Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study.

PURPOSE: A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS: Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS: Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION: Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.

RéSUMé: OBJECTIF: Il existe une discordance, qui tend surtout vers un sur-traitement, entre les préférences exprimées par les patients pour les interventions de maintien de la vie et celles documentées lors de l'admission à l'hôpital. Cette étude d'amélioration de la qualité avait pour objectif d'évaluer cette discordance au sein de notre institution. Les objectifs secondaires de notre étude étaient d'explorer la possibilité que les équipes de médecine interne (MI) identifient les patients qui pourraient bénéficier de conversations approfondies et de voir si la discordance pouvait être corrigée en temps réel. MéTHODE: Deux infirmières ont intégré des équipes de MI dans un hôpital tertiaire pour discuter avec les patients hospitalisés de leurs préférences en matière de réanimation entre le 1er août 2016 et le 31 août 2018; les patients leur étaient soit spécifiquement référés (groupe I, n = 165), ou sélectionnés au hasard (groupe II, n = 164). Les préférences en matière de réanimation ont été documentées et communiquées aux équipes, entraînant une révision des ordonnances de réanimation, le cas échéant. La régression logistique multivariée a été utilisée afin de déterminer les facteurs de risque potentiels de discordance. RéSULTATS: Trois cent vingt-neuf patients ont été évalués, d'un âge moyen (écart type) de 80 ans (12) et avec un score de 6,8 (2,6) à l'Indice de comorbidité de Charlson. Une discordance a été identifiée chez 63/165 (38 %) et 27/164 (16 %) patients dans les groupes I et II, respectivement. Au total, 42/194 patients (21 %) ne souhaitaient pas de réanimation cardiorespiratoire (RCR) et 15/36 (41 %) préféraient ne pas être admis à l'unité de soins intensifs (USI), malgré une mention dans leurs préférences initiales. Parmi les patients chez lesquels une discordance a été notée, 93 % (84/90) ont préféré une désescalade des soins. La discordance a pu être corrigée pour 77 % (69/90) des patients. CONCLUSION: La documentation des patients hospitalisés pourrait indiquer des préférences pour des interventions de RCR et d'admission à l'USI contraires aux véritables préférences. Des infirmières formées à cet effet peuvent identifier les patients hospitalisés qui bénéficieraient d'une conversation approfondie sur leurs préférences en matière de réanimation. Une fois identifiée, une discordance peut être corrigée lors de l'admission initiale.

Acceptability of cardiac donation after circulatory determination of death: a survey of the Canadian public.

PURPOSE: Cardiac transplantation is a definitive therapy for end-stage heart failure, but demand exceeds supply. Cardiac donation after circulatory determination of death (cardiac DCDD) can be performed using direct procurement and perfusion (DPP), where cardiac activity is restored after heart recovery, or (NRP), where brain blood supply is surgically interrupted, circulation to the thoraco-abdominal organs is restored within the donor's body, followed by heart recovery. While cardiac DCDD would increase the number of heart donors, uptake of programs has been slowed in part because of ethical concerns within the medical community. These debates have been largely devoid of discussion regarding public perceptions. We conducted a national survey of public perceptions regarding cardiac DCDD. METHODS: We surveyed 1,001 Canadians about their attitudes towards cardiac DCDD using a rigorously designed and pre-tested survey. RESULTS: We found that 843 of 1,001 respondents (84.2%; 95% confidence interval [CI], 81.8 to 86.3) accepted the DPP approach, 642 (64.1%; 95% CI, 61.1 to 67.0) would agree to donate their heart using DPP, and 696 (69.5%; 95% CI, 66.6 to 72.3) would consent to the same for a family member. We found that 779 respondents of 1,001 respondents (77.8%; 95% CI, 75.1 to 80.3) accepted the NRP approach, 587 (58.6%; 95% CI, 55.5 to 61.6) would agree to donate their heart using NRP, and 636 (63.5%; 95% CI, 60.5 to 66.4) would consent to the same for a family member. Most respondents supported the implementation of DPP (738 respondents or 73.7%; 95% CI, 70.9 to 76.3) and NRP (655 respondents or 65.4%; 95% CI, 62.4 to 68.3) in Canada. CONCLUSION: The results of this national survey of public attitudes towards cardiac DCDD will inform the implementation of cardiac DCDD programs in a manner that is consistent with public values.

Attitudes of healthcare providers towards cardiac donation after circulatory determination of death: a Canadian nation-wide survey.

PURPOSE: The number of patients on cardiac transplant waitlists exceeds the number of available donor organs. Cardiac donation is currently limited to those declared dead by neurologic criteria in all but three countries. Cardiac donation after circulatory determination of death (cardiac DCDD) can be conducted using direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). Implementation of cardiac DCDD in many countries has been slowed by ethical debates within the donation and transplantation community. We conducted a national survey to determine the perceptions of healthcare providers regarding cardiac DCDD. METHODS: We conducted an electronic survey of 398 healthcare providers who are involved in the management of heart donors and/or heart transplant recipients in Canada (226 nurses, 82 critical care physicians, 31 donation specialists, and 59 transplant specialists). Our primary outcomes were their attitudes towards and concerns regarding cardiac DCDD protocols and their implementation in Canada. We distributed the survey electronically through several Canadian donation and transplantation organizations. RESULTS: We identified that 361 of 391 respondents (92.3%; 95% confidence interval [CI], 89.6 to 95.1) believed that DPP is acceptable, and 329 of 377 respondents (87.3%; 95% CI, 83.9 to 90.7) supported its implementation in Canada. We found that 301 of 384 respondents (78.4%; 95% CI, 74.2 to 82.6) believed that NRP is acceptable and 266 of 377 respondents (70.6%; 95% CI, 66.0 to 75.2) supported its implementation in Canada. CONCLUSION: This is the first survey describing the attitudes of healthcare providers towards cardiac DCDD. We identified widespread support for cardiac DCDD and its implementation in Canada among Canadian healthcare providers within the organ donation and transplantation community in Canada.

