Frailty, Outcomes, Recovery and Care Steps of Critically Ill Patients (FORECAST): a prospective, multi-centre, cohort study.

PURPOSE: Frailty is common in critically ill patients but the timing and optimal method of frailty ascertainment, trajectory and relationship with care processes remain uncertain. We sought to elucidate the trajectory and care processes of frailty in critically ill patients as measured by the Clinical Frailty Scale (CFS) and Frailty Index (FI). METHODS: This is a multi-centre prospective cohort study enrolling patients ≥ 50 years old receiving life support > 24 h. Frailty severity was assessed with a CFS, and a FI based on the elements of a comprehensive geriatric assessment (CGA) at intensive care unit (ICU) admission, hospital discharge and 6 months. For the primary outcome of frailty prevalence, it was a priori dichotomously defined as a CFS ≥ 5 or FI ≥ 0.2. Processes of care, adverse events were collected during ICU and ward stays while outcomes were determined for ICU, hospital, and 6 months. RESULTS: In 687 patients, whose age (mean ± standard deviation) was 68.8 ± 9.2 years, frailty prevalence was higher when measured with the FI (CFS, FI %): ICU admission (29.8, 44.8), hospital discharge (54.6, 67.9), 6 months (34.1, 42.6). Compared to ICU admission, aggregate frailty severity increased to hospital discharge but improved by 6 months; individually, CFS and FI were higher in 45.3% and 50.6% patients, respectively at 6 months. Compared to hospital discharge, 18.7% (CFS) and 20% (FI) were higher at 6 months. Mortality was higher in frail patients. Processes of care and adverse events were similar except for worse ICU/ward mobility and more frequent delirium in frail patients. CONCLUSIONS: Frailty severity was dynamic, can be measured during recovery from critical illness using the CFS and FI which were both associated with worse outcomes. Although the CFS is a global measure, a CGA FI based may have advantages of being able to measure frailty levels, identify deficits, and potential targets for intervention.

Organ donation following medical assistance in dying, Part II: a scoping review of existing processes and procedures.

OBJECTIVE: The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). For this second part of a 2-part scoping review, the focus is on the existing procedures and processes for organ donation following MAiD. INTRODUCTION: Organ donation following MAiD is a novel and contentious issue worldwide. To give direction for future research and initiatives, a comprehensive understanding of the available evidence of existing procedures and processes for organ donation following MAiD is needed. INCLUSION CRITERIA: For this review, the population of interest included all individuals who underwent organ donation following MAiD; the concept was defined as procedures and processes involved in organ donation after MAiD; and the context was reports of organ donation following MAiD at home or in any health care setting worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders. METHODS: This scoping review was conducted in line with JBI methodology. Published studies were retrieved from MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from websites and organ donation organizations in Canada, Belgium, and The Netherlands. Two independent reviewers screened all reports (both title and abstract, and full text) against the predetermined inclusion criteria, extracted data, and completed a content analysis. Any disagreements between the 2 reviewers were resolved through discussion or with another reviewer. RESULTS: We included 121 documents across parts I and II, and we report on 107 documents in this second part. The majority of the 107 documents were discussion papers, published in English, and in Canada from 2019 to 2021. In the content analysis, we identified 5 major categories regarding existing procedures and processes of organ donation following MAiD: i) clinical pathways for organ donation following MAiD; ii) organ donation following MAiD and the donor; iii) clinical practice tools for organ donation following MAiD; iv) education and support for health care providers involved in organ donation following MAiD; and v) health care providers' roles and perceptions during organ donation following MAiD. CONCLUSIONS: Findings from this review can be used to provide support and guidance for improvements in procedures and processes, as well as a rich resource for countries currently planning to establish programs for organ donation after MAiD.

Organ donation following medical assistance in dying, Part I: a scoping review of legal and ethical aspects.

