Below is an abridged version of the LTC-CARES Ethical Framework for Virtual Care in Long Term Care Facilities.

Principles to guide decisions: Stewardship, Beneficence, Non-maleficence, Autonomy, Proportionality, Equity, Solidarity, Non-abandonment

Principles to guide decision-making processes: Transparency, Consistency, Inclusiveness, Accountability, Trust

Long Term Care Ethical Decision-Making Tool

Criteria Things to Consider
Risk to Patient (Treatment/ procedure)     Length of time to treatment can be delayed before seeing a decline in condition.

Impact of deferral on successful outcome/prognosis.
Likelihood delayed treatment results in increased ER visits/in-patient admission.

Can the patient be managed as an outpatient if their condition worsens?

Can medical conditions/symptoms be reasonably managed while waiting for treatment/ procedure?

What level of frailty and palliative performance is the patient experiencing?
Patient Preferences and  Impact on Quality of Life Patient’s capacity: full, partial, none

What is important to the patient? (i.e. family presence, pain management, surviving illness)

Relevant values/wishes, evidence (i.e. Advance Care Plan, Advance Directive, Living Will, POA form, family conversations)

Can relief of pain and suffering (physical, emotional, spiritual) be reasonably managed?

What is the daily experience of the patient (i.e. ratio between moments of joy and moments of suffering)?
Health Care Provider/ Systems Considerations? Will providing treatment/intervention to the patient expose health care providers to more than usual risk, including through the consumption of resources required for providers’ safety?

Do you anticipate that the change in the proposed treatment plan will result in moral distress?

Will alteration of standard of care impact patient population or community?

Is there a current outbreak of COVID or other infectious disease currently in the LTC facility?

Does Patient require isolation?

Would Transfer back to LTC facility to be possible once ready for discharge?

Prioritizing Patient Procedures, Treatments and need for Transfer to Acute Care

Priority Category Definition Examples
Priority A Patients who: Are critically ill (unstable, suffering unbearably, and/or condition is immediately life threatening) OR

Need diagnostic procedures only available in acute care/life sustaining treatment (e.g. nephrostomy tube insertion) AND

For whom there is effective treatment AND

Are likely to benefit from the treatment AND

Patient’s (or SDM) goals of care includes transfer to hospital
Severe respiratory distress not improving with initial care

Sepsis requiring intensive management

Trauma resulting in (unstable) fractures

Active hemorrhage

Blocked nephrostomy tube

Curative chemotherapy, etc.
Priority B Patients who: Have a non-life-threatening condition and are stable AND For whom treatment can be deferred OR Are less likely to benefit from treatment

*Monitor to ensure patients are not at undue risk. If status changes: upgrade to priority A, send to acute care.
Non-severe respiratory illness

Non-severe worsening of chronic illness

Minor injuries

Routine feeding tube replacement

PICC line insertion

Nephrostomy tube

Suprapubic catheter change, etc.
Priority C Patients who: For whom services may be deferred until after the pandemic without significant consequences.

*Monitor to ensure patients are not at undue risk. If status changes: upgrade to priority A or B.
Routine non-urgent follow-up appointments (many of these will be cancelled by acute care)

Principles are listed in no particular order and are adapted from HHS Ethics Framework, The Ontario Ethics Pandemic Taskforce and Bridgepoint Treat vs Transfer During a COVID-19 Pandemic Surge