Comparing the attitudes of four groups of stakeholders from Quebec, Canada, toward extending medical aid in dying to incompetent patients with dementia.

OBJECTIVE: The Canadian province of Quebec has recently legalized medical aid in dying (MAID) for competent patients who satisfy strictly defined criteria. The province is considering extending the practice to incompetent patients. We compared the attitudes of four groups of stakeholders toward extending MAID to incompetent patients with dementia. METHODS: We conducted a province-wide postal survey in random samples of older adults, informal caregivers of persons with dementia, nurses, and physicians caring for patients with dementia. Clinical vignettes featuring a patient with Alzheimer's disease were used to measure the acceptability of extending MAID to incompetent patients with dementia. Vignettes varied according to the stage of the disease (advanced or terminal) and type of request (written or oral only). We used the generalized estimating equation (GEE) approach to compare attitudes across groups and vignettes. RESULTS: Response rates ranged from 25% for physicians to 69% for informal caregivers. In all four groups, the proportion of respondents who felt it was acceptable to extend MAID to an incompetent patient with dementia was highest when the patient was at the terminal stage, showed signs of distress, and had written a MAID request prior to losing capacity. In those circumstances, this proportion ranged from 71% among physicians to 91% among informal caregivers. CONCLUSION: We found high support in Quebec for extending the current MAID legislation to incompetent patients with dementia who have reached the terminal stage, appear to be suffering, and had requested MAID in writing while still competent.

Are Informal Caregivers of Persons With Dementia Open to Extending Medical Aid in Dying to Incompetent Patients? Findings From a Survey Conducted in Quebec, Canada.

Euthanasia is a controversial and complex issue, especially when involving incompetent patients. On December 10, 2015, Quebec became the first Canadian province to give access to medical aid in dying (MAiD) (ie, euthanasia performed by a physician) to competent patients who satisfy strictly defined criteria. Less than 2 years later, Quebec is considering extending MAiD to incompetent patients who made an advance request. With the objective of contributing scientific data to current societal debates, we conducted a survey among 471 informal caregivers of persons with dementia, reached through Alzheimer Societies. We used a series of vignettes featuring a person with Alzheimer disease to investigate respondents' attitudes towards MAiD. The response rate was 69%. Two-thirds [68%; 95% confidence interval, 63%-73%] found it acceptable to extend MAiD to an incompetent patient at an advanced stage of Alzheimer disease who had made a written request while competent, and 91% (95% confidence interval, 87%-94%) found it acceptable at the terminal stage. Self-determination was the most widely endorsed argument in favor of access to MAiD for incompetent patients. Findings suggest strong support among informal caregivers for extending MAiD to incompetent patients, provided they are terminally-ill and had made a written request before losing capacity.

Characterization of Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: A Qualitative Analysis.

Approximately 15-20% of patients with chronic obstructive pulmonary disease (COPD) also display characteristics of asthma. In May 2014, the asthma-COPD overlap syndrome (ACOS) was briefly addressed in the Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy documents. We evaluated how pulmonologists diagnose and treat ACOS and how they assess its control. Pulmonologists from two university healthcare centers, having ≥ 1 year experience, treating patients with asthma, COPD, or ACOS, were invited to participate in focus groups. Two focus groups (1 hour duration) were convened with seven and five participants, respectively. According to pulmonologists from both institutions, ACOS is a new name for an existing syndrome rather than a new disease. It is characterized by incomplete reversible airflow limitations and changes in forced expiratory volume in one second over time. The pulmonologists noted that its diagnosis must be based on clinical characteristics, pulmonary function test results, and clinical intuition. To diagnose ACOS, pulmonologists must rely on their clinical judgment. They also agreed that the treatment of patients with ACOS should target the features of both asthma and COPD. Pulmonologists from both institutions used asthma control criteria to assess ACOS control. A deeper understanding would enable clinicians to establish specific criteria for the diagnosis, treatment, and follow-up of subjects with ACOS.

Optimizing Practices, Use, Care, and Services-Antipsychotics (OPUS-AP) in Long-Term Care Centers in Quebec, Canada: A Successful Scale-Up.

OBJECTIVES: To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. DESIGN: Prospective, closed cohort. SETTING AND PARTICIPANTS: Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. METHODS: The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months. RESULTS: OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2. CONCLUSIONS AND IMPLICATIONS: The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

Pharmacist-led transitions of care between hospitals, primary care clinics, and community pharmacies.