OBJECTIVE: The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). Additionally, for this first part of a 2-part scoping review, the focus is on legal and ethical considerations regarding organ donation following MAiD. INTRODUCTION: Organ donation following MAiD is a relatively new procedure that has sparked much debate and discussion. A comprehensive investigation into the legal and ethical aspects related to organ donation following MAiD is needed to inform the development of safe and ethical practices. INCLUSION CRITERIA: In this review, we included documents that investigated legal and/or ethical issues related to individuals who underwent organ donation following MAiD in any setting (eg, hospital or home) worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders. METHODS: This scoping review followed JBI methodology. Published studies were retrieved from databases, including MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from organ donation organizations in Canada, The Netherlands, and Belgium. Two independent reviewers screened all reports (both by title and abstract and by full text) against the inclusion criteria, extracted data, and completed a content analysis. Disagreements between the 2 reviewers were resolved through discussions among the reviewers and the lead reviewer. RESULTS: We included 121 documents for parts I and II of our scoping review, 89 of which are included in part I. The majority of the 89 documents were discussion papers published in English and in Canada from 2019 to 2021. In the content analysis, we identified 4 major categories regarding ethical and legal aspects of organ donation following MAiD: i) legal definitions, legislation, and guidelines; ii) ethics, dilemmas, and consensus; iii) consent and objection; and iv) public perceptions. We identified the main legislation regulating the practices of organ donation following MAiD in countries where both procedures are permitted, the many ethical debates surrounding this topic (eg, eligibility criteria for organ donation and MAiD, disclosure of donors' and recipients' information, directed organ donation, death determination in organ donation following MAiD, ethical safeguards for organ donation following MAiD), as well as the public perceptions of this process. CONCLUSIONS: Organ donation following MAiD has raised many legal and ethical concerns regarding establishing safeguards to protect patients and families. Despite the ongoing debates around the risks and benefits of this combined procedure, when patients who request MAiD want to donate their organs, this option can help fulfill their last wishes and diminish their suffering, which should be the main reasons to offer organ donation following MAiD.

Transplant Recipient Preferences Regarding Organ Donor Research: Their Role in Consent and use of Their Data.

Research on deceased organ donors has been hindered by concerns related to seeking research consent from transplant recipients. We undertook this qualitative study to elucidate solid organ transplant recipients views on organ donor research, their role in the consent for such research, and their preferences related to providing their data. We conducted interviews with 18 participants and three themes emerged from the data. The first centered around participant research literacy. The second described practical preferences of participating in research, and the third related to the connection between donor and recipient. We concluded that previously held views about the requirement for transplant recipients to have a consenting role in donor research is not always suitable.

A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline.

This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.

RéSUMé: Ces Lignes directrices de pratique clinique 2023 Lignes directrices de pratique clinique dicale du décès basée sur l'arrêt permanent de la fonction cérébrale qui s'applique à toute personne, ainsi que des recommandations pour la détermination du décès par des critères circulatoires pour des donneurs d'organes potentiels et des recommandations pour la détermination du décès par des critères neurologiques pour tous les patients sous ventilation mécanique, indépendamment de leur potentiel de donneur d'organes. Les présentes Lignes directrices sont approuvées par la Société canadienne de soins intensifs, l'Association médicale canadienne, l'Association canadienne des infirmiers/infirmières en soins intensifs, la Société canadienne des anesthésiologistes, la Fédération des sciences neurologiques du Canada (représentant la Société canadienne de neurologie, la Société canadienne de neurochirurgie, la Société canadienne de neurophysiologie clinique, l'Association canadienne de neurologie pédiatrique, la Société canadienne de neuroradiologie et le Consortium neurovasculaire canadien), la Société canadienne du sang, le Programme de recherche en don et transplantation du Canada, l'Association canadienne des médecins d'urgence, l'Association des infirmières et infirmiers praticiens du Canada, et la Société canadienne de soins intensifs cardiovasculaires (CANCARE) et la Société canadienne de pédiatrie.

When is a person dead? The Canadian public's understanding of death and death determination: a nationwide survey.

