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.

The promises and limitations of codes of medical ethics as instruments of policy change.

Codes of medical ethics (codes) are part of a longstanding tradition in which physicians publicly state their core values and commitments to patients, peers, and the public. However, codes are not static. Using the historical evolution of the Canadian Medical Association's Code of Ethics as an illustrative case, we argue that codes are living, socio-historically situated documents that comprise a mix of prescriptive and aspirational content. Reflecting their socio-historical situation, we can expect the upheaval of the COVID-19 pandemic to prompt calls to revise codes. Indeed, Alex John London has argued in favour of specific modifications to the World Medical Association's International Code of Medical Ethics (which has since been revised) in light of moral and scientific failures that occurred during the COVID-19 pandemic. Responding to London, we address the more general question: should codes be modified to reflect lessons drawn from the COVID-19 pandemic or future such upheavals? We caution that codes face limitations as instruments of policy change because they are inherently interpretive and 'multivocal', that is, they usually underdetermine or provide more than one answer to the question, 'What should I do now?' Nonetheless, as both prescriptive and aspirational documents, codes also serve as tools for reflection and deliberation-collective practices that are necessary to engaging with and addressing the moral and scientific uncertainties inherent to medicine.

Informal coercion in psychiatry: a focus group study of attitudes and experiences of mental health professionals in ten countries.

PURPOSE: Whilst formal coercion in psychiatry is regulated by legislation, other interventions that are often referred to as informal coercion are less regulated. It remains unclear to what extent these interventions are, and how they are used, in mental healthcare. This paper aims to identify the attitudes and experiences of mental health professionals towards the use of informal coercion across countries with differing sociocultural contexts. METHOD: Focus groups with mental health professionals were conducted in ten countries with different sociocultural contexts (Canada, Chile, Croatia, Germany, Italy, Mexico, Norway, Spain, Sweden, United Kingdom). RESULTS: Five common themes were identified: (a) a belief that informal coercion is effective; (b) an often uncomfortable feeling using it; (c) an explicit as well as (d) implicit dissonance between attitudes and practice-with wider use of informal coercion than is thought right in theory; (e) a link to principles of paternalism and responsibility versus respect for the patient's autonomy. CONCLUSIONS: A disapproval of informal coercion in theory is often overridden in practice. This dissonance occurs across different sociocultural contexts, tends to make professionals feel uneasy, and requires more debate and guidance.

Identifying prioritization criteria to supplement critical care triage protocols for the allocation of ventilators during a pandemic influenza.

The purpose of this study was to identify supplementary criteria to provide direction when the Ontario Health Plan for an Influenza Pandemic (OHPIP) critical care triage protocol is rendered insufficient by its inability to discriminate among patients assessed as urgent, and there are insufficient critical care resources available to treat those in that category. To accomplish this task, a Supplementary Criteria Task Force for Critical Care Triage was struck at the University of Toronto Joint Centre for Bioethics. The task force reviewed publically available protocols and policies on pandemic flu planning, identified 13 potential triage criteria and determined a set of eight key ethical, legal and practical considerations against which it assessed each criterion. An online questionnaire was distributed to clinical, policy and community stakeholders across Canada to obtain feedback on the 13 potential triage criteria toward selecting those that best met the eight considerations. The task force concluded that the balance of arguments favoured only two of the 13 criteria it had identified for consideration: first come, first served and random selection. The two criteria were chosen in part based on a need to balance the clearly utilitarian approach employed in the OHPIP with equity considerations. These criteria serve as a defensible "fail safe" mechanism for any triage protocol.

The care delivery experience of hospitalized patients with complex chronic disease.

OBJECTIVE: This study investigated what is important in care delivery from the perspective of hospital inpatients with complex chronic disease, a currently understudied population. PARTICIPANTS AND SETTING: One-on-one semi-structured interviews were conducted with inpatients at a continuing care/rehabilitation hospital (n = 116) in Canada between February and July 2011. DESIGN: The study design was mixed methods and reports on patient characteristics and care delivery experiences. Basic descriptive statistics were run using SPSS version 17, and thematic analysis on the transcripts was conducted using NVivo9 software. RESULTS: Patients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and emotional disturbance. Three broad themes (each with one or more subthemes) were generated from the data representing important components of care delivery: components of the care plan (a comprehensive assessment, supported transitions and a bio-psycho-social care package); care capacity and quality (optimal staff to patient ratios, quicker response times, better patient-provider communication and consistency between providers) and the patient-provider relationships (characterized by respect and dignity). CONCLUSIONS: As health systems throughout the industrialized world move to sustain health budgets while optimizing quality of care, it is critical to better understand this population, so that appropriate metrics, services and policies can be developed. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health-care system. Moving forward, exploration around the appropriate funding models and skill mix is needed to move the evidence into changed practice.

