Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU.

Shortage of nurses on the ICU is not a new phenomenon, but has been exacerbated by the COVID-19 pandemic. The underlying reasons are relatively well-recognized, and include excessive workload, moral distress, and perception of inappropriate care, leading to burnout and increased intent to leave, setting up a vicious circle whereby fewer nurses result in increased pressure and stress on those remaining. Nursing shortages impact patient care and quality-of-work life for all ICU staff and efforts should be made by management, nurse leaders, and ICU clinicians to understand and ameliorate the factors that lead nurses to leave. Here, we highlight 10 broad areas that ICU clinicians should be aware of that may improve quality of work-life and thus potentially help with critical care nurse retention.

Caring for Critically Ill Patients in Humanitarian Settings.

Critical care medicine is far from the first medical field to come to mind when humanitarian action is mentioned, yet both critical care and humanitarian action share a fundamental purpose to save the lives and ease the suffering of people caught in acute crises. Critically ill children and adults will be present regardless of resource limitations and irrespective of geography, regional or cultural contexts, insecurity, or socioeconomic status, and they may be even more prevalent in a humanitarian crisis. Critical care is not limited to the walls of a hospital, and all hospitals will have critically ill patients regardless of designating a specific ward an ICU. Regular and consistent consideration of critical care principles in humanitarian settings provides crucial guidance to intensivists and nonintensivists alike. A multidisciplinary, systematic approach to patient care that encourages critical thinking, checklists that encourage communication among team members, and context-specific critical care rapid response teams are examples of critical care constructs that can provide high-quality critical care in all environments. Promoting critical care principles conveys the message that critical care is an integral part of health care and should be accessible to all, no matter the setting. These principles can be effectively adopted in humanitarian settings by normalizing them to everyday clinical practice. Equally, core humanitarian principles-dignity, accountability, impartiality, neutrality-can be applied to critical care. Applying principles of critical care in a context-specific manner and applying humanitarian principles to critical care can improve the quality of patient care and transcend barriers to resource limitations.

Issues of Vulnerability and Equality: The Emerging Need for Court Evaluations of Physicians' Fiduciary Duties in High Stakes End-of-Life Decisions.

At the heart of high stakes end of life (EOL) decisions such as withdrawal of life-sustaining treatments (WLST) or medical assistance in dying (MAiD), are concerns that vulnerable people in our society need to be legally protected from prematurely ending their own lives or from having their lives inappropriately ended by healthcare teams predisposed to negatively assess their quality of life. Recently, two Supreme Court of Canada rulings in Rasouli and Carter (MAiD) have clearly emphasized the role of consent in providing legal protections to people at the end of life. The role of the medical standard of care is less clear: though the Supreme Court in Rasouli was careful to state there had been no ruling on the medical standard of care with respect to WLST, the Court did state that standard of care considerations would be important in such decisions. In contrast to Rasouli, the result of the Carter ruling was that consent alone is insufficient protection for physician assisted death without a medical standard of care. Subsequently, in its new legislation, the Canadian Government restricted access to MAiD on the grounds that some people - those who lose capacity, with mental illnesses and mature minors - are so vulnerable that this potential choice at the EOL must be denied. In simple terms, for some, consent and the medical standard of care are insufficient protections. Such claims and their consequences are a sign of an emerging and significant problem: the reduction of medicine to a mere contractual relationship while disregarding its fiduciary nature simply because the courts have, in the words of Chief Justice McLachlin, "never reviewed physicians' good faith treatment decisions on the basis of fiduciary duty". The goals of this article are to explore issues of vulnerability and equality, the existing protections in both medicine and law and the emerging need for courts to evaluate physicians' fiduciary duties in high stakes EOL decisions in order to resolve conflicts with respect to WLST, to ensure access to MAiD and to promote the future aualitv of EOL care for all Canadians.

"Must do CPR??": strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care.

