Interdisciplinary co-teaching as a sustainable model for health humanities pedagogy.

Academics and students from marginalised identities encounter challenges and barriers at all levels of participation in the settler colonial university, in both practices of teaching and learning. While this observation holds true for courses in the health humanities, their unique interdisciplinary position and context creates space for challenging dominant norms in society and in academia. In this paper, we describe our experiences as two black and queer graduate students developing and co-teaching an online interdisciplinary course, 'Race and Medicine'. The idea for co-teaching originated as a means of ensuring continuity and sustainability in the course (AvB was expecting her first child and contending with the possibility of unplanned preterm birth) and emerged into what we suggest, in line with the transformative pedagogical theory of bell hooks, was a micro-scale transgressive learning community. We argue that our co-teaching partnership facilitated practices of revealing, mitigating and disrupting oppressive structures in the white heteropatriarchal academy, in addition to offering unique learning opportunities for students. The intersections of difference and similarity between our disciplinary, professional and social identities transformed and enhanced the types of conversations and learning activities we held with the class and were a feature of the course which was rated highly in evaluations. We conclude by suggesting co-teaching as a possible model of sustainable pedagogy for the health humanities, one that is especially valuable for racialised graduate students who are developing professional identities as instructors and exploring careers in the health humanities. In addition to facilitating interdisciplinary student learning, co-teaching and the subsequent formation of micro-scale transgressive learning communities challenges the dominant power structures of the academy by making space for teaching and learning in the contexts of solidarity, care and sustainability.

Variability in criteria for death determination in the intensive care unit.

PURPOSE: Variability in practice exists in death determination by circulatory criteria in the context of organ donation. We sought to describe the practices of intensive care health care professionals for death determination by circulatory criteria with and without organ donation. METHODS: This study is a retrospective analysis of prospectively collected data. We included patients with death determination by circulatory criteria in intensive care units at 16 hospitals in Canada, three in the Czech Republic, and one in the Netherlands. Results were recorded using a checklist for the determination of death questionnaire. RESULTS: A total of 583 patients had their death determination checklist reviewed for statistical analysis. The mean (standard deviation) age in years was 64 (15). Three hundred and fourteen (54.0%) patients were from Canada, 230 (39.5%) were from the Czech Republic, and 38 (6.5%) were from the Netherlands. Fifty-two (8.9%) patients proceeded with donation after death determination by circulatory criteria (DCD). The most common diagnostic tests reported for the whole group were absent heart sounds by auscultation (81.8%), flat continuous arterial blood pressure (ABP) tracing (77.0%), and flat electrocardiogram tracing (73.2%). In patients who successfully underwent DCD (N = 52), death was determined most frequently using a flat continuous ABP tracing (94%), absent pulse oximetry (85%), and absent palpable pulse (77%). CONCLUSION: In this study, we have described practices for death determination by circulatory criteria both within and between countries. Though some variability exists, we are reassured that appropriate criteria are almost always used in the context of organ donation. In particular, the use of continuous ABP monitoring in DCD was consistent. It highlights the need for standardization of practice and up to date guidelines, especially within the context of DCD where there is both an ethical and a legal requirement to adhere to the dead donor rule, while minimizing time between death determination and organ procurement.

