Covid-19, Triage guidelines and nursing home deaths.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Nursing home residents, with Covid-19, may be experiencing discrimination by being denied beneficial life-saving treatment. It appears that some nursing homes are not transferring residents to the hospital, even when treatment is available. Some of these decisions should be considered elder abuse.

The disability movement is also concerned that people with disabilities are being denied medical treatment.

I understand that there are times when the person is nearing death and it is not reasonable to transfer the person to the hospital. I also understand that there are times when the hospital lacks the treatment capacity to accept the elderly person. I am concerned that treatable elderly people are not receiving treatment, even when there is treatment capacity.

I was interviewed by OneNewsNow about an article that I wrote concerning the Covid-19 triage guidelines developed by Dr James Downar, the former chair of the Physicians Advisory Council for Dying with Dignity, a euthanasia lobby group. OneNewsNow reported:

Alex Schadenberg of the Euthanasia Prevention Coalition tells OneNewsNow one of the problems is that if a hospital ICU is near capacity, then certain people would not receive medical treatment.

"Basically if a hospital, due to the COVID-19 crisis, [if] the ICU is full, then anybody who … has a medical condition [and] is less likely to recover, or they're over a certain age, they would simply not be given medical treatment," Schadenberg explains. 

But hospitals with a less populated ICU would treat them, and hospitals who are full could transfer patients to facilities that have beds available.

I continued by commenting about my concerns about the growing deaths of elderly people in nursing homes. I stated:

So Schadenberg is mainly concerned about elderly people in Ontario nursing homes

"What we've seen based on these triage protocols is that the decision is not to transfer these people to a hospital, even if they have a significant condition, that is treatable," he reports. "So what you're finding is somebody who's living in a nursing home … if they come down with COVID-19 … they're basically only cared [for] in that nursing home, which is very limiting." 

He says that means they are more likely to die.

Chris Aung-Thwin reported for the National Post that Theresa Tam, Canada's chief public health officer stated that:

the spread of the virus in care homes has been at the root of half of the more than 700 deaths across the country.

Covid-19 nursing home deaths is a national problem. Adrian Humphries reported for the National Post that: 

In Quebec, a police investigation is underway after 31 residents at a care home in Dorval died under what Quebec Premier Francois Legault alleged was “gross negligence.”

Pinecrest Nursing Home in Bobcaygeon, Ont., saw 29 COVID-19 linked deaths in its 65-bed home. In Toronto, 22 residents with COVID-19 died at Seven Oaks.

Eighteen residents at Lynn Valley Care Centre in North Vancouver died with COVID-19; 10 at Almonte Country Haven in Ottawa.

And on and on and on, in communities large and small.

Some would suggest that the large number Covid-19 deaths in nursing homes is due to the age or other health condition of those who died. I am convinced that there are other factors.

Some treatment protocols dictate that residents in a nursing home will not be transferred to the hospital, even when the hospital has the treatment capacity to care for them, leaving them far more likely to die.
 
Many residents or their families have stated, in a health care directive, that they would not want treatment or that they would not want to be sent to the hospital for treatment and that they would only want "comfort care" measures.

Order the Life-Protecting Power of Attorney for Personal Care from Euthanasia Prevention Coalition to protect your life (Link).

It is likely that some of the nursing home residents who died by Covid-19 may have survived with treatment. This is a form of discrimination, agism and elder abuse.

Elderly people need patient advocates. If your parent needs beneficial life-saving treatment that could enable recovery, then you need to demand equal treatment.

These are life and death decisions.

Decision Making Protocols during the Covid-19 Pandemic

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Canadian Medical Association (CMA) approved a Framework for Ethical Decision Making During the Coronavirus Pandemic that is based on the protocol by Ezekiel J Emanuel et al (the protocol) that was published in the NEJM on March 23, 2020 titled: Fair Allocation of Scarce Medical Resources in the Time of Covid-19

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of resources are limited then decisions are made which are often unjust and lack equality.

I am concerned that many Covid-19 deaths in Canada are related to decisions not to provide treatment for elderly people, even when capacity for treating these people existed. The high rates of death at nursing homes is not only based on the age of those who died, but also the decision not to transfer these patients to a hospital capable of treatment. This is why a doctor at one nursing home lamented that all they could do was provide comfort care.