PURPOSE: We aimed to describe the Canadian public's understanding and perception of how death is determined in Canada, their level of interest in learning about death and death determination, and their preferred strategies for informing the public. METHODS: We conducted a nationwide cross-sectional survey of a representative sample of the Canadian public. The survey presented two scenarios of a man who met current criteria for neurologic death determination (scenario 1) and a man who met current criteria for circulatory death determination (scenario 2). Survey questions evaluated understanding of how death is determined, acceptance of death determination by neurologic and circulatory criteria, and interest and preferred strategies in learning more about the topic. RESULTS: Among 2,000 respondents (50.8% women; n = 1,015), nearly 67.2% believed that the man in scenario 1 was dead (n = 1,344) and 81.2% (n = 1,623) believed that the man in scenario 2 was dead. Respondents who believed that the man was not dead or were unsure endorsed several factors that may increase their agreement with the determination of death, including requiring more information about how death was determined, seeing the results of brain imaging/tests, and a third doctor's opinion. Predictors of disbelief that the man in scenario 1 is dead were younger age, being uncomfortable with the topic of death, and subscribing to a religion. Predictors of disbelief that the man in scenario 2 is dead were younger age, residing in Quebec (compared with Ontario), having a high school education, and subscribing to a religion. Most respondents (63.3%) indicated interest in learning more about death and death determination. Most respondents preferred to receive information about death and death determination from their health care professional (50.9%) and written information provided by their health care professional (42.7%). CONCLUSION: Among the Canadian public, the understanding of neurologic and circulatory death determination is variable. More uncertainty exists with death determination by neurologic criteria than with circulatory criteria. Nevertheless, there is a high level of general interest in learning more about how death is determined in Canada. These findings provide important opportunities for further public engagement.

RéSUME: OBJECTIF: Notre objectif était de décrire la compréhension et la perception du public canadien quant à la façon dont le décès est déterminé au Canada, son niveau d'intérêt à en apprendre davantage sur le décès et la détermination du décès, et ses stratégies préférées pour informer le public. MéTHODE: Nous avons réalisé un sondage transversal national auprès d'un échantillon représentatif de la population canadienne. L'enquête a présenté deux scénarios : un homme qui répondait aux critères actuels de détermination d'un décès neurologique (scénario 1) et un homme qui répondait aux critères actuels de détermination d'un décès cardiocirculatoire (scénario 2). Les questions de l'enquête évaluaient la compréhension de la façon dont le décès est déterminé, l'acceptation de la détermination du décès selon des critères neurologiques et circulatoires, et l'intérêt et les stratégies préférées pour en apprendre davantage sur le sujet. RéSULTATS: Parmi les 2000 répondants (50,8 % de femmes; n = 1015), près de 67,2 % ont estimé que l'homme du scénario 1 était décédé (n = 1344) et 81,2 % (n = 1623) ont estimé que l'homme du scénario 2 était décédé. Les répondants qui croyaient que l'homme n'était pas décédé ou qui n'étaient pas sûrs ont acquiescé à plusieurs facteurs qui pourraient accroître leur accord avec la détermination du décès, y compris le besoin de plus de renseignements sur la façon dont le décès a été déterminé, la consultation des résultats d'imagerie et des tests cérébraux et l'opinion d'un troisième médecin. Les prédicteurs de non-conviction que l'homme dans le scénario 1 était décédé étaient le fait d'être plus jeune, le fait d'être mal à l'aise avec le sujet de la mort et la croyance en une religion. Les prédicteurs de non-conviction à l'égard du décès de l'homme dans le scénario 2 étaient le fait d'être plus jeune, d'être résident du Québec (comparativement à l'Ontario), d'avoir complété des études secondaires et la croyance en une religion. La plupart des répondants (63,3 %) ont indiqué qu'ils souhaiteraient en apprendre davantage sur le décès et la détermination du décès. La plupart des répondants préféraient recevoir de l'information sur le décès et la détermination du décès de leur professionnel de la santé (50,9 %) et de l'information écrite fournie par leur professionnel de la santé (42,7 %). CONCLUSION: Parmi le public canadien, la compréhension de la détermination du décès neurologique et cardiocirculatoire est variable. Il existe plus d'incertitude en matière de détermination du décès selon des critères neurologiques que selon des critères cardiocirculatoires. Néanmoins, il existe un grand intérêt général à en apprendre davantage sur la façon dont le décès est déterminé au Canada. Ces résultats offrent d'importantes possibilités de participation accrue du public à l'avenir.

Death determination by neurologic criteria-what do families understand?

PURPOSE: Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs). METHODS: We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs. RESULTS: From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting. CONCLUSION: Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.