RéSUMé: OBJECTIF: Il existe de la variabilité dans la pratique en matière de détermination du décès selon des critères circulatoires dans le contexte d'un don d'organes. Nous avons cherché à décrire les pratiques des professionnels de la santé en soins intensifs en ce qui touche à la détermination du décès selon des critères circulatoires avec et sans don d'organes. MéTHODE: Cette étude est une analyse rétrospective de données recueillies prospectivement. Nous avons inclus des patients dont le décès avait été déterminé par des critères circulatoires dans les unités de soins intensifs de 16 hôpitaux au Canada, trois en République tchèque et un aux Pays-Bas. Les résultats ont été consignés à l'aide de la liste de contrôle d'un questionnaire sur la détermination du décès. RéSULTATS: Au total, les listes de contrôle pour la détermination du décès de 583 patients ont été examinées à des fins d'analyse statistique. L'âge moyen (écart type) en années était de 64 ans (15). Trois cent quatorze (54,0 %) patients provenaient du Canada, 230 (39,5 %) de la République tchèque et 38 (6,5 %) des Pays-Bas. Cinquante-deux (8,9 %) patients ont procédé au don après la détermination du décès selon des critères circulatoires (DCC). Les tests diagnostiques les plus fréquemment rapportés pour l'ensemble du groupe étaient l'absence de bruits cardiaques à l'auscultation (81,8 %), le tracé plat continu de la tension artérielle (TA) (77,0 %) et le tracé plat à l'électrocardiogramme (73,2 %). Chez les patients ayant été soumis avec succès à un DCD (N = 52), le décès a été déterminé le plus souvent à l'aide d'un tracé continu plat de la TA (94 %), d'une oxymétrie de pouls absente (85 %) et d'un pouls palpable absent (77 %). CONCLUSION: Dans cette étude, nous avons décrit les pratiques de détermination du décès selon des critères circulatoires à la fois à l'intérieur et entre les pays. Bien qu'il existe une certaine variabilité, nous sommes rassurés par le fait que des critères appropriés sont presque toujours utilisés dans le contexte du don d'organes. En particulier, l'utilisation du monitorage continu de la TA était constant en cas de DCC. Cela souligne la nécessité de normaliser la pratique et de disposer de lignes directrices mises à jour, en particulier dans le contexte de DCC où il existe une exigence à la fois éthique et légale de respecter la règle du donneur décédé, tout en minimisant le temps entre la détermination du décès et la collecte d'organes.

Machine learning determination of motivators of terminal extubation during the transition to end-of-life care in intensive care unit.

Procedural aspects of compassionate care such as the terminal extubation are understudied. We used machine learning methods to determine factors associated with the decision to extubate the critically ill patient at the end of life, and whether the terminal extubation shortens the dying process. We performed a secondary data analysis of a large, prospective, multicentre, cohort study, death prediction and physiology after removal of therapy (DePPaRT), which collected baseline data as well as ECG, pulse oximeter and arterial waveforms from WLST until 30 min after death. We analysed a priori defined factors associated with the decision to perform terminal extubation in WLST using the random forest method and logistic regression. Cox regression was used to analyse the effect of terminal extubation on time from WLST to death. A total of 616 patients were included into the analysis, out of which 396 (64.3%) were terminally extubated. The study centre, low or no vasopressor support, and good respiratory function were factors significantly associated with the decision to extubate. Unadjusted time to death did not differ between patients with and without extubation (median survival time extubated vs. not extubated: 60 [95% CI: 46; 76] vs. 58 [95% CI: 45; 75] min). In contrast, after adjustment for confounders, time to death of extubated patients was significantly shorter (49 [95% CI: 40; 62] vs. 85 [95% CI: 61; 115] min). The decision to terminally extubate is associated with specific centres and less respiratory and/or vasopressor support. In this context, terminal extubation was associated with a shorter time to death.

Challenging the logic of lifesaving in the intensive care unit.

Intensive care units are considered life-saving medical services and a vital component of healthcare systems. These specialized hospital wards contain the life support machines and technical expertise to sustain seriously ill and injured bodies. However, as the COVID-19 pandemic has demonstrated, intensive care is an expensive, finite resource which is not necessarily available to all citizens, and which may be unjustly rationed. As a result, the intensive care unit may contribute more towards biopolitical narratives of investment in lifesaving than measurable improvements in population health. Drawing from ethnographic fieldwork and a decade of involvement in clinical research, this paper examines everyday activities of lifesaving in the intensive care unit and interrogates epistemological assumptions upon which they are organized. A closer look at how healthcare professionals, medical devices, patients, and families accept, refuse, and modify imposed boundaries of bodily finitude reveals how activities of lifesaving often lead to uncertainty and may even impose harm when they deny possibilities for desired death. Refiguring death as a personal ethical threshold, rather than inherently tragic ending, challenges the power of the logic of lifesaving and instead insists on greater attention towards improving conditions for living.

Predicting Time to Death After Withdrawal of Life-Sustaining Measures Using Vital Sign Variability: Derivation and Validation.