The triage guidelines developed by the disability rights community seem to represent the fairest and most equitable response to providing treatment during a pandemic. (Link to the guidelines).

This article will provide some insight into the NEJM protocol by Emanuel et al that has been approved by the CMA.

The protocol states that the demand for medical resources may be greater than the supply of resources. I will not comment on the projections only on the proposed allocation of scarce medical resources. The protocol is based on utilitarian principles.

The protocol based on four fundamental values that they define as: 

1. maximizing the benefits produced by scarce resources,
2. treating people equally, 
3. promoting and rewarding instrumental value, and 
4. giving priority to the worst off.

They define each of the fundamental values in this manner:

1. Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.
2. Treating people equally could be attempted by random selection, such as a lottery, or by a first-come, first-served allocation. 
3. Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past. 
4. Giving priority to the worst off could be understood as giving priority either to the sickest or to younger people who will have lived the shortest lives if they die untreated. 

The protocol states that none of the fundamental values should be assessed alone but in relation to the other fundamental values.

The protocol then examines who would receive health resources in a Covid-19 pandemic. They state that the four fundamental values would be examined based on six specific recommendations for allocating medical resources in the Covid-19 pandemic, which are:

1. maximize benefits;
2. prioritize health workers; 
3. do not allocate on a first-come, first-served basis; 
4. be responsive to evidence; 
5. recognize research participation; and 
6. apply the same principles to all Covid-19 and non–Covid-19 patients

The protocol explains how the six recommendations work.

Recommendation one focuses on priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. ...There are many reasonable ways of balancing saving more lives against saving more years of life, whatever balance between lives and life-years is chosen must be applied consistently.

A controversial proposal is the withdrawing ventilator support from someone who is currently receiving ventilator treatment. Emanuel states:

Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.

This is simply wrong. There are many people with disabilities, including Not Dead Yet President Diane Coleman, who require oxygen assistance to live. In Withdrawing ventilator treatment is a treatment decisions and should require consent. Decisions to approve or withdraw treatment should be defined as treatment decisions and should require consent.

Recommendation two focuses on the care of front-line health care workers. Healthcare workers are needed to ensure a successful pandemic response, therefore their health is a priority. I agree with recommendation two.

Recommendation three states that when making decision for who should receive care among people with a similar prognosis that those decisions should be based on a lottery and not a first come first served basis. 

I personally don't agree with this point considering that our culture is used to a first come first served basis. Who will decide the parameters of the "lottery" and how is it to be fairly determined? I think that a lottery system will give the healthcare bureaucrat to more control of the system.

Recommendation four suggests that the approach should be based on scientific evidence, which may change over time. Therefore it is suggested that a vaccine, which are preventative, should be given to the elderly and other vulnerable patients first, to reduce the loss of life.

The protocol then states that ICU beds and ventilators, which involve curative treatments, should be allocated to those most likely to survive first. But the protocol goes further and suggests not only those who are most likely to survive but those who are most likely to survive the most number of years.

This proposal denies treatment to older persons and people with disabilities in a discriminatory manner.

As I stated in a previous article:

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment. 

In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care. 

A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment. 

A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.

Recommendation five states that people who are willing to participate in medical trials for Covid-19 research should receive priority.

Recommendation six states that if medical resources become scarce that all medical decision should be made based on the decision making protocol. For instance it states that if there is a scarcity of ventilators and a healthcare worker needs a ventilator for a different condition, that priority should be given.

The pandemic decision making protocols developed by the disability community represent a fair and equitable response to the possible scarcity of resources. (Link to the protocol). I am concerned that the quality of life ethic, mixed with a utilitarian and discriminatory ethic towards people with disabilities will only lead to ingraining decisions that will result in the deaths of vulnerable persons.

These utilitarian guidelines, such as the one designed by Emanuel et al, ingrains negative and discriminatory attitudes to vulnerable populations.

Medical decisions should be made based on Justice and equality (non-maleficence) and not the elimination of the weak.

More information on this topic:

1. Pandemic Palliative care protocol. Selecting people to die (Link).
2. As the threat of triage grows. Disability rights advocacy is needed more than ever (Link).
3. Euthanasia doctor developed Covid-19 triage guidelines (Link).

