Palliative-care physicians are being advised to prepare for scenarios they never thought possible, like facing patients denied ventilators because there aren’t enough to go around.

“I have a lot of difficult discussions with people all the time,” said Dr. James Downar, a palliative-care specialist at The Ottawa Hospital. “But I have to say, that would be a new one for me.

“No one has ever operated in a context where that’s the kind of thing you have to disclose to somebody and talk to somebody about.”

This week, an article co-written by Downar in the Canadian Medical Association Journal warned that a surge in coronavirus cases could make such heart-wrenching situations a reality if hospitals are forced into triage protocols that reserve a short supply of ventilators for those with the best chance of survival.

The article notes the risk of death from COVID-19 is higher for older patients with chronic illnesses. Some will already have decided they prefer the comfort measures provided by palliative care. Others might face chilling triage scenarios.

“Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated,” Downar and his colleagues write, using the terms for inserting or removing a ventilation tube. “A third group of patients may be denied ventilation because of resource scarcity.

“Thus, in a viral pandemic, we expect the need for palliative care to increase substantially.”

Palliative care involves discussing a patient’s wishes, managing symptoms and supporting families. The care is provided in hospitals, hospices or in family homes. It usually — but not always — means care at the end of life, especially in hospices.

Downar’s article is essentially a manual for palliative caregivers during a COVID surge. It recommends they stock up on necessary medication, suggests language to use when explaining triage choices, and describes how care can be adapted for patients isolated due to the contagious virus.

“Any triage system that does not integrate palliative-care principles is unethical,” the article states. “Patients who are not expected to survive should not be abandoned, but must receive palliative care as a human right.”

In a phone interview, Downar stressed he and others remain hopeful hospitals can manage the expected increase in patients without resorting to triage. But Italy’s example, where a flood of COVID-19 victims forced heartbreaking triage in the country’s north, is everyone’s worst nightmare.

“We’re hoping for the best, obviously, but we’re not doing our job if we don’t have a plan B,” said Downar, also head of the palliative care division at the University of Ottawa.

COVID-19 has already forced a change in palliative care.

On Wednesday, Hospice Palliative Care Ontario, which represents 53 hospices in the province, advised its members to restrict visits to only one family member — and always the same one.

When the resident is within hours of dying, the hospice’s medical director can then decide whether two more people are allowed by the bedside, said Rick Firth, president and CEO of HPCO.

The visiting restrictions will make processing grief more difficult for many loved ones, but Firth said COVID-19 has left hospices no choice.

“Honestly, there was some grief expressed by the staff that have to do that,” Firth said, “because they’ve all gone through their own losses too and they know what it’s like. But the protection of the residents and the staff really have to override those other considerations.”

Firth said hospices are not accepting infected patients because they don’t have the safety or medical equipment to deal with them. So far, only one patient tested positive for the virus after being admitted for end-of-life care due to cancer.

One staff hospice member in the province had no symptoms while on the job but tested positive after self-isolating.

If COVID becomes widespread, hospices might change the admission policy and start accepting infected patients if they’re dying from something other than COVID-19, said Firth, who has worked in the hospice sector since the late 1990s.

“But right now, we’re doing our best to keep the facilities COVID-free for as long as possible,” he added.

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Ontario’s hospice system includes about 8,000 people in residential facilities receiving end-of-life care, Firth said. They’re generally older, typically stay between 15 and 18 days, and almost all of them die in the hospice. About 80 per cent suffer from cancer.

HPCO programs care for another 20,000 people in their homes, mostly with volunteers. All of those services are now provided by phone or social media, Firth said. That includes grief and bereavement support, which is given to about 100,000 family members each year. (More than 270,000 Canadians die each year, 90 per cent from chronic illnesses such as cancer and heart disease.)

COVID-19 has also placed hospices, which are charities, under severe financial strain. Provincial government funding covers up to 50 per cent of operating costs, Firth said. The rest comes from fundraising events such as galas and bikeathons — all of which have been cancelled due to physical distancing directives.

“They need those dollars to support their clinical care,” Firth said, adding he hopes governments will come through with emergency funding.

In the meantime, hospices are getting creative. At St. Joseph’s Hospice in Sarnia, staff push the beds of residents up to ground-floor windows and patio doors so they can see — and speak by phone — to family gathered outside the building.

“Last week, we had six family members outside singing Happy Birthday to their loved one, which was really sweet,” said Dr. Glen Maddison, the hospice’s medical director.

Maddison also provides palliative care at the Bluewater Health hospital in Sarnia Lambton, an area with 59 confirmed COVID cases, six of which caused death. The hospital has a 40-bed COVID unit, which is two-thirds full, and a 12-bed palliative-care unit, he added.

Maddison is confident Bluewater hospital can avoid triage scenarios. Still, he urges Ontario residents to discuss their health-care wishes with their “substitute decision maker” — the person doctors will turn to for consent if a patient is unable to provide it. (By law, a doctor will in most cases first ask a spouse or partner.)

Even without triage, a ventilator may not be the best choice for some COVID patients whose chances of surviving a strong bout of the illness are low, Maddison said.

People often don’t realize how invasive a ventilator is, he added. It not only involves a tube down your throat but one in your bladder and stomach. If you cough and wake up from sedation you may want to pull out the tube from your throat, which then means you’ll be physically restrained to the bed, Maddison said.

“If they recover they’re not going to likely be the same person,” he added, referring to some older patients. “They’re still going to have breathing problems, they may actually be more confused — we know that somebody who has mild dementia will probably have worse dementia.”

He recalled a COVID patient in his 90s, brought to Bluewater by his son last week. “He was desperately short of breath, very low on oxygen, his X-rays looked like a winter blizzard,” Maddison said.

The son said his dad had already chosen palliative care in such circumstances. Maddison gave him some oxygen and medicine to ease his pain and symptoms. “Amazingly enough, the next day he woke up,” Maddison added.

The man spent the next 48 hours speaking by phone to his children and grandchildren scattered across the country. His condition then worsened and by the fourth day he was dead.

“We know he felt more peaceful when he left this world, but so did his family. They actually had that final conversation,” Maddison said.