The College of Physicians and Surgeons of Ontario recently released a new policy, Planning for and Providing Quality End-of-Life Care. The revised policy is more accurate in its consideration of the legal framework in which physicians practice and more reflective of ethical issues that arise in end-of-life (EOL) care. It also recognizes valid instances for not offering cardiopulmonary resuscitation (CPR). Nevertheless, the policy poses a significant ethical and legal dilemma-i.e., if disputes over EOL care arise, then physicians must provide CPR even when resuscitation would fall outside this medical standard of care. While the policy applies in Ontario, it is likely to influence other physician colleges across Canada as they review their standards of practice. This paper explores the rationale for the mandated CPR, clarifies the policy's impact on the medical standard of care, and discusses strategies to improve EOL care within the policy. These strategies include understanding the help-hurt line, changing the language used when discussing cardiac arrest, clarifying care plans during the perioperative period, engaging the intensive care unit team early in goals-of-care discussions, mentoring hospital staff to improve skills in goals-of-care discussions, avoiding use of the "slow code", and continuing to advocate for quality EOL care and a more responsive legal adjudication process.

Liver transplantation in patients with end-stage liver disease requiring intensive care unit admission and intubation.

Data regarding transplantation outcomes in ventilated intensive care unit (ICU)-dependent patients with end-stage liver disease (ESLD) are conflicting. This single-center cohort study investigated the outcomes of patients with ESLD who were intubated with mechanical support before liver transplantation (LT). The ICU plus intubation group consisted of 42 patients with decompensated cirrhosis and mechanical ventilation before transplantation. LT was considered for intubated ICU patients if the fraction of inspired oxygen was ≤40% with a positive end-expiratory pressure ≤ 10, low pressor requirements, and the absence of an active infection. Intubated ICU patients were compared to 80 patients requiring ICU admission before transplantation without intubation and to 126 matched non-ICU-bound patients. Patients requiring ICU care with intubation and ICU care alone had more severe postoperative complications than non-ICU-bound patients. Intubation before transplantation was associated with more postoperative pneumonias (15% in intubated ICU transplant candidates, 5% in ICU-bound but not intubated patients, and 3% in control group patients; P = 0.02). Parameters of reperfusion injury and renal function on postoperative day (POD) 2 and POD 7 were similar in all groups. Bilirubin levels were higher in the ICU plus intubation group at POD 2 and POD 7 after transplantation but were normalized in all groups within 3 months. The ICU plus intubation group versus the ICU-only group and the non-ICU group had decreased 1-, 3-, and 5-year graft survival (81% versus 84% versus 92%, 76% versus 78% versus 87%, and 71% versus 77% versus 84%, respectively; P = 0.19), but statistical significance was not reached. A Glasgow coma scale score of <7 versus >7 before transplantation was associated with high postoperative mortality in ICU-bound patients requiring intubation (38% versus 23%; P = 0.01). In conclusion, ICU admission and mechanical ventilation should not be considered contraindications for LT. With careful patient selection, acceptable long-term outcomes can be achieved despite increased postoperative complications.

Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Medical mentorship in Afghanistan: How are military mentors perceived by Afghan health care providers?

BACKGROUND: Previous work has been published on the experiences of high-resource setting physicians mentoring in low-resource environments. However, not much is known about what mentees think about their First World mentors. We had the opportunity to explore this question in an Afghan Army Hospital, and we believe this is the first time this has been studied. METHODS: We conducted a pilot cross-sectional survey of Afghan health care providers evaluating their Canadian mentors. We created a culturally appropriate 19- question survey with 5-point Likert scores that was then translated into the local Afghan language. The survey questions were based on domains of Royal College of Physicians and Surgeons of Canada's CanMEDS criteria. RESULTS: The survey response rate was 90% (36 of 40). The respondents included 13 physicians, 21 nurses and 2 other health care professionals. Overall, most of the Afghan health care workers felt that working with mentors from high-resource settings was a positive experience (median 4.0, interquartile range [IQR] 4-4), according to CanMEDS domains. However, respondents indicated that the mentors were reliant on medical technology for diagnosis (median 5.0, IQR 4-5) and failed to consider the limited resources available in Afghanistan. CONCLUSION: The overall impression of Afghan health care providers was that mentors are appropriate and helpful. CanMEDS can be used as a framework to evaluate mentors in low-resource conflict environments.