As the Threat of Triage Grows, Disability Rights Advocacy Is Needed More Than Ever

This article was published by Not Dead Yet on April 6, 2020

Diane Coleman, Not Dead Yet.

On Friday, April 3rd, six leading disability rights attorneys and their respective organizations issued a statement entitled Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. The statement, which helps to interpret the federal bulletin issued a week earlier, was joined by over 90 organizations, including NDY.

One of the most critical parts of the statement focuses on the following language in the federal bulletin:

“[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities. Decisions by covered entities concerning whether an individual is a candidate for treatment should be based on an individualized assessment of the patient based on the best available objective medical evidence.”

The disability advocates’ statement explained this, in part, as follows:

• All persons should be eligible for, and qualified to receive, lifesaving care regardless of the presence of an underlying disability or co-morbid conditions, unless it is clear that the person will not survive in the immediate term or the treatment is contra-indicated.
• Treatment allocation decisions may not be made based on misguided assumptions that people with disabilities experience a lower quality of life . . . .
• Every patient must be treated as an individual, not a diagnosis. This means that the mere fact that a patient may have a diagnosis of, for example, intellectual disability, autism, cystic fibrosis, diabetes, spina bifida, spinal muscular atrophy, or schizophrenia cannot be a basis (in part or whole) for denying care or making that person a lower priority to receive treatment.
• Generalized assumptions must be avoided and doctors must instead focus on the most current and best available objective medical evidence available to determine an individual patient’s ability to respond to treatment. . . .
• . . . [V]alue judgments about the fact that a patient may require extensive support in activities of daily living, uses augmentative or alternative communication, uses a wheelchair, or experiences a psychiatric disability are irrelevant to decisions about whether such individuals should receive life-sustaining treatment.
• Protocols which equate survival with “health” or the absence of chronically debilitating symptoms, risk importing quality life criteria on the triage process.

Clearly, a carefully conducted individual assessment will protect many people with disabilities from being assigned a lower priority to receive treatment. Of course, as disability advocates know from decades of experience, individualized assessment, planning and services are easy words to say but much harder to get in practice. Our community must continue to press for this. It will save lives.

An equal or greater concern is that people whose “individual assessment” suggests they may have a lower likelihood of survival from COVID-19, or (under some triage approaches) a shorter predicted life expectancy for other reasons, would be given lower priority for treatment that could benefit them in terms of potential for survival.

One such “model” policy that is receiving a lot of attention is from the University of Pittsburgh. It calls for prioritizing individuals based on a combination of two primary factors. First, the “Sequential Organ Failure Assessment (SOFA) score (or an alternate, validated, objective measure of probability of survival to hospital discharge) is used to determine patients’ prognoses for hospital survival.” The second factor is “the presence of conditions in such an advanced state that life expectancy is very limited” {less than 1 year or less than 5 years), which is used to characterize patients’ longer-term prognosis. This does not inspire confidence in the policy’s objectivity. It provides for the kind of blatant discrimination that worries many of us (see, e.g., Alice Wong’s moving article in Vox.com).

As the potential for implementing triage policies increases, advocacy will be needed more than ever. For more information, one excellent resource is the DREDF COVID-19 page.

Candice Lewis has died a natural death RIP. Candice made a difference in the world.

Alex Schadenberg

Executive Director, Euthanasia Prevention Coalition

Yesterday, Candice Lewis died a natural death. Candice made a difference in the world. (Link to her obituary)

We first learned about Candice and her mom Sheila in July 2017 when CBC Newfoundland published an article concerning the complaint by Sheila about Candice being pressured to ask for Medical Aid in Dying (MAiD) while she was receiving medical treatment in August 2016. (Link)

An in-depth article was written by Stephen Roberts, for the Northern Pen concerning the complaint letter that Sheila, sent to the hospital. It stated:

Elson wrote that Heroux had taken her out into the hallway by Lewis’s hospital room to discuss physician-assisted death and advise her the option was legal in Canada. 

She alleges the doctor said he supported physician-assisted death for Lewis. 