RéSUMé: OBJECTIF: À l'heure actuelle, il y a peu de données empiriques sur la compréhension des familles de la mort cérébrale et de la détermination du décès. Le but de cette étude était de décrire la compréhension des membres de la famille de la mort cérébrale et du processus de détermination du décès dans le contexte du don d'organes dans les unités de soins intensifs (USI) canadiennes. MéTHODE: Nous avons mené une étude qualitative à l'aide d'entrevues semi-structurées et approfondies avec des membres de la famille à qui on a demandé de prendre une décision de don d'organes au nom de patients adultes ou pédiatriques dont le décès avait été déterminé selon des critères neurologiques (DCN) dans les unités de soins intensifs canadiennes. RéSULTATS: Sur la base d'entrevues avec 179 membres de la famille, six thèmes principaux ont émergé : 1) l'état d'esprit, 2) la communication, 3) le DCN peut être contre-intuitif, 4) la préparation à l'évaluation clinique pour un DCN, 5) l'évaluation clinique pour un DCN et 6) le moment du décès. Des recommandations sur la façon dont les cliniciens peuvent aider les membres de la famille à comprendre et à accepter un DCN par la communication à des moments clés ont été décrites, y compris la préparation des membres de la famille à la détermination du décès, l'autorisation de la présence des membres de la famille et l'explication de l'heure légale du décès, combinées à des stratégies multimodales. Pour de nombreux membres de la famille, la compréhension du DCN s'est développée au fil du temps et a été facilitée par des rencontres et des explications répétées plutôt qu'au cours d'une seule rencontre. CONCLUSION: La compréhension qu'ont les membres de la famille de la mort cérébrale et de la détermination du décès représente un parcours qu'ils ont décrit lors de rencontres successives avec des acteurs de soins de santé, et particulièrement avec des médecins. Les facteurs modifiables pour améliorer la communication et les issues du deuil pendant un DCN comprennent l'attention portée à l'état d'esprit de la famille, le rythme et la répétition des discussions en fonction de la compréhension exprimée par les familles, ainsi que la préparation et l'invitation des familles à être présentes pour la détermination clinique, y compris pendant le test d'apnée. Nous avons fourni des recommandations familiales qui sont pragmatiques et peuvent être facilement mises en œuvre.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study.

Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions. OBJECTIVES: To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. DESIGN: Interview-based qualitative study using inductive thematic analysis. SETTING AND PARTICIPANTS: Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. RESULTS: Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. CONCLUSIONS AND RELEVANCE: An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Outcomes from organ donation following medical assistance in dying: A scoping review.

AIM: To collate and summarize the current international literature on the transplant recipient outcomes of organs from Medical Assistance in Dying (MAiD) donors, as well as the actual and potential impact of organ donation following MAiD on the donation and transplantation system. BACKGROUND: The provision of organ donation following MAiD can impact the donation and transplantation system, as well as potential recipients of organs from the MAiD donor, therefore a comprehensive understanding of the potential and actual impact of organ donation after MAiD on the donation and transplantation systems is needed. DESIGN: Scoping review using the JBI framework. METHODS: We searched for published (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Academic Search Complete), and unpublished literature (organ donation organization websites worldwide). Included references discussed the actual and potential impact of organ donation following MAiD on the donation and transplantation system. All references were screened, extracted and analysed by two independent reviewers. RESULTS: We included 78 references in this review and our finding were summarized across three categories: (1) Impact in the donor pool: (2) statistics on organ donation following MAiD; and (3) potential and actual impact of MAiD on the donation and transplant system. CONCLUSIONS: The potential impact of the MAiD donor on the transplant waiting list is relatively small as this process is still rare, however, due to the current organ shortage worldwide the contribution of this procedure should not be disregarded. Additionally, despite being limited, the existing research provided scanty evidence that organs retrieved from MAiD donors are associated with satisfactory graft function and survival rates and that outcomes from transplant recipients are comparable to those of organs from donation following brain death and may be better than those of organs from other types of donation after circulatory determined death. Still, further studies are required for comprehensive and reliable evidence.

Moral Distress in Canadian Intensivists: A Complex Interplay of Contextual and Relational Factors.

