TORONTO, April 28, 2021 — In the pandemic’s first wave, emergency physician Erin O’Connor was working with little information about the COVID-19 virus and inconsistent access to personal protective equipment when she was faced with a difficult personal decision.
Would she rent an apartment, or go home to her toddlers after each shift, where she could risk exposing them to the virus?
“I certainly wasn’t going to stop seeing patients — and stop doing my job as an emergency physician but then the trade-off was what is the cost to my family?” the deputy medical director of UHN’s emergency departments said at a recent OMA media briefing.
“Ultimately, I made the decision to stay home, and it was the right one,” she said. “But I think it could have gone either way based on the information that we had about the virus last March (2020) and that’s not a unique decision. Many health-care providers had to make it at that time.”
Flash forward one year. The pandemic is in its third wave. Vaccines are still limited and infection rates are still running high. ICUs are almost at capacity, and Dr. O’Connor and her colleagues have been role-playing how to tell people their loved ones are ineligible for life support as they train to implement the province’s emergency triage protocol.
“I’m hoping that they are not coming, but I worry about the hard decisions yet to come,” she said.
Physicians and others working in health care say they have been forced to make some of the most difficult decisions of their careers during their time battling the pandemic. With so many lives lost, and many more at stake, these complex and sometimes unpopular choices are being taken on behalf of patients across the health-care spectrum every day, and they are taking their toll.
Public health physicians are focused on stopping the spread of COVID-19 and keeping individuals and communities as safe as possible. Simultaneously, they are considering issues around medicine, infection disease control, community health and the social determinants of health, while also staying keenly aware of the potential economic and political consequences of their recommendations.
For Dr. Lawrence Loh, medical officer of health for Peel Region, the most difficult decisions have been to order the closure of workplaces, including Amazon distribution centres, to control workplace outbreaks in his densely populated area. Like others in his role, Dr. Loh has used Section 22 of the Health Protection and Promotion Act to require employers to notify public health if there are two or more cases of the virus in a two-week period. If the number exceeds five, the workplace can be shut down.
“There are almost as many people in the Region of Peel as there are in the Maritime provinces put together,” Dr. Loh explained. “It makes it a much more fertile ground for a disease that spreads from person to person.”
Implementing a shutdown that he feels is in the best interest of his community, but that may appear more stringent than provincial rules, or disproportionately harsh on particular groups, is difficult — and it’s unpopular.
“There is a recognition in my office that when we are moving to use Section 22 to address a specific disease threat … it may open up not just myself but certain of my staff and health care and hospital partners to abuse and harassment,” Dr. Loh said.
Dr. Anju Anand, a respirologist at St. Michael’s Hospital who is leading grassroots education efforts in the South Asian community, particularly around vaccination, said putting her family life aside to stand up for people who don’t have a voice has been the hardest part of pandemic life.
“That doesn’t sound like a hard decision, but when everyone is burned out and you have other responsibilities … It has been something that has been hard but rewarding for me,” she said. “To date it’s that. But my most difficult decisions are coming.”
As an ethicist at London, Ont.’s Western University, Prof. Maxwell Smith is not on the front lines. But behind the scenes he has been making difficult decisions that weigh on him, advising on the framework for critical care triage at hospitals and vaccine rollout as part of his work for Ontario’s COVID-19 Bioethics Table.
“I have had to play a role in making recommendations,” he said. “Of the two most difficult, the first is as a member of the Bioethics Table to provide a proposed framework for critical care triage. That is, of course, one of the most difficult decisions anyone will have to make. Having to think through the different needs and interests and perspectives has been very, very challenging.”
He faced similarly difficult choices when identifying populations that should be prioritized for vaccinations as the supply lagged behind need.
“We need everyone in this province to be vaccinated at the end of the day, and so no one is without risk,” he explained. “Hearing the calls that these certain groups are at risk, it’s really difficult to say, ‘Yes, I hear that but there are other groups that are simply at greater risk at the moment.’”
Dr. Samantha Hill, a cardiac surgeon and president of the OMA, said the difficult decisions for those in health care are leaving a mark on both a professional and a personal level.
“We are at a place for most health-care workers where we’ve gone through what we jokingly refer to our adrenal reserves,” she said.
“We’ve been put in a situation that is high stress and we’ve stepped up … and we have pushed. We have pushed through personal decisions around whether or not to go home to our toddlers and whether or not to see our elderly parents and we’ve pushed through decisions about whether or not to send our kids back to school.”
These are the issues all Ontarians have been forced to confront, she said, and for physicians the professional stress is an additional strain.
“We’ve also carried the burden of consequences of health-care decisions on our population,” Dr. Hill said. “Physicians by and large go into medicine because they want to help people and they carry that weight and that toll very personally … We feel the burden of going in and making sure that our patients are cared for.”