“This left me dumbfounded and I told him it was something I did not want to consider,” she said.
She contends the doctor suggested she was being selfish and that she told him that she didn’t believe Lewis was able to fully comprehend what was being suggested. 

She says Lewis could hear the conversation from her room and it was causing emotional distress for them both. 

“I am still very concerned about this, it is always on my mind. I am emotionally exhausted. I see that it has been also very stressful for Candice and one of my main reasons for writing this letter is that I don’t want any other family to have to go through this,” Elson wrote.

We learned more in August 2017 when Roberts wrote a follow up article for the Northern Pen indicating that Candice's health had improved (Link).

Candice and Kevin

Kevin Dunn then visited Candice and Sheila for the filming of the Fatal Flaws film. After returning from Newfoundland we published this article and film clip.

Yesterday Kevin published a tribute to Candice on his blog (Link).

Since that time, Kevin and I have continued communicating with Candice and Sheila. They have made a difference in the lives of so many.

How many cases, similar to Candice Lewis have occurred in Canada and either died by lethal injection or were so shocked by the experience of being pressured that they have not spoken about it? Thank you Candice for sharing your story.

My deepest condolences go to Sheila and the family. Sheila loved and cared for her daughter Candice. Sheila told me that her heart is broken. 

Candice lived her life and will be remembered for how she helped to change the world.

Pandemic palliative care protocol. Selecting people to die and abusing the purpose of palliative care.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of certain resources are limited then decisions are made which are often unjust and lack equality.

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment.

In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care.

A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment.

A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.

Diane Coleman, Not Dead Yet.

People with disabilities genuinely fear that they will not be considered "worthy" for treatment, even when the benefit of the treatment is recovery. Further to that, some people with disabilities already require ventilator support to live. Should these people be denied ventilator support or have it withdrawn against their needs and wishes simply because another person requires a ventilator?

Pandemic palliative care: beyond ventilators and saving lives.

The CMAJ (March 31) published a protocol on the care of Covid-19 patients who are being withheld or withdrawn from treatment titled: Pandemic palliative care: beyond ventilators and saving lives. The authors of the protocol include Dr James Downar, the former chair of the Dying with Dignity Physician Advisory Committee and Dr Sandy Buchman, President of the Canadian Medical Association.

Read: Euthanasia doctor developed Ontario Covid-19 triage guidelines (Link).

The authors are asking for a response to the protocol. This is my assessment.

The protocol claims to be based on fairness and equality, but actually institutionalizes the inequality and injustice that lead to people with disabilities and other vulnerable groups being selected for death based on negative and discriminatory attitudes.

The protocol states:

Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill. Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity.

This statement tells us not to have blanket statements in our healthcare directive requiring comfort measures only. Certain medical conditions may lead to recovery with treatment, but with the above wording, no treatment will be provided.

This statement is also unethical. Withdrawing a ventilator is a treatment decision that requires consent from the patient or the power of attorney. Decisions to withdraw treatment are treatment decisions that in some jurisdictions require consent in the same manner as decisions to provide treatment. 

People with disabilities who require a ventilator fear that decisions will be made to extubate them because their health condition is not clinically improving. People with disabilities may not "clinically improve" not because they are treatment resistant but because of the nature of the disability. It is discrimination to deny treatment based on disability.

The protocol states that when a person is denied treatment that they must be provided palliative care. The authors state that they are not abandoning the patient when they provide palliative care and yet the triage system has already abandoned the patient.

The protocol leads to an abuse of the ethical use of palliative sedation.

Palliative sedation or terminal sedation is properly used for a patient who has symptoms that cannot be effectively alleviated in any other way. For instance, a person who is living with Neuropathic pain may only be effectively relieved of the pain through sedation. The authors of this protocol are proposing the use of sedation as a means of causing death, instead of (MAiD) euthanasia which is legal in Canada. The protocol states:

In our opinion, palliative sedation is preferable to medical assistance in dying (MAiD) for patients with severe respiratory failure caused by SARS-CoV-2, given the 10-day reflection period, number of witnesses and assessors required, and the current requirement for full capacity to determine eligibility for MAiD. 