To develop a predictive model using vital sign (heart rate and arterial blood pressure) variability to predict time to death after withdrawal of life-supporting measures. DESIGN: Retrospective analysis of observational data prospectively collected as part of the Death Prediction and Physiology after Removal of Therapy study between May 1, 2014, and May 1, 2018. SETTING: Adult ICU. PATIENTS: Adult patients in the ICU with a planned withdrawal of life-supporting measures and an expectation of imminent death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Vital sign waveforms and clinical data were prospectively collected from 429 patients enrolled from 20 ICUs across Canada, the Czech Republic, and the Netherlands. Vital sign variability metrics were calculated during the hour prior to withdrawal. Patients were randomly assigned to the derivation cohort (288 patients) or the validation cohort (141 patients), of which 103 and 54, respectively, were eligible for organ donation after circulatory death. Random survival forest models were developed to predict the probability of death within 30, 60, and 120 minutes following withdrawal using variability metrics, features from existing clinical models, and/or the physician's prediction of rapid death. A model employing variability metrics alone performed similarly to a model employing clinical features, whereas the combination of variability, clinical features, and physician's prediction achieved the highest area under the receiver operating characteristics curve of all models at 0.78 (0.7-0.86), 0.79 (0.71-0.87), and 0.8 (0.72-0.88) for 30-, 60- and 120-minute predictions, respectively. CONCLUSIONS: Machine learning models of vital sign variability data before withdrawal of life-sustaining measures, combined with clinical features and the physician's prediction, are useful to predict time to death. The impact of providing this information for decision support for organ donation merits further investigation.

Family experiences with non-therapeutic research on dying patients in the intensive care unit.

Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient.We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care.Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients' lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval.Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed.

Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review.

AIM: Pre-mortem interventions (PMIs) are performed on patients before the determination of death in order to preserve or enhance the possibility of organ donation. These interventions can be ethically controversial, and we thus undertook a scoping review of the ethical issues surrounding diverse PMIs. METHODS: Using modified scoping review methods, we executed a search strategy created by an information specialist. Screening and iterative coding of each article was done by two researchers using qualitative thematic analysis, and narrative summaries of coded themes were presented. RESULTS: We identified and screened 5365 references and coded 196 peer-reviewed publications. The most frequently cited issues were related to possible harms to the patient who is a potential donor, and legitimacy of consent. The most controversial issue was that PMIs may place patients at risk for physical harm, yet benefit is accrued mainly to recipients. Some authors argued that lack of direct medical benefit to the still living patient precluded valid consent from surrogate decision makers (SDMs), while many stated that some medical risk could be approved by SDMs if it aligns with non-medical benefits valued by the patient. CONCLUSION: PMIs require consensus that benefit includes concepts beyond medical benefit to the patient who is a potential donor. Informed consent must be confirmed for each PMI and not assumed to be part of general consent for donation. Risk must be proportionate to the potential benefit and newly proposed interventions should be reviewed carefully for medical efficacy and potential risks.

Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures.

BACKGROUND: The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied. METHODS: We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity. RESULTS: A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients. CONCLUSIONS: After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.).

Requests for somatic support after neurologic death determination: Canadian physician experiences.

PURPOSE: Neurologic determination of death (NDD) is legally accepted as death in Canada but remains susceptible to misunderstandings. In some cases, families request continued organ support after NDD. Conflicts can escalate to formal legal challenges, causing emotional, financial, and moral distress for all involved. We describe prevalence, characteristics, and common experiences with requests for continued organ support following NDD in Canada. METHODS: Mixed-methods design combining anonymous online survey with semi-structured interviews of Canadian critical care physicians (448 practitioners, adult and pediatric). RESULTS: One hundred and six physicians responded to the survey and 12 participated in an interview. Fifty-two percent (55/106) of respondents had encountered a request for continued organ support after NDD within two years, 47% (26/55) of which involved threat of legal action. Requests for continued support following NDD ranged from appeals for time for family to gather before ventilator removal to disagreement with the concept of NDD. Common responses to requests included: consultation with an additional physician (54%), consultation with spiritual services (41%), and delay of one to three days for NDD acceptance (49%). Respondents with prior experience were less likely to recommend ancillary tests (P = 0.004) or consultation with bioethics services (P = 0.004). Qualitative analysis revealed perceptions that requests for continued organ support were driven by mistrust, tensions surrounding decision-making, and cultural differences rather than a lack of specific information about NDD. CONCLUSIONS: Family requests for continued somatic support following NDD were encountered by half our sample of Canadian critical care physicians. Mitigation strategies require attention to the multifaceted social contexts surrounding these complex scenarios.

