trips within the country.

After long resisting stricter measures, and downplaying the role international travel plays in Canada’s pandemic, the government introduced new testing requirements for incoming international travellers in late December.

Those rules have slowed travel, but in the last two weeks there have still been several reports of new cases on many flights including cities like London, Amsterdam and Los Angeles, as well as sun destinations like Cancun, Mexico, Montego Bay, Jamaica and Puerto Plata in the Dominican Republic. The dozens of flights are all listed on a government website warning passengers they may have been exposed.

Trudeau did not specify what further measures could be put in place and took no immediate steps, but Public Safety Minister Bill Blair said everything was on the table including mandatory hotel quarantines and complete travel bans.

“We are looking at a number of measures that can include further restrictions on international travel, additional tracing measures, additional quarantine measures and enforcement measures in order to disincentive people from taking unnecessary trips.”

Blair said Canada’s quarantine measures are some of the toughest in the world already, but the government would not hesitate to go further.

“We have been responding very quickly and we’ve tried to be very upfront with Canadians to discourage them from taking non-essential, discretionary travel vacations, out of the country.”

Several significant variants to the virus have been found in countries around the world including Brazil, South Africa and the U.K.

British Prime Minister Boris Johnson said new research on the variant that has spread rapidly in Britain seems to indicate the mutation is 30 per cent more deadly.

“We have now learned that, in addition to spreading more quickly, the new variant of the virus may be associated with a higher degree of mortality,” Johnson said.

In a joint statement with industry unions, the National Airlines Council of Canada, pleaded with the government to work with them on any new restrictions.

In a statement, the council said international travel has dropped 93 per cent and travellers currently represent less than one per cent of new cases in Canada.

“Over the course of the pandemic, industry, labour, and government have for the most part worked effectively to implement a myriad of new regulations designed to continue to protect employee, passenger and public health,” said the group’s president Mike McNaney “Airlines and airline workers are the front-line implementors of these policy changes. We need to work together to ensure an effective outcome for all involved.”

As of Friday, Canada had reported 31 cases of the U.K variant and another three cases of the one from South Africa.

Dr. Theresa Tam, the chief public health officer, said Canada is testing a sample of five per cent of all positive cases looking specifically for the variants and also testing cases when usual outbreaks occur. She said most provinces have the capabilities to look for the variants, but some are sending samples to the national laboratory.

She said that can include outbreaks that seem to move quickly, involve international travel or appear resistant to vaccines, but she acknowledged the government should be doing more.

“We have been sampling at a relatively good rate but I think we need to do more so right now, efforts are being set up to do that in a more significant way.”

Blair also announced the government would be sending two mobile health units to help with hospital overcrowding in the Greater Toronto Area. The facilities can treat non-critical patients and Blair said each has a capacity of 100 beds.

“This will help relieve pressure on Ontario’s strained hospital capacity, due to the prevalence of COVID-19.”

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Source: National Post Quebec Nordiques

Why we hear so little about Kamala Harris’ father, the missing link in her biography

Kamala Harris pictured with her father Donald.

With COVID-19 precautions in place, the live audience for this week’s U.S. presidential inauguration was a pared-down version of the usual crowd.

But amidst the ex-presidents, judges, family members and other VIPs on the podium in Washington, there was at least one notable absence.

Nowhere to be seen was Kamala Harris’s sole surviving parent, father Donald, as Harris shattered centuries-old racial and gender barriers to become America’s vice president.

The immigrant success story of her endocrinologist mother from India, with its unique Canadian chapter, is now well known to anyone who follows American politics.

But the new vice president rarely says much about Donald Harris, equally successful as a

Stanford University economist

, who divorced Harris’s mother when the daughter was just seven.

He has lamented that biased California courts gave full custody of his daughters to their mother; another

family member has said

“he was not around after the divorce.”

But if he and Kamala are, as it seems, somewhat estranged, the full reasons are hazy. In a country where the family lives of prominent politicians are dissected in minute detail, the vice president’s relationship with Donald Harris, 82, remains something of a missing link in her biography.

 Kamala Harris, flanked by her husband Doug Emhoff, is sworn in as the 49th US Vice President by Supreme Court Justice Sonia Sotomayor on January 20, 2021, at the US Capitol in Washington, DC.