BACKGROUND: Health care professionals experience moral distress when they cannot act based on their moral beliefs because of perceived constraints. Moral distress prevalence is high among critical care (ICU) clinicians, but varies significantly between and within professions. RESEARCH QUESTION: How can the interindividual variability in moral distress of Canadian ICU physicians be explained to inform future system-based interventions? STUDY DESIGN AND METHODS: We analyzed 135 free-text comments written by 83 of the 225 ICU physicians who participated in an online cross-sectional wellness survey. An interdisciplinary team of five investigators completed the thematic analysis of anonymized survey comments according to published guidelines. RESULTS: Physicians identified contextual and relational factors that contributed to moral distress and work-related stress. Combined sources of distress created high work-related demands that were not always matched by equally high resources or mitigated by work-related rewards. An imbalance between demands and rewards could lead to undesirable individual and collective consequences. INTERPRETATION: Moral distress is experienced variably by ICU physicians and is linked to contextual and relational factors. Future studies should evaluate modifiable factors such as team interactions and the role of professional rewards as mitigators of distress to bring new insights into strategies to improve ICU clinician wellness and patient care.

The experiences of family members of deceased organ donors and suggestions to improve the donation process: a qualitative study.

BACKGROUND: Decisions about organ donation are stressful for family members of potential organ donors. We sought to comprehensively explore the donation process from interviews conducted with family members of patients admitted to pediatric and adult intensive care units in Canada. METHODS: We conducted a qualitative study using semistructured, in-depth interviews with 271 family members asked to make an organ donation decision. We recruited participants from all provinces with an organ donation organization (n = 10), and analyzed themes using a modified grounded theory approach. On the basis of these interviews, suggestions were made by researchers and family members on how to improve the process of organ donation. RESULTS: We identified 3 main themes and 9 subthemes. Families need more comprehensive support around the time of donation, including having access to someone with shared experiences, support during specific moments as needed and better support during critical transitions (e.g., when the donor body goes to the operating room). The theme of better connection to recipient(s) included receiving information about the donation surgery (e.g., which organs were recovered), establishing connection with recipients (e.g., via social networks or letters) and planned encounters. Support after donation, such as updates on organ transplantation, early mental health checks and continued connection to donor organizations, could be improved. We derived 20 suggestions for improving the organ donation process, derived from interviews with family members of pediatric and adult organ donors. INTERPRETATION: We found gaps in family support during end-of-life and donation care. Feelings of abandonment, lack of support and poor-to-little follow-up provide the empirical findings needed for hospitals and organ donor organizations to provide better support to donor families.

Economic feasibility of a novel tool to assist extubation decision-making: an early health economic modeling.

OBJECTIVES: To estimate the minimum percent change in failed extubation to make a tool designed to reduce extubation failure (Extubation Advisor [EA]) economically viable. METHODS: We conducted an early return on investment (ROI) analysis using data from intubated intensive care unit (ICU) patients at a large Canadian tertiary care hospital. We obtained input parameters from the hospital database and published literature. We ran generalized linear models to estimate the attributable length of stay, total hospital cost, and time to subsequent extubation attempt following failure. We developed a Markov model to estimate the expected ROI and performed probabilistic sensitivity analyses to assess the robustness of findings. Costs were presented in 2020 Canadian dollars (C$). RESULTS: The model estimated a 1 percent reduction in failed extubation could save the hospital C$289 per intubated patient (95 percent CI: 197, 459). A large center seeing 2,500 intubated ICU patients per year could save C$723,124/year/percent reduction in failed extubation. At the current annual price of C$164,221, the EA tool must reduce extubation failure by at least 0.24 percent (95 percent CI: .14, .41) to make the tool cost-effective at our site. CONCLUSIONS: Clinical decision-support tools like the EA may play an important role in reducing healthcare costs by reducing the rate of extubation failure, a costly event in the ICU.

The Intersection of Death Investigation and Organ Donation Systems: A Scoping Review.