RéSUMé: OBJECTIF: Au Canada, le diagnostic de décès neurologique (DDN) est légalement accepté en tant que décès, mais il est encore mal compris parfois. Dans certains cas, les familles demandent de maintenir artificiellement les fonctions vitales après un DDN. Les conflits peuvent dégénérer et devenir des contestations judiciaires formelles, provoquant de la détresse émotionnelle, financière et morale pour tous. Nous décrivons la prévalence, les caractéristiques et les expériences fréquemment vécues en lien avec des demandes de maintien artificiel des fonctions vitales après un DDN au Canada. MéTHODE: Méthodologie mixte combinant un sondage électronique anonyme à des entretiens semi-structurés de médecins intensivistes canadiens (448 praticiens, populations adulte et pédiatrique). RéSULTATS: Cent six médecins ont répondu au sondage et 12 ont participé à un entretien. Cinquante-deux pour cent (55/106) des répondants avaient déjà reçu une demande de maintien des fonctions vitales après un DDN au cours des deux dernières années, dont 47 % (26/55) étaient accompagnées de menaces de poursuite judiciaire. Les demandes de maintien continu à la suite d'un DDN allaient des requêtes de temps supplémentaire pour que la famille puisse se réunir avant de débrancher le respirateur aux désaccords quant au concept même de DDN. Les réponses fréquentes aux demandes étaient : la consultation d'un autre médecin (54 %), la consultation des services spirituels (41 %), et un délai d'un à trois jours pour accepter le DDN (49 %). Les répondants ayant déjà eu une expérience similaire avaient moins tendance à recommander des tests supplémentaires (P = 0,004) ou une consultation auprès des services de bioéthique (P = 0,004). L'analyse qualitative a révélé des perceptions selon lesquelles les demandes de maintien des soins étaient motivées par la méfiance, des tensions autour de la prise de décision et des différences d'ordre culturel plutôt que par le manque d'informations spécifiques concernant le DDN. CONCLUSION: La moitié de notre échantillon de médecins intensivistes canadiens ont déjà été confrontés à des demandes de la famille pour maintenir le soutien des fonctions vitales à la suite d'un DDN. Les stratégies de mitigation doivent tenir compte des contextes sociaux aux multiples facettes entourant ces situations complexes.

Patient engagement in a Canadian consensus forum for heart donation after circulatory determination of death.

PURPOSE: Heart donation and transplantation following circulatory determination of death has yet to be performed in Canada. A consensus forum was held to provide expert guidance to inform policy with a comprehensive patient partner strategy. This paper describes the process used to create fulsome patient partner engagement resulting in mutually beneficial policy development in this complex area. METHODS: A wide-ranging process for involving patient partners in this area included pre-meeting education, in-meeting expert support, full participation and permission to step back if desired, and post-meeting debriefing. Following the meeting, a questionnaire was used to guide a debrief discussion with patient partners and steering committee members who co-authored this paper. RESULTS: Five key themes arose that echoed the sentiments and contributions made by patient partners, including: 1) a strong desire to improve the system, 2) gratitude and honour, 3) expert support and process, 4) simplification of complex concepts, and 5) mutual benefit expressed by patient partners and healthcare professionals. CONCLUSION: Despite the complexity of the content and the emotionally sensitive nature of discussions around deceased organ donation, a well-planned strategy to involve patient partners is important, impactful, and central to the process. This suggests a broad interprofessional audience can engage with properly prepared and supported patient partners to strengthen and focus dialogue and outputs in the development of health policy in the donation and transplant sector.

RéSUMé: OBJECTIF: Le don et la greffe cardiaque à la suite d'un décès circulatoire n'ont encore jamais été réalisés au Canada. Un forum de consensus a été organisé dans le but de formuler des recommandations spécifiques qui guideraient les politiques avec une stratégie globale incluant les patients partenaires. Cet article décrit le processus utilisé pour susciter une implication complète des patients partenaires, avec pour résultat la mise au point de politiques mutuellement bénéfiques dans ce domaine complexe. MéTHODE: Nous avons amorcé un vaste processus pour impliquer les patients partenaires dans ce domaine, processus qui a consisté en une formation préliminaire avant la rencontre, le soutien d'experts pendant la rencontre, la participation complète et la permission de se retirer du processus si désiré, et le débriefing après la rencontre. À la suite de la rencontre, un questionnaire a servi à orienter les discussions de débriefing avec les patients partenaires et les membres du comité directeur ayant collaboré à cet article. RéSULTATS: Cinq thèmes clés sont ressortis des discussions, faisant écho aux sentiments et aux contributions des patients partenaires, soit : 1) un profond désir d'améliorer le système, 2) la gratitude et l'honneur, 3) le soutien par et un processus d'experts, 4) la simplification des concepts complexes, et 5) les avantages mutuels exprimés par les patients partenaires et les professionnels de la santé. CONCLUSION: Malgré la complexité du contenu et la nature émotionnellement sensible des discussions entourant le don d'organes après décès, une stratégie bien planifiée d'implication des patients partenaires est importante, a un impact et doit être placée au centre du processus. Cela suggère qu'une vaste équipe interprofessionnelle peut s'impliquer auprès de patients partenaires bien préparés et convenablement soutenus; une telle approche permettra de renforcer et de concentrer le dialogue et les résultats lors de la mise au point de politiques de santé dans le secteur du don et de la greffe.