When analyzing euthanasia data from the Netherlands and Belgium you will notice a significant number of "assisted deaths without explicit request." This protocol is endorsing the same procedures that are done in the Netherlands and Belgium to circumvent the euthanasia law. Downar is well aware that he is advocating for intentional acts to cause death. In 2014 Downar participated in the study:  Characteristics of Belgian "life ending acts without explicit request."

The protocol changes the ideology of palliative care. The concept of palliative care is to provide pain and symptom relief when a person is dying, to palliate the symptoms but never to hasten death. The protocol is suggesting that palliative care can replace active treatment, even when treatment may lead to recovery. So palliative care becomes a way of providing a comfortable death for people who have been medically abandoned.

The protocol claims that it will lead to greater equity. The protocol acknowledges that people who live with mental illness or other conditions face substantial challenges to receiving healthcare and they conclude that: "Palliative care thus becomes the compassionate option to counterbalance this inequality."

Palliative care is better than "sending them home to die" and to not palliate symptoms is to abandon the patient again. Nonetheless, this protocol institutionalizes the inequality and injustice. The protocol states that you must be kept comfortable as we abandon you. But it doesn't stop there, the protocol advocates for the abuse of the use of "palliative sedation" meaning, we will not only palliative your symptoms, but in certain circumstances we will end your life without your explicit consent.

Further information:

• US Department of Health and Human Services will uphold human rights in relation to health care resource allocation (link).
• Covid-19 reveals a deadly failure of priorities (link).

Ventilator Rationing, Universal DNRs and Covid 19 (Coronavirus)

This article was published by Nancy Valko on April 3, 2020

By Nancy Valko RN

As a nurse myself, it is hard to watch my fellow nurses bravely fighting on the front lines of this pandemic without being able to be there with them.

Nurses are a special breed. In my over 50 years as a nurse, I found that most of us chose nursing because we want to help people and alleviate suffering. We work the long hours on our feet, skip meals, hold hands and listen, cry when our patients die, etc. because we truly do care.

But the health care system has been changing. A dark new ethics movement is infecting our system and telling us not only that our patients have a right to choose to end their lives but also that some of our patients even “need” to die and that we can’t care for all of them during the Covid 19 pandemic.

Worst of all, we are being told that we can now know how to decide which patients are “expendable”.

Ventilator Rationing
A 71 year old man with a heart condition arrives at a hospital is diagnosed with Covid 19. His condition worsens and he is placed on a ventilator to help him breathe. Then the infection rate spikes in the city and the hospital is overrun with severely ill patients, many between 20 and 50 years old and otherwise healthy.

The health care team is forced to decide which patients should they focus on and care for.

This is the scenario posed in a March 20, 2020 Medpage article “Ethics Consult: Take Elderly COVID-19 Patient Off Ventilator?— You make the call” along with an online survey with 3 questions:

1. Would you prioritize the care of healthier and younger patients and shift the ventilator from the elderly man to patients with a higher probability of recovering? 
2. Would you change your decision if the elderly patient had been in intensive care for a non-COVID-19-related illness? 
3. Would you prioritize the older man over college students who had likely been infected during spring break trips?
   

After almost 4000 votes, the survey showed 55.65% voting yes on prioritizing the care of the healthier and younger patients, 78.11% voting no on changing their decision about the elderly patient if he didn’t have Covid 19 and 71.12% voting no on prioritizing the elderly man over college students likely to have been infected on a spring break trip.

So while most people fear becoming infected with Covid 19, less well-known ethical dangers may also affect us, especially those of us who are older or debilitated.

Every day, we hear about the shortage of ventilators needed for Covid 19 patients and the overworked and understaffed health care professionals providing the care. Now both mainstream media and medical journals are publishing articles about the ethical dilemma of denying CPR (cardiopulmonary resuscitation) or a ventilator to older patients or those with a poor prognosis with Covid 19 in a triage situation.

Triage is defined as “A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.” (Emphasis added)

But this definition does NOT include deciding how to triage people based on age or “productivity”.

Universal DNRs

A March 25, 2020 Washington Post article “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic” posed the question: “how to weigh the ‘save at all costs’ approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.”

This is not just an academic discussion.