BACKGROUND: Pharmacist-led transitions of care (TOC) interventions have been described as some of the most promising interventions to reduce medication-related harm (MRH) in older adults. This study analyzed the feasibility of pharmacist-led TOC interventions between hospitals, multidisciplinary primary care clinics (PCC), and community pharmacies. METHODS: Adults aged 65 years and older at risk of MRH in three regions of Quebec, Canada, with contrasting contexts of care based on university affiliation were recruited in this multicenter, single arm, and prospective intervention cohort. The hospital pharmacist developed the pharmaceutical care plan in collaboration with the hospital physician and transferred this plan with the hospitalization summary, at hospital discharge, to the PCC family physician and to the community and PCC pharmacists. A consultation with the community pharmacist was scheduled within seven days of hospital discharge and with the PCC pharmacist when appropriate. Feasibility outcomes included the time to complete the interventions and their location. RESULTS: The 123 eligible patients had a mean age of 78.5 years, and 63.4% were females. The most frequent inclusion criterion was 10 medications or more, including one high-risk medication for 90 patients (73%). Recruitment in one region was stopped after three months due to unsuccessful recruitment of key PCC. The hospital pharmacist interventions took a median of 165 min. The first consultations of the PCC and community pharmacists took a median of 15 and 50 min. Among the 96 patients with a post-discharge pharmacist follow-up, 23 (24.0%) had a consultation with a PCC pharmacist, with 65.2% of the consultations conducted at the PCC. The community pharmacists conducted a consultation with 88 patients (93%), with more than 70% of consultations conducted by phone. CONCLUSION: Our study showed the feasibility of pharmacist-led TOC interventions between hospitals, PCC, and community pharmacies and detailed the novel role that PCC pharmacists played in optimizing TOC interventions.

Pharmacist-led transitions of care for older adults at risk of drug-related problems: A feasibility study.

BACKGROUND: Transitions of care (TOC) is one of three key action areas identified in the World Health Organization (WHO)'s third Global Patient Safety Challenge, Medication Without Harm, released in 2017. Systematic reviews have shown that TOC interventions can improve health outcomes, although few studies have evaluated the role of the community pharmacist. OBJECTIVE: To evaluate the feasibility of a pharmacist-led TOC intervention for older adults at risk of drug-related problems. METHODS: Pragmatic feasibility study conducted in hospital and community pharmacies in a health region of Quebec, Canada. The interventions consisted of a pharmaceutical care plan developed by the hospital pharmacist and transferred at hospital discharge to the patients' community pharmacist, who completed patient consultations in the week following discharge and monthly for six months thereafter. Feasibility evaluations included recruitment, retention, time required, types of interventions, and modified classes of medications, based on clinical data entered in an electronic health record accessible to clinicians in all settings. RESULTS: Of the 90 recruited patients, 76 were discharged with a pharmaceutical care plan. The mean age of these 76 subjects was 79.5 years, and 52.6% were female. The most frequent inclusion criteria were 15 or more medications (57.9%), two or more emergency department visits (past three months), or one or more hospitalization (past twelve months) (42.1%). The hospital pharmacist interventions took a mean time of 222 min. The community pharmacist interventions took a mean time of 52 min and 32 min for the first and subsequent visits, respectively. Therapeutic goals were documented for 60.5% of patients. CONCLUSIONS: This study shows the feasibility of implementing a pharmacist-led TOC intervention in the Canadian context. Development of the TOC model in three health regions is currently being pursued along with the inclusion of primary care clinics who recently added pharmacists to their interdisciplinary teams.

Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) in Long-term Care Centers in Québec, Canada: A Strategy for Best Practices.

OBJECTIVES: Antipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a resident-centered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. DESIGN: Prospective, closed cohort supplemented by a developmental evaluation. SETTING AND PARTICIPANTS: Residents of designated wards in 24 LTC centers in Québec, Canada. METHODS: Provincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October 2018. Semistructured interviews (n = 20) were conducted with LTC teams to evaluate the implementation of OPUS-AP. RESULTS: Of 1054 residents, 78.3% had an MNCD diagnosis and 51.7% an antipsychotic prescription. The cohort included 464 residents with both MNCD and antipsychotic prescription. Antipsychotic deprescribing (cessation or dose decrease) was attempted in 220 of the 344 residents still admitted at 9 months. Complete cessation was observed in 116 of these residents (52.7%) and dose reduction in 72 (32.7%), for a total of 188 residents (85.5%; 95% confidence interval: 80.1%, 89.8%). A decrease in benzodiazepine prescriptions and improvements in Cohen-Mansfield Agitation Inventory scores were observed among residents who had their antipsychotics deprescribed. Caregivers and clinicians expressed satisfaction as a result of observing an improved quality of life among residents. CONCLUSIONS AND IMPLICATIONS: Antipsychotic deprescribing was successful in a vast majority of LTC residents with MNCD without worsening of BPSD. Based on this success, phase 2 of OPUS-AP is now under way in 129 LTC centers in Québec.

Quebec physicians' perspectives on medical aid in dying for incompetent patients with dementia.