Engaging family partners in deceased organ donation research-a reflection on one team's experience.

PURPOSE: Clinical researchers are now encouraged to include patient partners in all research projects. Nevertheless, published accounts of patient engagement in complex research projects, such as those involving critically ill and dying patients, are lacking. Whether this absence is due to the relatively new emergence of patient engagement research methods or fundamental challenges regarding family engagement in challenging research contexts is unclear. We describe our experiences with forming a researcher-family partnership in a deceased organ donation research project involving the prospective observation of potential and actual deceased organ donors dying in the intensive care unit. METHODS: We used the Guidance for Reporting Involvement of Patients and the Public evidence-based, consensus-informed reporting guidelines to organize our narrative. RESULTS: We were able to initiate and sustain a research consultant relationship with the mother of a deceased organ donor for over two years. Challenges faced included: constraints on money and time, communication preferences, and the emotional stress of participating in difficult conversations. Positive outcomes included: improvement of data collection tools, new opportunities for access to research populations, and motivation to include family partnership in future grant proposals. CONCLUSIONS: Family engagement in deceased organ donation research is feasible and contributes positively to study progress and outcomes. Patient and family engagement in challenging research contexts may require special attention to the emotional challenges of participation. We hope that our experience will encourage clinical researchers working in deceased organ donation and similarly complex domains to consider including patient partners in their projects.

RéSUMé: OBJECTIF: Les cliniciens sont maintenant encouragés à inclure les partenaires des patients dans tous leurs projets de recherche. Néanmoins, on ne dispose d'aucune publication sur la participation des patients et de leur famille dans des projets de recherche complexes tels que ceux impliquant des patients dans un état critique ou mourants. Savoir si cette absence est liée à l'émergence relativement récente des méthodes de recherche sur la participation des patients ou aux défis fondamentaux concernant la participation des familles dans un contexte de recherche difficile reste une question débattue. Nous décrivons nos expériences de la formation d'un partenariat chercheur-famille dans un projet de recherche sur le don d'organe impliquant l'observation prospective de donneurs d'organes potentiels ou décédés, décédant dans une unité de soins intensifs. MéTHODES: Nous utilisons le document intitulé Guidance for Reporting Involvement of Patients (conseils pour rendre compte de l'implication des patients) et les lignes directrices publiques basées sur des données probantes pour la publication fondées sur un consensus, pour organiser notre compte rendu. RéSULTATS: Nous avons pu instaurer et maintenir pendant plus de deux ans une relation de consultant en recherche avec la mère d'un donneur d'organe décédé. Les défis rencontrés étaient notamment les contraintes financières et de temps, les préférences en matière de communications et le stress émotionnel créé par la participation à des conversations sur des sujets difficiles. Les résultats positifs ont été, notamment l'amélioration des outils de collecte de données, les nouvelles possibilités d'accès à des populations de recherche et la motivation à inclure un partenariat avec la famille dans les futures propositions de subventions. CONCLUSIONS: La participation de la famille dans la recherche sur le don d'organe d'une personne décédée est faisable et contribue positivement à l'avancement et à l'aboutissement des études. La participation du patient et de sa famille dans un contexte de recherche difficile peut demander de porter une attention particulière aux défis émotionnels de cette participation. Nous espérons que notre expérience encouragera les cliniciens chercheurs qui travaillent sur le don d'organes de personnes décédées et d'autres domaines aussi complexes à envisager d'inclure les partenaires des patients dans leurs projets.

Feasibility of conducting prospective observational research on critically ill, dying patients in the intensive care unit.

