Medical assistance in dying in Canada: A scoping review on the concept of suffering.

OBJECTIVES: Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. METHODS: A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N = 1027) were identified from a review of 6 databases and GL documents (N = 537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. RESULTS: A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. CONCLUSIONS: Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.

Suicide in obstructive lung, cardiovascular and oncological disease.

Healthcare institutions face increasing demands stemming from the burden of noncommunicable diseases. The personal, social, financial and societal impact of these diseases are well-documented. However, the mental health concerns and trajectories of patients afflicted by chronic medical diseases have been under-recognized and are under-resourced. Despite that chronic diseases are associated with substantially increased risk of suicide, the medical world has largely failed to properly address suicide in the medically ill. Considering their high prevalence and mortality rate, this review article will highlight the mental health burden and suicide risk in obstructive lung, cardiovascular (including stroke) and oncological disease, in light of relevant data and conceptual models of suicide. Finally, general evidence-based suicide intervention strategies and potential selective adaptation of these strategies to the chronic medically ill patient populations and medical settings will be reviewed.

Immediate post-treatment supportive care needs of patients newly diagnosed with head and neck cancer.

OBJECTIVE: This study aimed at identifying supportive care needs of patients with head and neck cancer (HNC-P) immediately post-treatment, finding early predictors of unmet needs, and contrasting how immediate post-treatment needs differed from needs in longer-term survivorship. METHODS: Prospective longitudinal study of 223 consecutive adults (313 approached; 72% participation) newly diagnosed with a first occurrence of primary HNC. Patients completed the Supportive Care Needs Survey-Short Form (SCNS), the Structured Clinical Interview for DSM-IV, and other outcomes. Medical chart reviews were conducted. RESULTS: A total of 68% of patients (n = 145/223) completed the SCNS. The multiple linear regression indicated that when controlled for medical variables, patients presented higher levels of unmet needs when they presented with higher level of anxiety upon HNC diagnosis (p = 0.03), higher neuroticism (p = 0.03), and more stressful life events in the year pre-diagnosis (p = 0.01). Patients immediately post-treatment had a wider variety of unmet needs compared with those in extended survivorship, with psychological unmet needs most prevalent at both time points. Immediately post-treatment, patients needed more support regarding pain (p = 0.04) and worries about treatment results (p = 0.05), whereas patients in longer-term survivorship needed more support regarding anxiety (p = 0.02), changes in sexual relationships (p = 0.04), and fear of death and dying (p = 0.001). CONCLUSION: This study identifies areas needing further development to improve quality of care for HNC-P in the immediate post-treatment period, as well as early determinants of unmet needs. HNC clinics may want to routinely screen for anxiety, neuroticism, and burden from other life events, to pro-actively address needs upon treatment completion and alleviate disease burden.

Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study.

PURPOSE: The purpose of this study was to determine, within the first-year post-head and neck cancer (HNC) diagnosis, the contribution of past and upon HNC psychiatric diagnoses (ie, substance use disorder, major depressive disorder, and anxiety disorder) to the extent (ie, cumulated dose) of opioid prescription. METHODS: Prospective longitudinal study of 223 consecutive adults (on 313 approached; 72% participation) newly diagnosed (<2 weeks) with a first occurrence of primary HNC, including Structured Clinical Interviews for DSM-IV disorders, validated psychometric measures, and medical chart reviews. Opioid doses were translated into standardized morphine milligram equivalents (MME) using CDC guidelines. A model of variables was tested using multiple linear regression. RESULTS: Fifty-five percent (123/223) of patients received opioids at some point during the first 12 months post-HNC diagnosis, 37.7% (84/223) upon HNC diagnosis (pre-treatment), 40.8% (91/223) during treatments, and 31.4% (70/223) post-treatment. The multiple linear regression indicated that an AD (P = 0.04) upon HNC diagnosis in early stage contributes to cumulated MME dose in the first year post-HNC diagnosis. CONCLUSION: This study underlines how anxiety has important repercussions on the management of pain and illustrates the importance of screening for AD upon HNC diagnosis to allow for early prophylactic treatment and support.

Global health and rehabilitation education in Canada: a qualitative analysis of experiences and perspectives of educators.

BACKGROUND: Rehabilitation practice is increasingly tied to global trends. First, healthcare services are increasingly tailored to be patient-centered, requiring knowledge of sociocultural contexts and experiences of a diverse patient population. Second, non-communicable diseases and morbidity stemming from infectious diseases are creating greater needs for rehabilitation services in countries facing this double burden of disease. Third, globalization continues to shape the risk factors for disease and disability and influences the type of services accessible and the financing and management of such services. Given this context, there is a critical need to examine how global health (GH) is approached in rehabilitation curricula. How students learn about these various dynamics will impact their ability to practice in this environment and best meet the needs of the patients and populations they are caring for. OBJECTIVES: This study explores how university-level Canadian occupational and physical therapy educators understand GH within their academic and clinical practices. METHODS: The project followed a qualitative design. Semi-structured interviews were conducted with participants (n = 12; randomized purposive sampling was used). A deductive and inductive thematic analysis was performed to describe the participants perspectives on and practices of GH education in rehabilitation education programs. FINDINGS: There was an overall coherence between the literature and the participant's views of the constituent elements of GH. Participants viewed GH as a framework to broaden the clinical training of students by encouraging a critical "clinical toolbox" via themes of structural competency, cultural sensitivity, and a sense of global citizenship and stewardship. However, GH was also described by participants as being implicitly present in the curriculum due to ambiguities regarding the scope of GH, seen as a key obstacle in the integration of GH education in rehabilitation programs. INTERPRETATION: Despite the growing interest and relevance of GH, there is a noteworthy absence of GH education guidelines. There is a need to uncover the scope and underpinnings of GH and to outline rehabilitation-oriented GH competencies as per the positive value of GH attributed by the educators to the training of our healthcare workforce.IMPLICATIONS FOR REHABILITATIONGlobal health is seen by a sample of educators to provide rehabilitation students with a critical and holistic "clinical toolkit" by introducing themes of structural competency, cultural sensitivity and awareness, and global stewardship, enabling them to become good global clinicians and global citizens;The increased interest in global health throughout academic curricula presents new challenges for educators and students, specifically relating to understanding the mission and aims of this field. There is a need to clarify the notion and field of global health and how it complements clinical training within rehabilitation programs;There is a need to advance the literature on global health in rehabilitation by exploring what competencies are seen to be relevant to the field and practice of rehabilitation.

Psychosocial Effects of Head and Neck Cancer.

Head and neck cancer is known to be both physically and psychologically challenging. The present review summarizes the literature on the psychosocial effects of head and neck cancer by distinguishing features in the preoperative and postoperative periods. It outlines the importance of an integrated collaborative care approach in clinics as well as areas worthy of further program development.