OBJECTIVES: To elicit Quebec physicians' attitudes towards extending medical aid in dying (MAiD) to incompetent patients and to compare the attitudes of family physicians to those of other medical specialists. METHODS: We conducted a postal survey among physicians caring for patients with dementia. We used hypothetical vignettes to elicit their attitudes towards MAiD and continuous deep sedation (CDS) to relieve suffering at end of life. Two patients were depicted in the vignettes: one with cancer eligible for MAiD and one with dementia. The generalized estimating equation approach was used to investigate factors associated with attitudes, including the stage of the illness (advanced vs terminal dementia) and the presence or absence of a prior written request. RESULTS: A total of 136 physicians out of 653 returned the questionnaire. Physicians favoured CDS over MAiD for relieving suffering in the cancer vignette (93% vs 79%; p = 0.002). In advanced dementia, 45% of physicians supported giving the patient access to MAiD with a written request and 14% without such request. At the terminal stage of dementia, these proportions increased to 71% and 43%, respectively (p < 0.001), reaching 79% and 52% among family physicians. Support for CDS in terminal dementia was lower than in end-stage cancer (68% vs 93%; p < 0.001) and equal to MAiD with a written request (68% vs 71%; p = 0.623). CONCLUSION: Many Quebec physicians support extending MAiD to incompetent patients with dementia to relieve suffering at the terminal stage. This finding will inform current deliberations as to whether MAiD should be extended to these patients.

Should Medical Assistance in Dying Be Extended to Incompetent Patients With Dementia? Research Protocol of a Survey Among Four Groups of Stakeholders From Quebec, Canada.

BACKGROUND: Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity. OBJECTIVE: Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol. METHODS: Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes. RESULTS: The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail. CONCLUSIONS: This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions.

Adverse events among COPD patients treated with long-acting anticholinergics and ß2-agonists in an outpatient respiratory clinic.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in Canada. Most patients with COPD receive long-term treatment with long-acting anticholinergics (LAAC) and/or long-acting ß2-agonists (LABA). Adverse events (AEs) are also likely during long-term treatment with these medications. OBJECTIVE: To evaluate the prevalence of AEs in COPD patients on LAAC and LABA in a real-world setting. METHODS: We conducted a cross-sectional study of patients enrolled in the Registre de Données en Santé Pulmonaire (RESP) database, which records information on Canadian patients with asthma or COPD. COPD Patients completed a questionnaire about AEs that may be associated with LAAC and/or LABA. The prevalence of AEs and the corresponding 95% CI were calculated for three groups of patients (LAAC + LABA, LAAC alone, and LABA alone). RESULTS: Most patients with COPD (n = 154) were current or ex-smokers. Over 50% of patients were overweight or obese, and had an annual family income of less or equal to $42,000. Dry mouth (55.2%, 40%, and 43.5%) and dry throat (33.6%, 26.7%, and 34.8%) occurred most of the time or always in the LAAC + LABA, LAAC, and LABA groups, respectively. Headache was reported by 17.4% of patients in the LABA group, but less than 11.2% in the other groups. CONCLUSION: AEs reported in this study deserve clinical attention because they may negatively affect quality of life and treatment adherence of COPD patients.

Systemic corticosteroids for the treatment of asthma exacerbations during and outside of pregnancy in an acute-care setting.

BACKGROUND: Asthma exacerbations are common during pregnancy with a prevalence as high as 51.9% among women with severe asthma. OBJECTIVE: To compare the treatment of asthma exacerbations in an acute-care setting during and outside of pregnancy. METHODS: We formed a cohort of women who sought medical care for an asthma exacerbation at a teaching hospital during or in the year preceding pregnancy, between 1998 and 2008. An exacerbation was composed of one or more medical encounters in an acute-care setting (hospital-based outpatient clinic, emergency department, or during hospitalization). Data were retrieved from medical charts and health administrative databases. We compared the use of systemic corticosteroids (SCSs) during and outside of pregnancy with a Cox proportional hazards model. RESULTS: The cohort was formed of 39 women who had 40 exacerbations during and 39 exacerbations outside of pregnancy. Use of SCSs to treat exacerbations was less frequent (adjusted hazard ratio: 0.51; 95% CI: 0.31-0.84) during pregnancy. Moreover, upon the first medical encounter related to the exacerbation, SCSs, when administered, were given less frequently to women when pregnant than when non-pregnant (83% vs. 100%). The SCS prescription was filled at the community pharmacy 65% and 67% of the time when it was prescribed at discharge to women when pregnant than when non-pregnant, respectively. CONCLUSION: We observed a reduced and delayed use of SCSs for the treatment of asthma exacerbations in women when pregnant than when non-pregnant, with similar numbers of women in both conditions filling their SCSs prescription in pharmacies.