“It seems pretty clear that he wants to stay out of the limelight,” says Steven Fazzari, an

economics professor

at Washington University in St. Louis and a doctoral student of Harris’s in the 1980s. “It’s a bit unusual, but it could be what he wants, and she’s respecting it

He’s the academic’s academic. He’s very thoughtful, very deep in his thinking. Rather abstract and theoretical.”

Kamala Harris put it more bluntly in a 2003 interview, one of the few times she’s talked about the man publicly. “My father is a good guy,”

she told SF Weekly

, “but we are not close.”

Neither Donald Harris, now a retired professor emeritus, nor the White House responded to requests for comment.

In one of his own rare pronouncements since his daughter entered presidential politics, he seemed to confirm Fazzari’s suspicions. “The celebrity-seeking business is not my thing, and I have tried hard to keep out of it,” Harris told

the New York Times

.

As the vice president has often related, her father was an international student from Jamaica when he met Shyamala Gopalan, a science student from India, at the University of California’s Berkeley campus in 1962.

Berkeley was a hotbed of radicalism at the time, and they got to know each other at events promoting African-American civil rights.

The couple married in 1963, with Kamala born in 1964 and her sister Maya two years later.

Within eight years they were divorced and living in different cities, the girls staying with their mother.

 Donald Harris’ grandmother Iris, pictured with Kamala.

The original relationship between father and daughter “came to an abrupt halt in 1972,” Harris wrote in a

2019 article

about the family’s Jamaican heritage.

“After a hard-fought custody battle in the family court of Oakland, California,” he said, the judge imposed a settlement based on “the false assumption that fathers cannot handle parenting.”

Nevertheless, he said, “I persisted, never giving up on my love for my children or reneging on my responsibilities as their father.”

That jibed with Fazzari’s impressions. He noted that a scholarly tome Harris published in 1978 – Capital Accumulation and Income Distribution

was dedicated to young Kamala and Maya.

But with her comment to the

New Yorker

about Donald’s absences after the divorce, Kamala Harris’s niece Meena hinted at more complexities. And Shyamala’s brother, Gopalan Balachandran, told the Times that his sister was so angry after the split she refused even to talk to Donald.

Regardless, the vice president’s family narrative usually diverts at this point into a tale of how a single mother raised two daughters while pursuing an academic career as a breast cancer researcher, which included a stint at McGIll University when Kamala was in high school. The vice president also has a Canadian aunt and uncle, Chinni and Shankar Subash.

When the father’s name has arisen recently, controversy often ensued.

Asked during a 2019 radio interview whether she favoured legalizing marijuana, Kamala Harris laughingly replied: ““Half my family’s from Jamaica—are you kidding me?”

Her father

was not amused

, writing in a newspaper for the Jamaican diaspora his parents would be spinning in their graves to see their proud heritage “being connected, in any way, jokingly or not, with the fraudulent stereotype of a pot-smoking joy seeker, and in the pursuit of identity politics.”

“He’s entitled to his opinion,” Kamala told a

New Yorker

journalist about the rebuke. She went on to “glumly” say she was happy to talk about her father. “ ‘But, ya know,’ ” the magazine quoted Harris as adding. “She raised her eyebrows, and said nothing.”

Meanwhile, in that article about the family’s Jamaican history, the elder Harris mentioned in passing that one of their ancestors was white slave owner Hamilton Brown. The comment was seized on by conservative publications in the U.S., who accused the politician of hypocrisy on race relations. Fact-checking organization

Snopes said

it could find no evidence backing up the father’s contention, but noted that even if true, it meant that another of their maternal ancestors was a slave likely coerced into sexual relations with a white man.

As for Donald Harris himself, Fazzari said he was “very engaging” as a teacher.

Despite an analytical, almost mathematical approach to economics, “he had a kind of informality you associate with Jamaican culture,” said the economist. “I remember him being a friendly mentor without being your buddy-buddy …You weren’t going to go out and spend all night at the bar with him.”

A “Post-Keynesian” theorist, Harris was a leading figure in the small group of economists who posited alternative visions to neo-classical mainstream thinking about markets, and focused on the importance of income distribution long before income inequality became a widespread concern, said Fazzari.

A 1976 article in the

Stanford Daily

student paper described him as a “Marxist scholar,” and said detractors felt he was “too charismatic, a pied piper leading students astray from neo-classical economics.”