The impact of the Rasouli decision: a Survey of Canadian intensivists.

INTRODUCTION: In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown. OBJECTIVES: To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision. METHODS: We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses. RESULTS: We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups. CONCLUSIONS: Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli.

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.

Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers.

Background: Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited. Objectives: Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate. Methods: Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale. Results: Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty. Conclusions: While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.

General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative.

BACKGROUND/PURPOSE: Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period. METHODS: Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures. RESULTS: The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note. CONCLUSIONS: We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

Scarcity: the context of rationing in an Ontario ICU.

OBJECTIVES: Clinicians' perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting. DESIGN: Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity. SETTING: An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007. SUBJECTS: We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses. MAIN RESULTS: The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians' perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts. CONCLUSIONS: ICU clinicians' perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.

Beyond trail blazing: a roadmap for new healthcare ethics leaders (and the people who hire them).

This article is intended to serve as a roadmap to help new healthcare ethics leaders establish or renew an ethics program in a healthcare organization. The authors share a systemic step-by-step process for navigating this early career passage. In this paper, we describe five critical success strategies and provide explanations and concrete tools to help get you on the road to success as quickly and painlessly as possible. We will discuss how to define your role; diagnose your organization's needs; build important relationships; and develop a strategic plan for starting or revitalizing an ethics program. We also review some of the more personal challenges that may be encountered along the way, and identify social supports and self-care strategies. The advice we provide grows out of reflections on our collective experience as new ethics leaders in three Ontario healthcare organizations.

Managing access and flow through appropriate discharge: preventing common errors and improving processes.

Increased pressure on acute care hospitals to move patients seamlessly through the healthcare system has resulted in more attention to the process of discharging patients, particularly seniors, from hospitals. When alignment with the Health Care Consent Act is lacking, errors can occur in the process. Examples of mistakes by healthcare professionals include these: taking direction from the wrong substitute decision-maker (SDM); taking direction from a family member when the patient is capable; allowing an SDM to make an advance directive on behalf of a patient; being aware of a known prior expressed wish but ignoring that wish when considering a placement plan; waiting for an SDM who is not available, willing and capable instead of proceeding down the hierarchy of decision-makers; or permitting families to propose discharge plans. Such errors have the potential to compromise quality of care, but they also work to prevent timely and appropriate discharge. In order to minimize these common errors in the consent process for placements, we have proposed a checklist to help meet ethical and legal obligations in the discharge process. We suggest the checklist may minimize avoidable conflict and misunderstanding and promote a seamless discharge process.

Ethical framework for resource allocation during a drug supply shortage.

Drug supply shortages are common in health systems due to manufacturing and other delays. Frequently, shortages are successfully addressed through conservation and redistribution efforts, with limited impact on patient care. However, when Sandoz Canada Inc. announced in February 2012 that it was reducing production of a number of generic injectable drugs at its Quebec facility, the scope and magnitude of the drug supply shortage were unprecedented in Canada. The potential for an extreme scarcity of some drugs raised ethical concerns about patient care, including the need to limit access to some health services. In this article, the authors describe the development and implementation of an ethical framework to promote equitable access to drugs and healthcare services in the context of a drug supply shortage within and across health systems.

Socioeconomic Status and Medical Assistance in Dying: A Regional Descriptive Study.

Objective: Concerns that medical assistance in dying (MAiD) may harm vulnerable groups unable to access medical treatments and social supports have arisen since the legalization of MAiD on June 17, 2016; however, there is little research on the topic. The purpose of this study is to investigate the socioeconomic status (SES) of patients who request MAiD at the London Health Sciences Centre (LHSC). Methods: A retrospective analysis of patients from the LHSC MAiD database between June 6, 2016 and December 20, 2019 was conducted. Patients were linked to income data from the 2016 Canadian Census, and their corresponding income quintile was a proxy for SES. Geographic information system (GIS) mapping software was used to visualize the distribution of income and MAiD requests. Results: 39.4% of the LHSC catchment area was classified as low SES. Two hundred thirty-seven (58.1%) MAiD requests came from low SES patients and 171 (41.9%) requests came from high SES patients. Two hundred fifty-nine (63.5%) patients who requested a MAiD assessment did not receive MAiD following their request. Of the 237 lower SES patients, 150 (63.3% [95% CI 57.2-69.3]) did not receive MAiD. Of the 171 higher SES patients, 109 (63.7% [95% CI 56.5-70.9]) did not receive MAiD. Conclusion: A disproportionate number of requests for a MAiD assessment at LHSC came from lower SES patients; however, similar proportions of patients who requested MAiD from each SES group received aid in dying. Future research should explore why a disproportionately high number of low SES patients request MAiD at LHSC.