Canadian national surveys on pandemic influenza preparations: pre-pandemic and peri-pandemic findings.

BACKGROUND: Prior to the 2009 H1N1 Influenza pandemic, public health authorities in Canada and elsewhere prepared for the future outbreak, partly guided by an ethical framework developed within the Canadian Program of Research on Ethics in a Pandemic (CanPREP). We developed a telephone-based survey based on that framework, which was delivered across Canada in late 2008. In June, 2009, the WHO declared pandemic Phase 6 status and from the subsequent October (2009) until May 2010, the CanPREP team fielded a second (revised) survey, collecting another 1,000 opinions from Canadians during a period of pre-pandemic anticipation and peri-pandemic experience. METHODS: Surveys were administered by telephone with random sampling achieved via random digit dialing. Eligible participants were adults, 18 years or older, with per province stratification approximating provincial percentages of national population. Descriptive results were tabulated and logistic regression analyses used to assess whether demographic factors were significantly associated with outcomes, and to identify divergences (between the pre-pandemic and intra-pandemic surveys). RESULTS: N = 1,029 interviews were completed from 1,986 households, yielding a gross response rate of 52% (AAPOR Standard Definition 3). Over 90% of subjects indicated the most important goal of pandemic influenza preparations was saving lives, with 41% indicating that saving lives solely in Canada was the highest priority and 50% indicating saving lives globally was the highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with serious health conditions which that increased risks. Strong majorities favoured stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. CONCLUSIONS: Results suggest Canadians trust public health officials to make difficult decisions, providing emphasis is maintained on reciprocity and respect for individual rights. Canadians also support international obligations to help poorer countries and associated efforts to save lives outside the country, even if intra-national efforts are reduced.

Surgical site infection prevention: a qualitative analysis of an individualized audit and feedback model.

BACKGROUND: Surgical site infection (SSI) adversely affects patient outcomes and health care costs, so prevention of SSI has garnered much attention worldwide. Surgical site infection is recognized as an important quality indicator of patient care and safety. The purpose of this study was to use qualitative research methods to evaluate staff perceptions of the utility and impact of individualized audit and feedback (AF) data on SSI-related process metrics for their individual practice, as well as on overall communication and teamwork as they relate to SSI prevention. STUDY DESIGN: This study was performed in a tertiary care center, based on patients treated in the colorectal and hepatic-pancreatic-biliary surgical oncology services. Eighteen clinicians were interviewed. Analysis of interviews via comparative analysis techniques and coding strategies were used to identify themes. RESULTS: The most important finding of this study was that although nearly all participants believed that the individualized AF model was useful in effecting individual practice change as well as improving awareness and accountability around individual roles in preventing SSIs, it was not seen as a means to enable the multidisciplinary teamwork required for sustainable practice changes. Moreover, such teamwork requires a team leader. CONCLUSIONS: Provision of individualized AF data had a significant impact on promoting individual practice change. Despite this, we concluded that practice change is a shared responsibility, requiring a team leader. So, AF had little bearing on establishing a necessary multidisciplinary team approach to SSI prevention, to create more effective and sustainable practice change among an entire team.

The duty to care in an influenza pandemic: a qualitative study of Canadian public perspectives.

Ever since the emergence of SARS, when we were reminded that the nature of health care practitioners' duty to care is greatly contested, it has remained a polarizing issue. Discussions on the nature and limits of health care practitioners' duty to care during disasters and public health emergencies abounds the literature, ripe with arguments seeking to ground its foundations. However, to date there has been little public engagement on this issue. This study involved three Townhall meetings held between February 2008 and May 2010 in three urban settings in Canada in order to probe lay citizens' views about ethical issues related to pandemic influenza, including issues surrounding the duty to care. Participants included Canadian residents aged 18 and over who were fluent in English. Data were collected through day-long facilitated group discussions using case scenarios and focus group guides. Participant's views were organized according to several themes, including the following main themes (and respective sub-themes): 1. Legitimate limits; a) competing obligations; and b) appeal to personal choice; and 2. Legitimate expectations; a) reciprocity; and b) enforcement and planning. Our findings show that participants moved away from categorical notions of the duty to care towards more equivocal and often normative views throughout deliberations. Our analysis contributes a better understanding of the constitutive nature of the duty to care, defined in part by taking account of public views. This broadened understanding can further inform the articulation of acceptable norms of duty to care and policy development efforts. What is more, it illustrates the urgent need for policy-makers and regulators to get clarity on obligations, responsibilities, and accountability in the execution of HCPs' duty to care during times of universal vulnerability.

Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public's perspectives.