Source: National Post Quebec Nordiques

After U.S. Capitol siege, Canadian rallied for storming of Parliament and killing of politicians, health officials

The MeWe user posted several messages over months threatening Prime Minister Justin Trudeau, saying he should be shot, and “die allready (sic).”

The day after the deadly siege in Washington D.C., a Canadian user on an alternative social media platform — where hard right users flocked after Facebook and Twitter started moderating misinformation — tried to muster an attack in Ottawa to overthrow the Canadian government, and posted a stream of assassination threats against politicians and public health figures.

Among those targeted were Prime Minister Justin Trudeau; Alberta Premier Jason Kenney; federal NDP leader Jagmeet Singh; and Alberta’s chief medical officer of health, Dr. Deena Hinshaw.

Also targeted were prominent Americans, including President Joe Biden; the face of the U.S. pandemic medical response, Dr. Anthony Fauci; Microsoft co-founder Bill Gates; and Facebook CEO Mark Zuckerberg.

The posts by a user of MeWe were flagged as supporting domestic terror-related activity by the Middle East Media Research Institute (MEMRI), an organization that tracks and documents extremist and terrorist communications.

MeWe said Thursday the user has now been banned.

The ban follows months of heated and violent posts calling for a long list of people to be killed, including health officials, over political decisions and COVID-19 pandemic restrictions.

The day after the U.S. Capitol building was ransacked by supporters of Donald Trump in an attempt to prevent Biden from replacing him as U.S. president, the user tried to rally people to Ottawa for a similar siege on Parliament.

“If we Canadians do not go in force and march to Ottowa (sic) and storm the government, physically take out and down the government, we are all slaves of China, socialism, and Communist Canada,” he said in one post saved by MEMRI.

He urged insurgents to come “fully ready” to force Trudeau out of office.

The user, who claims to have completed Grade 12 in his user profile, begged Canadians to “take off your mask” because “there is no such thing as a virus that is spreadable.”

Last month, he shared a post on the legal challenge of Alberta’s COVID-19 restrictions by the Calgary-based Justice Centre for Constitutional Freedoms. The post featured a photograph of Kenney and Hinshaw, who he said should be hung or shot. He added 16 handgun emojis and said they were “hated beyond hate.”

He posted several messages over months threatening Trudeau, saying he should be shot, and “die allready (sic),” often accompanied by several handgun emojis. In one message he warned both Trudeau and Singh they were the “2 most wanted DEAD people in Canada.”

He posted on MeWe under the username Davil1 OSCP. He gives his location as Canada and says he is an “OSCP consultant.”

OSCP likely stands for “Offensive Security Certified Professional,” which is professional certification in ethical hacking, also known as “white hat” computer security that looks for holes in computer systems to help block them from malicious attacks. What appears to be one of two Facebook accounts for the same man uses hacker imagery and messages.

MeWe said that the user has been removed from its platform for violating its terms of service (TOS).

“MeWe’s terms of service prohibits inciting violence, hate, harassment, bullying, illegal activity, etc.,” said David Westreich, a company spokesman.

“Due to recent rapid membership growth, the company is currently expanding its Trust and Safety Team and adding new tools to help moderators find and remove TOS-violators” in order to “stop known bad actors at the door and find them if they’ve gotten inside.”

When Facebook and Twitter cracked down on posts from former U.S. president Donald Trump, specifically for broadcasting false or misleading information about the U.S. election, many of his supporters flocked to other platforms, some specifically created to welcome radical and alternative views of users who felt unwelcome elsewhere, often referred to as alt-tech.

Unlike some platforms, MeWe was not designed as a haven for fringe or radical views, MeWe said. The corporate model was simply supporting privacy and opposing surveillance capitalism.

Westreich said MeWe “stands head and shoulders above the current social media giants,” because there is no newsfeed manipulation or ways for messages to be boosted beyond those choosing to read them.

“This prevents any information or opinion — false or true — from being broadly promoted. Members need to deliberately seek out information for themselves and cannot be targeted by others who wish to reach and manipulate their thoughts, purchase decisions, or votes,” Westreich said.

The moderation of messages on MeWe appears to have significant lag time, however. Davil1 OSCP joined in September 2020 and was posting threatening content for at least three months.