Introduction: Death investigators (DIs) such as coroners, medical examiners, and forensic pathologists play important and evolving roles in deceased organ donation. DIs communicate with organ donation organizations (ODOs) to gather case-specific information and release or restrict organs depending on the medicolegal requirements. This scoping review aims to identify the breadth of roles and decision-making processes that may facilitate or hinder deceased donation in DI cases. Methods: This study was conducted using a scoping literature review and subsequent thematic analysis. Results: Thirty-one eligible papers described 8 common themes with region-specific nuances. These include: 1) shared (ODO and DI) protocols for early communication around each case; 2) shared standards and education for death investigation practices related to organ donation; 3) DI support staff or teams to facilitate organ donation; 4) DI authority to order additional testing and imaging before organ recovery; 5) donation-specific legislation to enhance DI and/or ODO operations; 6) legally trained DI authority to veto medical decisions to proceed with organ donation; 7) DI attendance at organ recovery; and 8) surgeons recording specific DI evidence during organ recovery. Conclusion: These findings have cultural and resource-allocation implications and expose gaps in the international literature describing practices at the intersection of deceased organ donation and death investigation. A better understanding of the rationale and execution of various systems for DI and ODO cooperation may serve to advance both organ donation and death investigation.

Healthcare Professionals' Understandings of the Definition and Determination of Death: A Scoping Review.

Background: During the 1950s, advances in critical care, and organ transplantation altered the relationship between organ failure and death. There has since been a shift away from traditional cardiocirculatory based to brain-based criteria of death, with resulting academic controversy, despite the practice being largely accepted worldwide. Our objective is to develop a comprehensive description of the current understandings of healthcare professionals regarding the meaning, definition, and determination of death. Methods: Online databases were used to identify papers published from 2003 to 2020. Additional sources were searched for conference proceedings and theses. Two reviewers screened papers using predefined inclusion and exclusion criteria. Complementary searches and review of reference lists complemented the final study selection. A data extraction instrument was developed to iteratively chart the results of the review. A qualitative approach was conducted to thematically analyze the data. Results: Seven thousand four hundred twenty-eight references were identified. In total, 75 papers met the inclusion criteria. Fourteen additional papers were added from complementary searches. Most were narratives (35%), quantitative investigations (21%), and reviews (18%). Identified themes included: (1) the historical evolution of brain death (BD), (2) persistent controversies about BD and death determination, (3) wide variability in healthcare professionals' knowledge and attitudes, (4) critical need for BD determination revision. Conclusions: We concluded that although BD is widely accepted, there exists variation in healthcare providers' understanding of its conceptual basis. Death determination remains a divisive issue among scholars. This review identified a need for increased opportunities for formal training on BD among healthcare providers.

Public Understandings of the Definition and Determination of Death: A Scoping Review.

Background: Advances in medicine and technology that have made it possible to support, repair, or replace failing organs challenge commonly held notions of life and death. The objective of this review is to develop a comprehensive description of the current understandings of the public regarding the meaning/definition and determination of death. Methods: This scoping review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Online databases were used to identify articles published from 2003 to 2021. Two reviewers (S.S. and K.Z.) screened the articles using predefined inclusion and exclusion criteria, extracted data for specific content variables, and performed descriptive examination. Complementary searches of reference lists complemented the final study selection. A search strategy using vocabulary of the respective databases was created, and criteria for the inclusion and exclusion of the articles were established. Results: Seven thousand four hundred twenty-eight references were identified. Sixty were retained for analysis, with 4 additional references added from complementary searches. A data extraction instrument was developed to iteratively chart the results. A qualitative approach was conducted to thematically analyze the data. Themes included public understanding/attitudes toward death and determination of death (neurological determination and cardiocirculatory determination of death), death and organ donation, public trust and legal variability, and media impacts. Conclusions: This review provides a current and comprehensive overview of the literature related to the general public's understanding and attitudes toward death and death determination and serves to highlight the gaps in this topic.

Feasibility of implementing Extubation Advisor, a clinical decision support tool to improve extubation decision-making in the ICU: a mixed-methods observational study.