As the article reveals, “Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.” (Emphasis added) And Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

Bioethicist Scott Halpern at the University of Pennsylvania is cited as the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a universal DNR for Covid 19 patients was too “draconian” and could sacrifice a young person in otherwise good health. He also noted that the reality of health-care workers with limited protective equipment cannot be ignored. “If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

The article notes that “Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.” (Emphasis added)

This could not only upend traditional ethics but also the law as “Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise.”

Both disability and pro-life groups have condemned such health care rationing with Covid 19, especially for older people and people with disabilities.

However, this and more is apparently already happening.

In an April 1, 2020 Wall Street Journal article “What the Nurses See: Bronx Hospital Reels as Coronavirus Swamps New York” a co-worker told the nurse interviewed that the nurses were no longer doing chest compressions to resuscitate Covid 19 patients because “it uses lots of protective gear and puts workers at greater risk than chemical resuscitations”. This was corroborated by other nurses who said this has become an “unspoken rule.”

Conclusion

How can we protect ourselves and our loved ones in these circumstances?

At the very least and whether or not we are older or have disabilities, we should consider or reconsider our advance directives.

As the Life Legal Defence Foundation writes in their “SPECIAL MESSAGE ABOUT COVID-19 AND ADVANCE HEALTH CARE DIRECTIVES”:

As COVID-19 spreads around the globe, the public is learning about the importance of mechanical ventilators in providing temporary breathing support for many of those infected. Ventilators are saving lives!

A false understanding of respirators and ventilators has become commonplace in recent years. Many people think that these and similar machines’ only role is prolonging the dying process. The widely publicized treatment of COVID-19 patients is helping to dispel that myth. Many patients rely on machines temporarily every day for any number of reasons and go on to make full recoveries.

Unfortunately, many individuals have completed advance health care directives stating or suggesting that they do not wish to receive breathing assistance through mechanical ventilation.

Please take the time to review any advanced medical directives (including POLST forms) signed by you or your loved ones to make sure they are clear that mechanical ventilation is not among the forms of care that are refused. If there is any ambiguity, you may want to consider writing, signing, and dating an addendum specifying that mechanical ventilation is authorized. (Emphasis in original)

I would add that other treatments or care such as DNRs and feeding tubes also not be automatically checked off. I believe it is safer to appoint a trusted person to insist on being given all information concerning risks and benefit before permission is given to withdraw or withhold treatment.

Even as the nation is racing to get more ventilators and staff as we cope with this terrible pandemic, we all must continue to affirm the value of EVERY human life.

Assisted suicide by telehealth and medical misdiagnosis.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

On March 20 I reported that the assisted suicide lobby was using the Covid-19 crisis to promote approving assisted suicide by telehealth. 

This is not a new plan. The 2019 New Mexico assisted suicide bill included a telehealth provision and the recent bill to expand assisted suicide in Hawaii included a telehealth provision.

On March 26 I reported that the association of death doctors were also using the Covid-19 crisis to promote "aid-in-dying" by telehealth. 

On March 26, the assisted suicide lobby group that urged governments to allow assisted suicide by telehealth thanked Congressional leaders for expanding access to telehealth during the Coronavirus crisis.

I understand the need to expand telehealth services during the Covid-19 crisis but assisted suicide is not medical treatment. 

The online medical dictionary defines treatment as: the management and care of a patient, the combating of a disease or disorder. Assisted suicide does not manage or combat a disease or disorder and it is not about providing care.

Let's think this through. A person with difficult health issues who feels like a burden on others, or is experiencing depression or existential distress, could be assessed, approved and prescribed a lethal drug cocktail for suicide by telehealth.
 
Further to that, if you consider the amount of medical misdiagnosis, is it reasonable to give a physician the right to prescribe a lethal drug cocktail without examining the patient to confirm the medical diagnosis?

Let's examine this further.
 
According to Brian Mastroianni who was published by healthline.com on February 22, medical misdiagnosis is more common than you think. According to the data:

• In the United States, 12 million people are affected by medical diagnostic errors each year.
• An estimated 40,000 to 80,000 people die annually from complications related to misdiagnoses and a similar number of people will experience a permanent disability related to misdiagnosis.

Mya DeRyan

In October 2016 Mya DeRyan survived a suicide attempt. While recovering DeRyan learned that the terminal diagnosis that she was trying to escape from was in fact a wrong diagnosis.