Studying patients during the end of life is important, as it has the potential to lead to improvements in care for the dying. For patients who die after a controlled withdrawal of life-sustaining therapies in the intensive care unit, information about the natural history of death and the process of removing life support has additionally led to advances in practice for deceased organ donation. However, this unique population of severely critically ill and imminently dying patients has been difficult to study, largely due to assumptions made by research teams and ethics boards alike about the logistical difficulties of obtaining consent and completing research procedures before or during the process of withdrawal of life-sustaining therapies. In this paper, we describe the ethics substudy of the first prospective observational research study in Canada to obtain consent and collect clinical data on patients during the process of withdrawal of life-sustaining therapies in the intensive care unit. We describe in detail the process of protocol development, review by five institutional research ethics boards and bedside staff satisfaction with the study. We conclude that prospective research on a critically ill and imminently dying population is feasible and can be conducted in an ethical manner. Further information is needed about the experiences and motivations of families and substitute decision makers who provide consent for research on critically ill intensive care unit patients at the end of life.

Exploration of Withdrawal of Life-Sustaining Therapy in Canadian Intensive Care Units.

OBJECTIVE: The process of controlled donation after circulatory death (cDCD) is strongly connected with the process of withdrawal of life-sustaining therapy. In addition to impacting cDCD success, actions comprising withdrawal of life-sustaining therapy have implications for quality of palliative care. We examined pilot study data from Canadian intensive care units to explore current practices of life-sustaining therapy withdrawal in nondonor patients and described variability in standard practice. DESIGN: Secondary analysis of observational data collected for Determination of Death Practices in Intensive Care pilot study. SETTING: Four Canadian adult intensive care units. PATIENTS: Patients ≥18 years in whom a decision to withdraw life-sustaining therapy was made and substitute decision makers consented to study participation. Organ donors were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prospective observational data on interventions withdrawn, drugs administered, and timing of life-sustaining therapy withdrawal was available for 36 patients who participated in the pilot study. Of the patients, 42% died in ≤1 hour; median length of time to death varied between intensive care units (39-390 minutes). Withdrawal of life-sustaining therapy processes appeared to follow a general pattern of vasoactive drug withdrawal followed by withdrawal of mechanical ventilation and extubation in most sites but specific steps varied. Approaches to extubation and weaning of vasoactive drugs were not consistent. Protocols detailing the process of life-sustaining therapy withdrawal were available for 3 of 4 sites and also exhibited differences across sites. CONCLUSIONS: Standard practice of life-sustaining therapy withdrawal appears to differ between selected Canadian sites. Variability in withdrawal of life-sustaining therapy may have a potential impact both on rates of cDCD success and quality of palliative care.

Variations in the Operational Process of Withdrawal of Life-Sustaining Therapy.

OBJECTIVE: The process of withdrawal of life-sustaining therapy remains poorly described in the current literature despite its importance for patient comfort and optimal end-of-life care. We conducted a structured review of the published literature to summarize patterns of withdrawal of life-sustaining therapy processes in adult ICUs. DATA SOURCES: Electronic journal databases were searched from date of first issue until April 2014. STUDY SELECTION: Original research articles describing processes of life-support therapy withdrawal in North American, European, and Australian ICUs were included. DATA EXTRACTION: From each article, we extracted definitions of withdrawal of life-sustaining therapy, descriptions and order of interventions withdrawn, drugs administered, and timing from withdrawal of life-sustaining therapy until death. DATA SYNTHESIS: Fifteen articles met inclusion criteria. Definitions of withdrawal of life-sustaining therapy varied and focused on withdrawal of mechanical ventilation; two studies did not present operational definitions. All studies described different aspects of process of life-support therapy withdrawal and measured different time periods prior to death. Staggered patterns of withdrawal of life-support therapy were reported in all studies describing order of interventions withdrawn, with vasoactive drugs withdrawn first followed by gradual withdrawal of mechanical ventilation. Processes of withdrawal of life-sustaining therapy did not seem to influence time to death. CONCLUSIONS: Further description of the operational processes of life-sustaining therapy withdrawal in a more structured manner with standardized definitions and regular inclusion of measures of patient comfort and family satisfaction with care is needed to identify which patterns and processes are associated with greatest perceived patient comfort and family satisfaction with care.

Ethical concerns for maternal surrogacy and reproductive tourism.

Reproductive medical tourism is by some accounts a multibillion dollar industry globally. The seeking by clients in high income nations of surrogate mothers in low income nations, particularly India, presents a set of largely unexamined ethical challenges. In this paper, eight such challenges are elucidated to spur discussion and eventual policy development towards protecting the rights and health of vulnerable women of the Global South.