The future of decision-making in critical care after Cuthbertson v. Rasouli.

PURPOSE: The Supreme Court of Canada (SCC) ruling on Cuthbertson v. Rasouli has implications for all acute healthcare providers. This well-publicized case involved a disagreement between healthcare providers and a patient's family regarding the principles surrounding withdrawal of life support, which the physicians involved considered no longer of medical benefit and outside the standard of care, and whether consent was required for such withdrawals. Our objective in writing this article is to clarify the implications of this ruling on the care of critically ill patients. SOURCE: SCC ruling Cuthbertson v. Rasouli. PRINCIPAL FINDINGS: The SCC ruled that consent must be obtained for all treatments that serve a "health-related purpose", including withdrawal of such treatments. The SCC did not fully consider what the standard of care should be. Health-related purpose is not sufficient in and of itself to mandate treatment, and clinicians must still ensure that their patients or decision-makers are aware of the possible medical benefits, risks, and expected outcomes of treatments. The provision of treatments that have no potential to provide medical benefit and carry only risks would still fall outside the standard of care. Nevertheless, due to their health-related purpose, physicians must seek consent for the discontinuation of these treatments. CONCLUSION: The SCC ruled that due to the legal definition of "health-related purpose", which is distinct from medical benefit, consent is required to withdraw life-support and outlined the steps to be taken should conflict arise. The SCC decision did not directly address the role of medical standard of care in these situations. In order to ensure optimal decision-making and communication with patients and their families, it is critical for healthcare providers to have a clear understanding of the implications of this legal ruling on medical practice.

Using standardized family members to teach communication skills and ethical principles to critical care trainees.

OBJECTIVE: We sought to determine the effectiveness of standardized family members for improving communication skills and ethical and legal knowledge of senior intensive care unit trainees. DESIGN: Multimodal evaluation of mixed-methods educational intervention. SETTING: Postgraduate critical care medicine academic program. SUBJECTS: Postgraduate subspecialty critical care medicine trainees. INTERVENTION: Communication workshop featuring a short didactic session and four simulated family meetings using trained professionals as standardized family members. MEASUREMENTS: Ethical and legal knowledge and comfort with communication (before and after the workshop) and communication skill (during the workshop). MAIN RESULTS: Fifty-one postgraduate critical care medicine subspecialty trainees participated in the workshop over a 5-yr period. Ethical and legal knowledge and comfort scores improved significantly among trainees who participated in the workshop. Ninety percent of trainees felt that the workshop had met or exceeded their expectations and would recommend it to other trainees. Ninety-eight percent of trainees felt that the workshop had met the highest priority learning objectives they identified. Communication scores showed a trend towards improvement over the course of the workshop, although the improvements were not significant. Participants reflecting on the workshop >1 yr later overwhelmingly felt that it had prepared them for real communication challenges in training and practice. CONCLUSIONS: This workshop was effective for improving ethical and legal knowledge and comfort with communication among critical care medicine trainees. Participants overwhelmingly felt that it had met their learning needs and that it was an effective teaching tool that had prepared them for real communication challenges in training and practice. It could be used in a variety of contexts to address an often-neglected area of education.

Impact of a continuous enhanced cardio-respiratory monitoring pathway on cardio-respiratory complications after bariatric surgery: A retrospective cohort study.