Several months ago, the user complains he was chastised by Facebook, adding, “all because I said, kill Trudeau war is war freedom of speech freedom of expressed opinion. Nothing more.”

On Jan. 9, three days after the Capitol siege, he posted a message using all capital letters: “Civil war arm up and delete the deep state… this is a f*cking war” His post, accompanied by emojis of guns, also railed against “masked up idiots.”

On Jan. 4, he posted a photo of Zuckerberg and wrote above it, in all capital letters: “Find seek and kill this asshole along with Biden, Clinton, Bates, Fauci… Kill them all.” (“Bates” is probably meant to be Gates; in a post last week he asked someone to kill Gates immediately.)

Westreich said illegal activity can be reported to law enforcement at MeWe’s discretion, but declined to say if this user or his posts had been reported.

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Source: National Post Quebec Nordiques

10/3 podcast: What Joe Biden killing Keystone XL means for Alberta

FIle photo of unused pipe, prepared for the proposed Keystone XL pipeline, sit in a lot on October 14, 2014 outside Gascoyne, North Dakota.

The Keystone XL pipeline project has long been a sticking point in both Canadian and American politics.

It has been a hot potato for successive American presidents, and Alberta Premier Jason Kenney bet big, with more than a billion in investment, plus loan guarantees.

But now, the new U.S. president has put a stop to it.

Calgary Herald columnist Chris Varcoe joins me to discuss Joe Biden’s motives for cancelling the project, what the ramifications are for Canada’s oil industry, and what it means for Alberta Premier Jason Kenney.

BACKGROUND READING:  

Varcoe: Keystone XL is shot down, and the target turns to other pipelines

TC Energy and Alberta face long odds if they sue U.S. government over cancelled Keystone XL

Subscribe to 10/3 on your favourite podcast app.

#distro

Source: National Post Quebec Nordiques

Ontario urged to suspend need for consent before withdrawing life support when COVID crushes hospitals

The COVID-19 vaccine has started to be administered in Canada, but Ontario, Quebec and other provinces still need to prepare protocols to determine who should get critical care — and who should be left behind — in the event that hospitals become flooded with COVID patients.

Canada’s Supreme Court ruled in 2013 that a major Toronto Hospital could not withdraw life-support from a minimally conscious and severely brain-damaged man without his family’s consent.

Now, in another sign of these extraordinary times, the Ontario government is being asked to temporarily suspend the law requiring doctors get consent of patients or families before withdrawing a ventilator or other life-sustaining treatment from people facing a grim prognosis, should COVID-19 crush hospitals.

The recommendation for an Executive Order to suspend the province’s Health Care Consent Act for withdrawal of treatment in the ICU, should the situation become so dire, comes as Ontario, Quebec and other provinces prepare protocols to determine who should get critical care — and who should be left behind — if hospitals are flooded with COVID patients.

The request, deeply troubling to some advocacy groups, comes from Ontario’s COVID-19 Bioethics Table, which is recommending that the province ensure “liability protection for all those who would be involved in implementing the

Proposed Framework

… including an Emergency Order related to any aspect requiring a deviation for the Health Care Consent Act.” The act requires doctors obtain agreement from patients, or their substitute decision makers, with disputes resolved by the Consent and Capacity Board, an independent tribunal.

This week, the Ontario Critical Care Covid Command Centre issued an “emergency standard of care” to prepare hospitals for the worst-case scenario, an Italy-like surge in demand for critical care. The over-arching objective, the document states, is to “save the most lives in the most ethical manner possible.”

A critical care triage should be considered an option of last resort, invoked only after all reasonable attempts have been made to move people to other hospitals where there

is

space and staff to care for them, and only for as long as the surge lasts, the document says.

The goal is to minimize deaths, minimize the risk of discrimination and “unconscious bias” against people with disabilities, racialized communities and other vulnerable groups, and minimize “moral injury and burnout” among staff forced to decide who may live and who may die.

According to the document, prepared on behalf of Ontario’s critical care COVID command centre, priority should be given to people with the greatest likelihood of surviving whatever it is that brought them to hospital — COVID-19, heart attack, liver disease, a bleed in the brain or other life-threatening illness. Those with a high likelihood of dying within 12 months from that critical sickness would receive lower priority for an ICU bed.