BACKGROUND: Pandemic influenza may exacerbate existing scarcity of life-saving medical resources. As a result, decision-makers may be faced with making tough choices about who will receive care and who will have to wait or go without. Although previous studies have explored ethical issues in priority setting from the perspective of clinicians and policymakers, there has been little investigation into how the public views priority setting during a pandemic influenza, in particular related to intensive care resources. METHODS: To bridge this gap, we conducted three public town hall meetings across Canada to explore Canadian's perspectives on this ethical challenge. Town hall discussions group discussions were digitally recorded, transcribed, and analyzed using thematic analysis. RESULTS: Six interrelated themes emerged from the town hall discussions related to: ethical and empirical starting points for deliberation; criteria for setting priorities; pre-crisis planning; in-crisis decision-making; the need for public deliberation and input; and participants' deliberative struggle with the ethical issues. CONCLUSIONS: Our findings underscore the importance of public consultation in pandemic planning for sustaining public trust in a public health emergency. Participants appreciated the empirical and ethical uncertainty of decision-making in an influenza pandemic and demonstrated nuanced ethical reasoning about priority setting of intensive care resources in an influenza pandemic. Policymakers may benefit from a better understanding the public's empirical and ethical 'starting points' in developing effective pandemic plans.

Restrictive measures in an influenza pandemic: a qualitative study of public perspectives.

OBJECTIVES: Recent experiences have demonstrated that restrictive measures remain a useful public health tool during infectious disease outbreaks. However, the use of restrictive measures is not without controversy, as there is no agreed-upon threshold for when and how to invoke restrictive measures. The objectives of this study are to solicit perspectives from Canadians on the ethical considerations of using restrictive measures in response to influenza pandemics, and in turn, to use public views to contribute to a better understanding of what is considered to be the justifiable use of restrictive measures. METHODS: A series of town hall focus groups with Canadian residents from June 2008 to May 2009, in three Canadian regions, in order to achieve broad public engagement (n=3 focus groups with a total of 17 participants). RESULTS: Two key themes emerged from all town hall focus groups: 1) create an environment for compliance through communication rather than enforcement, and 2) establish the delineation between individual rights, community values, and the greater good. CONCLUSION: While there is a need for a decision-making authority and even a mechanism for enforcement, our data suggest that a more tractable approach to restrictive measures is one that enables individuals to voluntarily comply by creating an environment to compel compliance based on communication. This approach requires restrictive measures to be a) proportional to the threat, b) implemented along with reciprocal arrangements provided to those affected, and c) accompanied by open and transparent communication throughout all stages so that citizens can both understand and participate in decision-making.

Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: a qualitative study of emergency department and critical care workers.

OBJECTIVE: To identify the barriers to implementation of mild therapeutic hypothermia for adult survivors of cardiac arrest. Despite scientific evidence to support therapeutic hypothermia for resuscitated cardiac arrest patients, it is inconsistently and at times inadequately used. DESIGN: Qualitative study, using semistructured interviews. SETTING: A stratified random sample of 14 sites from an established network of 43 hospitals, including both community and tertiary care centers in Southern Ontario, Canada. PARTICIPANTS: Twenty-one intensive care unit and emergency department physicians and nurses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Purposive sampling was used to interview individuals who were most likely to be involved in the implementation and evaluation of the hypothermia protocol. All interviews were conducted by telephone by a clinician and a qualitative researcher. Interviews were recorded electronically and transcribed unless the participant declined to have the interview recorded. Untranscribed interviews were recorded as field notes and as direct quotations. New interviews were conducted until thematic saturation occurred. The analysis was completed through three phases of coding. Respondents identified lack of familiarity and availability of concrete therapeutic hypothermia protocols and process issues as the most frequent barriers. Process concerns included availability of equipment, equipment costs, and high workload demands for emergency nurses. Other barriers identified were variable nursing awareness, variable staff uptake, lack of agreement with supporting evidence, lack of interdisciplinary collaboration between the intensive care unit and emergency department, lack of interprofessional education between nurses and physicians, and challenges inherent in applying an intervention infrequently. CONCLUSIONS: This study demonstrated that the systematic adoption of a new intervention, therapeutic hypothermia, is met with interdependent generic, local, and individual barriers. A working awareness of the types of barriers that exist at multiple sites will assist in targeting specific knowledge translation strategies to improve adherence to evidence-based practice.

A qualitative study of the duty to care in communicable disease outbreaks.