OBJECTIVES: Although spontaneous breathing trials (SBTs) are standard of care to extubation readiness, no tool exists that optimises prediction and standardises assessment. In this study, we evaluated the feasibility and clinical impressions of Extubation Advisor (EA), a comprehensive clinical extubation decision support (CDS) tool. DESIGN: Phase I mixed-methods observational study. SETTING: Two Canadian intensive care units (ICUs). PARTICIPANTS: We included patients on mechanical ventilation for ≥24 hours and clinicians (respiratory therapists and intensivists) responsible for extubation decisions. INTERVENTIONS: Components included a predictive model assessment, feasibility evaluation, questionnaires and interviews with clinicians. RESULTS: We enrolled 117 patients, totalling 151 SBTs and 80 extubations. The incidence of extubation failure was 11% in low-risk patients and 21% in high-risk patients stratified by the predictive model; 38% failed extubation when both the model and clinical impression were at high risk. The tool was well rated: 94% and 75% rated the data entry and EA report as average or better, respectively. Interviews (n=15) revealed favourable impressions regarding its user interface and functionality, but unexpectedly, also concerns regarding EA's potential impact on respiratory therapists' job security. CONCLUSIONS: EA implementation was feasible, and users perceived it to have potential to support extubation decision-making. This study helps to understand bedside implementation of CDS tools in a multidisciplinary ICU. TRIAL REGISTRATION NUMBER: NCT02988167.

A qualitative exploratory case series of patient and family experiences with ECPR for out-of-hospital cardiac arrest.

OBJECTIVE: There is currently no existing data examining the opinions of patients and families after treatment with extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). We sought to interview family members and patients to learn from their experiences and satisfaction with treatment. METHODS: We contacted family members and survivors for all cases treated with ECPR for refractory OHCA at St. Paul's Hospital between January 2014 and July 2018. We performed semi-structured interviews with participants, specifically within the topics of: information sharing (including impressions of an ECPR informational pamphlet), prognostication, organ donation, and perceived value of ECPR. Due to low participant enrolment, we described all interviews in a narrative approach. RESULTS: Within the study period, there were 23 OHCAs treated with ECPR; two survivors and three family members agreed to participate. Participants were satisfied with the treatment provided, including information sharing and prognostication. There were mixed opinions about the best method of information-sharing (verbal vs written), as well as the timing of organ donation conversations. All participants believed ECPR for OHCA to be of high value. CONCLUSION: Patient's conveyed satisfaction with ECPR treatment, with mixed views on the best information sharing strategy. Further study is needed to define the optimal methods and timing for discussions of organ donation, especially for treatments of with a relatively low likelihood success.

Moral Distress and Other Wellness Measures in Canadian Critical Care Physicians.

Rationale: Understanding the magnitude of moral distress and its associations may point to solutions. Objectives: To understand the magnitude of moral distress and other measures of wellness in Canadian critical care physicians, to determine any associations among these measures, and to identify potentially modifiable factors. Methods: This was an online survey of Canadian critical care physicians whose e-mail addresses were registered with either the Canadian Critical Care Society or the Canadian Critical Care Trials Group. We used validated measures of moral distress, burnout, compassion fatigue, compassion satisfaction, and resilience. We also measured selected individual, practice, and workload characteristics. Results: Of the 499 physicians surveyed, 239 (48%) responded and there were 225 usable surveys. Respondents reported moderate scores of moral distress (107 ± 59; mean ± standard deviation, maximum 432), one-third of respondents had considered leaving or had previously left a position because of moral distress, about one-third met criteria for burnout syndrome, and a similar proportion reported medium-high scores of compassion fatigue. In contrast, about one-half of respondents reported a high score of compassion satisfaction, and overall, respondents reported a moderate score of resilience. Each of the "negative" wellness measures (moral distress, burnout, and compassion fatigue) were associated directly with each of the other "negative" wellness measures, and inversely with each of the "positive" wellness measures (compassion satisfaction and resilience), but moral distress was not associated with resilience. Moral distress was lower in respondents who were married or partnered compared with those who were not, and the prevalence of burnout was lower in respondents who had been in practice for longer. There were no differences in any of the wellness measures between adult and pediatric critical care physicians. Conclusions: Canadian critical care physicians report moderate scores of moral distress, burnout, and compassionate fatigue, and moderate-high scores of compassion satisfaction and resilience. We found no modifiable factors associated with any wellness measures. Further quantitative and qualitative studies are needed to identify interventions to reduce moral distress, burnout, and compassion fatigue.