In April 2013, Pietro D’Amico, a 62-year-old magistrate from Calabria Italy, died by assisted suicide at a Swiss assisted suicide clinic. His autopsy found that he was misdiagnosed.

Considering the data, it is irresponsible for a physician to prescribe a lethal drug cocktail, upon request, without examining the person and ensuring that the person has an accurate diagnosis.

It is unlikely that the US Department of Health and Human Services (HHS) realizes that the assisted suicide lobby took advantage of the Covid-19 crisis to gain approval for assisted suicide by telehealth.

Queensland Australia report approves euthanasia with a condition that will cause death some day

Published by the Australian Care Alliance on April 1, 2020.

Queensland Australia Parliament

Legalising euthanasia for any Queensland adult with a medical condition that two doctors or nurses think “will cause death” someday has been recommended by a parliamentary committee.

The Health, Communities, Disability Services and Domestic and Family Violence Prevention Committee of the Queensland Parliament has, in a report tabled on 31 March 2020, recommended that:

“the Queensland Government use the well-considered draft legislation submitted to the inquiry by Professors Lindy Willmott and Ben White as the basis for a legislative scheme for voluntary assisted dying.”

That draft legislation would legalise euthanasia and assisted suicide for any person over 18 years of age, with “an incurable, advanced and progressive medical condition that” two doctors say “will cause death”.

The Committee recommended also allowing two registered nurses to make the eligibility assessment and one of the nurses to administer the lethal poison to kill the person.

Unlike the Victorian or Western Australian laws the draft legislation would require a registered medical practitioner to be present if the prescribed lethal substance is self-administered.

There would, however, be no requirement for the medical practitioner (or nurse) to remain with the person after the lethal poison is administered either by the person or by the medical practitioner or nurse.

Interestingly, Willmott and White note:

Given that where choice is available, practitioner administration [i.e. euthanasia] is overwhelmingly chosen, these disadvantages [the inconvenience of requiring a medical practitioner to be present] are only likely to arise in the small number of voluntary assisted dying cases where a person specifically wants to self-administer [assisted suicide].

Section 10 of the draft legislation makes it clear that whether a person’s medical condition will cause the person’s death is to be determined by reference to available medical treatment that is acceptable to the person. This means, for example, that any insulin dependent diabetic would qualify simply by deciding no longer to take insulin.

The section also makes it clear that the suffering element is purely subjective and could be limited to existential suffering (such as feeling like a burden on others).

The draft legislation would require a medical practitioner with a conscientious objection to euthanasia to refer the person to a medical practitioner willing to perform it.

Like the laws in Victoria and Western Australia, the draft legislation would allow both an initial and final request for euthanasia to be made by a gesture.

Rejecting evidence presented by the Australian Care Alliance (see p. 22-24) about suicide contagion where assisted suicide has been legalised the Committee claims that:

temporary suicidal ideation is quite distinct from an enduring, considered and rational decision to end one’s life in the face of unbearable suffering. Given this distinction, the committee considers that a decision to legislate for the introduction of voluntary assisted dying [euthanasia and assisted suicide] is not inconsistent with suicide prevention campaigns and messaging.

The Committee does recommend adding a provision to the draft legislation that only the person may instigate a discussion about euthanasia or assisted suicide.

The Committee suggests that further consideration be given as to whether euthanasia by advanced directive should also be allowed.

The Greens member of the Committee, Mr Michael Berkman, favours the use of advanced directives as well as allowing children to request euthanasia.

The two LNP members of the Committee rejected the key recommendation:

This recommendation is not supported with any written assessment of the document. As the Report does not show the Committee undertook a detailed analysis it is very difficult to conclude that the “draft legislation” is “well considered.” There is also no evidence in the Report that the Bill was disseminated to stakeholders nor detailed evidence taken from them including professional bodies as to whether or not the Bill should be put forward as “draft legislation”. This is a fundamental breach of any Committee’s obligation. If it is to recommend a Bill, then the Report should and must provide a rigorous assessment undertaken with all stakeholders.

It seems unlikely that any Bill would be introduced before the Queensland State election which is due on 31 October 2020.

The Premier's office has said that Premier Annastacia Palaszczuk's focus was "100 per cent on the state's response to COVID-19".