STUDY OBJECTIVE: To determine the impact of an enhanced monitoring pathway consisting of continuous postoperative cardio-respiratory monitoring on adverse outcomes after bariatric. DESIGN: Single-center, retrospective cohort study. PATIENTS: Adult patients who underwent bariatric surgeries between 2009 and 2016. INTERVENTIONS: We evaluated the use of an enhanced monitoring pathway consisting of a distant, continuous, non-invasive respiratory monitoring system on postoperative cardio-respiratory complications in patients undergoing bariatric surgery. Treating physicians had the option to assign patients to enhanced monitoring (intervention group) in the postoperative period for suspected or diagnosed OSA or other clinical concerns. The control group had intermittent vital sign checks as per institutional standards. MEASUREMENTS: The primary outcome was a composite of cardio-respiratory complications (rapid response team activation, intensive care admission, respiratory complications), major adverse cardiac events, and all-cause mortality. The secondary outcome was length of stay (LOS). MAIN RESULTS: Of 1450 patients, 752 patients received enhanced monitoring (intervention) and 698 patients received standard monitoring (control). Univariate analysis showed that, compared to control, enhanced monitoring was associated with lower odds of composite cardio-respiratory complications (OR: 0.41, 95%CI: 0.32-0.53, p < 0.001) and lower odds of prolonged LOS > 2 days (OR: 0.37, 95% CI: 0.28-0.49, p < 0.001. After adjusting for potential confounders, enhanced monitoring remained associated with a reduction in composite cardio-respiratory complications (OR: 0.64, 95% CI: 0.46-0.88, p = 0.005). CONCLUSIONS: Our study demonstrates that postoperative enhanced monitoring pathway was associated with a lower incidence of cardio-respiratory composite events, compared to a standard of care, in patients undergoing bariatric surgery. As our results show association rather than causation, future prospective randomized trials are needed to confirm the benefit of enhanced monitoring. Findings of our study add to the existing literature involved in clinical management pathways to reduce the incidence of adverse postoperative outcomes in high-risk patients undergoing inpatient surgeries.

Support for health care workers and psychological distress: thinking about now and beyond the COVID-19 pandemic. / Soutien aux travailleurs de la santé et détresse psychologique : réflexion sur la situation actuelle et la période suivant la pandémie de COVID-19.

INTRODUCTION: This study explores the relationship between emotional support, perceived risk and mental health outcomes among health care workers, who face high rates of burnout and mental distress since the beginning of the COVID-19 pandemic. METHODS: A cross-sectional, multicentred online survey of health care workers in the Greater Toronto Area, Ontario, Canada, during the first wave of the COVID-19 pandemic evaluated coping strategies, confidence in infection control, impact of previous work during the 2003 SARS outbreak and emotional support. Mental health outcomes were assessed using the Generalized Anxiety Disorder scale, the Impact of Event Scale - Revised and the Patient Health Questionnaire (PHQ-9). RESULTS: Of 3852 participants, 8.2% sought professional mental health services while 77.3% received emotional support from family, 74.0% from friends and 70.3% from colleagues. Those who felt unsupported in their work had higher odds ratios of experiencing moderate and severe symptoms of anxiety (odds ratio [OR] = 2.23; 95% confidence interval [CI]: 1.84-2.69), PTSD (OR = 1.88; 95% CI: 1.58-2.25) and depression (OR = 1.88; 95% CI: 1.57-2.25). Nearly 40% were afraid of telling family about the risks they were exposed to at work. Those who were able to share this information demonstrated lower risk of anxiety (OR = 0.58; 95% CI: 0.48-0.69), PTSD (OR = 0.48; 95% CI: 0.41-0.56) and depression (OR = 0.55; 95% CI: 0.47-0.65). CONCLUSION: Informal sources of support, including family, friends and colleagues, play an important role in mitigating distress and should be encouraged and utilized more by health care workers.

Why do patients agree to a "Do not resuscitate" or "Full code" order? Perspectives of medical inpatients.

BACKGROUND: The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS: We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS: We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia. CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

Surviving SARS and living through COVID-19: Healthcare worker mental health outcomes and insights for coping.