Health care providers' (HCPs') duty to care during communicable disease outbreaks has resurfaced as an important and contentious topic. This renewed interest follows the re-emergence of communicable diseases, largely thought to have disappeared and therefore irrelevant to modern day practitioners. The 2003 SARS outbreak particularly presented propitious circumstances for reconsidering this issue. This study seeks to characterize the views of individuals on the nature and limits of this duty. The authors employed qualitative methods to gather lay and expert perspectives. Individual interviews were conducted with 67 participants consisting of HCPs, spiritual leaders, regulators, and members of the public from the greater Toronto area. Participants' views were analyzed and organized according to three main themes, constituting a framework that combines micro-, meso-, and macro-level structures and processes: the scope of obligations of HCPs, the roles of health care institutions, and the broader social context, respectively. Our data suggest that the duty to care must be placed in a wider context to include considerations that transcend individual provider obligations. It thus follows, based on our data, that the duty to care cannot be left to personal choice or an appeal to morality based on an ethic derived entirely from individual obligations. The micro-meso-macro analytical framework that we have developed can guide the articulation of accepted norms of duty to care during epidemics and the development of policy for public health crises. It can also enhance the focus of our current expectations of HCPs' duty during epidemics. This can be achieved by informing regulatory bodies, collaborating with policy makers and engaging the public.

Evidence and effectiveness in decisionmaking for quarantine.

When public health decisionmakers turned to quarantine during the recent severe acute respiratory syndrome (SARS) epidemic, difficult questions were raised about the legitimacy and acceptability of restrictive measures to attain public health goals. SARS also brought to light how scientific uncertainty can permeate public health decisionmaking, leading us to think about the relationship between the adequacy of evidence of the effectiveness of an intervention and its role in the justification of public health action. In this article, we critically examine the role of evidence and effectiveness in decision-making for quarantine. It is our contention that the effectiveness of a public health intervention should not be defined exclusively in (absolute and objective) scientific terms but rather conceptualized relationally and normatively in public health decisionmaking.

On pandemics and the duty to care: whose duty? who cares?

BACKGROUND: As a number of commentators have noted, SARS exposed the vulnerabilities of our health care systems and governance structures. Health care professionals (HCPs) and hospital systems that bore the brunt of the SARS outbreak continue to struggle with the aftermath of the crisis. Indeed, HCPs - both in clinical care and in public health - were severely tested by SARS. Unprecedented demands were placed on their skills and expertise, and their personal commitment to their profession was severely tried. Many were exposed to serious risk of morbidity and mortality, as evidenced by the World Health Organization figures showing that approximately 30% of reported cases were among HCPs, some of whom died from the infection. Despite this challenge, professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk. DISCUSSION: In the aftermath of SARS and with the spectre of a pandemic avian influenza, it is imperative that we (re)consider the obligations of HCPs for patients with severe infectious diseases, particularly diseases that pose risks to those providing care. It is of pressing importance that organizations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. In this paper, we address the issue of special obligations of HCPs during an infectious disease outbreak. We argue that there is a pressing need to clarify the rights and responsibilities of HCPs in the current context of pandemic flu preparedness, and that these rights and responsibilities ought to be codified in professional codes of ethics. Finally, we present a brief historical accounting of the treatment of the duty to care in professional health care codes of ethics. SUMMARY: An honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue.

Developing sustainability: a new metaphor for progress.

In this paper, we propose a new model for development, one that transcends the North-South dichotomy and goes beyond a narrow conception of development as an economic process. This model requires a paradigm shift toward a new metaphor that develops sustainability, rather than sustains development. We conclude by defending a 'report card on development' as a means for evaluating how countries perform within this new paradigm.

Stakeholders' views about cardiac report cards: a qualitative study.

CONTEXT: Health care report cards provide stakeholders with information on health care outcomes and other measures of care. Report cards are most well developed in cardiac care. A necessary first step to ground the development of cardiac report cards in actual experience is to understand the views of those most closely involved. To date, there has been no systematic description of stakeholders' views. OBJECTIVE: To describe stakeholders' views about cardiac report cards. DESIGN: The present study involved qualitative person-to-person interviews with 58 stakeholders from seven Canadian cities with major cardiac programs: Vancouver, Calgary, London, Toronto, Ottawa, Montreal and Halifax. PARTICIPANTS: A total of 58 participants from six stakeholder groups in cardiac care consisting of 15 administrators, 13 nurses, 12 cardiologists, seven outcomes researchers, six cardiac surgeons and five members of the media who report on health care. OUTCOME MEASURES: Participants' views and expectations of cardiac report cards were analyzed and organized into themes. RESULTS: The views of stakeholders on cardiac report cards were organized according to four themes: PURPOSE: Participants identified two purposes--accountability for quality care as well as public education and informed decision-making; DEVELOPMENT: Participants thought that the development of report cards should involve multistakeholder collaboration; CONTENT: Participants discussed three concepts--context, level of reporting and data; and Dissemination: Mechanisms discussed include the Internet, media and directly to health care providers. CONCLUSIONS: The views of stakeholders regarding cardiac report cards can be the basis of an evidence-based conceptual framework that can guide in the development, implementation and delivery of cardiac report cards. In the present study, the views of cardiologists, cardiac surgeons, cardiac nurses, administrators, outcomes researchers and members of media are described. A next step is to explore the views of cardiac patients.