“It’s really important to be clear here — this is not about how long you’re likely to live, it’s not a life span question,” said Dr. James Downar, head of the division of palliative care at the University of Ottawa and a member of the Bioethics Table. “It’s your probability of being alive 12 months after developing critical illness.”

The protocol is meant to be applied to new patients, or people already in hospital whose condition is worsening. “We’re suggesting, out of a principle of fairness, the same approach should apply to people inside the ICU,” Downar said. “It would be unfair to treat people differently depending on the timing that they presented.”

“Nobody likes the idea of ever withdrawing life-support on somebody without their permission, without their consent,” Downar said. “But in a triage scenario, we’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole, and trying to maximize the number of people who will survive an overwhelming surge.”

 Dr. James Downar: “We’re talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole.”

The document now being circulated to Ontario hospitals doesn’t include a provision for withdrawal of potentially life-sustaining treatment without consent. Instead, it says that ICU doctors should regularly reassess people admitted to ICU, and consider withdrawal of life support “through a shared decision-making process with SDMs (substitute decision-makers) if a patient does not appear to be improving.”

But Downar and other doctors said it’s not possible to operate a triage model in which all decisions are made with the consent and permission of people involved, because many people would simply opt out.

“We are going to say, ‘by the way, we are taking your family member off the ventilator in lieu of another patient who we feel has a better prognosis, given this pandemic condition. Do you agree?’ I think that if we did that we would not get consent. Nobody is going to give us consent,” said Dr. Peter Goldberg, head of critical care at Montreal’s McGill University Health Centre.

The Bioethics Table’s request is now before the Ontario Health Ministry. “We are hopeful that, as part of the state of emergency, should we need it, that there will be an executive order allowing us to withdraw,” Downar said

With an Executive Order in place, doctors could put off escalating triage and continue to offer intensive care to every person who might benefit, including borderline cases  — “right up to the point that the critical care beds are literally full,” he said. ICUs could run at full capacity. Only then, as new patients come in who meet the triage criteria — a lower risk of death — and who need beds would ICU care slowly start to be withdrawn from people who aren’t responding and are least likely to, Downar said.

Without the Executive Order, triage would have to be started sooner, in order to reserve beds for people with a high likelihood of survival. Fewer people would be offered intensive care, and more people would die, Downar said.

“It’s difficult to imagine how troubling that would be, that we would actually have to suspend the consent act,” said Dr. Andrea Frolic, director of the Program for Ethics and Care Ecologies at Hamilton Health Sciences and a consultant to Ontario’s COVID critical care command centre.

“It would be a rare circumstance that we would have to resort to implementing a care plan that would not have the consent of the patient or substitute decision-maker,” Frolic said.

But should hospitals become maxed out, with a massive surge of people coming through the doors who have a very high chance of survival, and people in the ICU who aren’t benefitting from critical care and who are highly likely to die  — “if we don’t have the tool to provide equitable access to care, that will create a lot of distress on the system,” Frolic said.

It becomes a first-come, first-served system, she said  — a car crash victim who needs surgery and a short ICU stay to save his life can’t get into the ICU, because he arrived after a person with end-stage cancer and COVID-related pneumonia who may not be likely to survive their critical illness, or weeks later. “That is a situation of inequity caused by fate, really, or chance. One person happened to get critically ill before another person.”

Withdrawing treatment without consent would be very rare, happen only after every effort to reach consensus with the patient and family has been exhausted, and only as a last resort, Frolic added.

Families who feel strongly could use all avenues of advocacy, she said. “The hope is that families will see what’s happening around them. You can imagine if we get to this level of surge, there are patients in hallways; there are patients in gymnasiums. My hope is that families will see their own patient deteriorating but will see the context that we’re in a public health emergency, that it’s not personal, it’s not what we wish to do, it’s a situation caused by the pandemic.”

Mariam Shanouda, a lawyer at ARCH Disability Law Centre in Toronto, said she was “flabbergasted” when told by the

National Post

about the prospect of an order to allow doctors to operate outside the consent act.

“This is literally life and death and to not only give doctors that power to operate outside (the act) but to insulate them from any liability whatsoever, that is not something to be taken likely,” Shanouda said.

“We don’t know the process by which these decisions will be made, who will be making the decisions to withdraw care. Is there going to be an appeal procedure whereby a family can challenge that decision? Is there going to be accountability?”

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Source: National Post Quebec Nordiques