OBJECTIVE: Explore how previous work during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak affects the psychological response of clinical and non-clinical healthcare workers (HCWs) to the current COVID-19 pandemic. METHODS: A cross-sectional, multi-centered hospital online survey of HCWs in the Greater Toronto Area, Canada. Mental health outcomes of HCWs who worked during the COVID-19 pandemic and the SARS outbreak were assessed using Impact of Events-Revised scale (IES-R), Generalized Anxiety Disorder scale (GAD-7), and Patient Health Questionnaire (PHQ-9). RESULTS: Among 3852 participants, moderate/severe scores for symptoms of post- traumatic stress disorder (PTSD) (50.2%), anxiety (24.6%), and depression (31.5%) were observed among HCWs. Work during the 2003 SARS outbreak was reported by 1116 respondents (29.1%), who had lower scores for symptoms of PTSD (P = .002), anxiety (P < .001), and depression (P < .001) compared to those who had not worked during the SARS outbreak. Multivariable logistic regression analysis showed non-clinical HCWs during this pandemic were at higher risk of anxiety (OR, 1.68; 95% CI, 1.19-2.15, P = .01) and depressive symptoms (OR, 2.03; 95% CI, 1.34-3.07, P < .001). HCWs using sedatives (OR, 2.55; 95% CI, 1.61-4.03, P < .001), those who cared for only 2-5 patients with COVID-19 (OR, 1.59; 95% CI, 1.06-2.38, P = .01), and those who had been in isolation for COVID-19 (OR, 1.36; 95% CI, 0.96-1.93, P = .05), were at higher risk of moderate/severe symptoms of PTSD. In addition, deterioration in sleep was associated with symptoms of PTSD (OR, 4.68, 95% CI, 3.74-6.30, P < .001), anxiety (OR, 3.09, 95% CI, 2.11-4.53, P < .001), and depression (OR 5.07, 95% CI, 3.48-7.39, P < .001). CONCLUSION: Psychological distress was observed in both clinical and non-clinical HCWs, with no impact from previous SARS work experience. As the pandemic continues, increasing psychological and team support may decrease the mental health impacts.

The perils of medico-legal advocacy in ICU conflicts at the end of life: A qualitative study of what happens when advocacy and best interests collide.

An unexplored aspect of conflicts and conflict resolution in the ICU at EOL is the role of advocacy in both medicine and law. GOAL: Qualitative study to explore perspectives of SDM/patient lawyers on issues of advocacy at EOL to better understand conflicts and resolution processes. METHODS: Purposive sampling with criterion and snowball techniques were used to recruit 11 experienced lawyers for semi-structured interviews. Interviews explored respondents' beliefs, views, and experiences with conflicts; were audio-recorded, coded inductively and iteratively following interpretive analysis. Recurring themes were identified using NVivo Qualitative Software. RESULTS: We interviewed 11 participants and achieved conceptual saturation. Participants identified insufficient advocacy and overaggressive advocacy as major contributors to the initiation of ICU conflicts and the inhibition of resolution processes before and after the legal system is engaged. These breakdowns in advocacy contribute to challenges when conflicts arise, leading to prolongation of conflict-resolution processes and to outcomes that sometimes reflect the goals of legal advocacy rather than patient-centred goals. CONCLUSION: This study explores legal perspective of conflict at EOL and how these perspectives can be used to inform the development of better approaches to conflict resolution.

Psychological 'burnout' in healthcare professionals: Updating our understanding, and not making it worse.

Many healthcare professionals and professional societies are demanding action to counter 'burnout', especially in the acute care medical specialties. This review is intended to empower this laudable 'call to arms', while also validating concerns that have been raised about how we typically define, measure and counter this important issue. This review aims to advance the discussion, dispel common misconceptions, add important nuance, and identify common ground. We also encourage the ideas contained within the military term 'occupational stress injury', which include a cultural shift away from blame and stigmatization, and towards shared responsibility and empathy. We also outline why mandatory testing can be troublesome and why interventions should be tailored to individuals. While the need for immediate action may seem self-evident, we wish to mitigate the real possibility that good intentions could make a perilous situation worse. 'Burnout' matters, but how individuals and organizations go forward matters even more.