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Healthcare Consent Quality Collaborative http://consentqi.ca A resource for anyone interested in improving quality in healthcare. Wed, 07 Feb 2018 14:43:22 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 http://consentqi.ca/wp-content/uploads/2013/02/cropped-Noname2-32x32.png Healthcare Consent Quality Collaborative http://consentqi.ca 32 32 CCB Stirring Again… http://consentqi.ca/ccb-stirring-again/ Thu, 14 Sep 2017 13:44:51 +0000 http://consentqi.ca/?p=1580 Applications to the Consent and Capacity Board to resolve end of life conflict are not new. Typically, patients are critically ill and dependent on various life support systems in the ICU before a physician (or group of physicians) is willing to challenge a substitute decision-maker that the level of intervention is not in the best interests of the patient, or representative of their prior expressed wishes. Following the first CCB application for an end-of-life case in 2003, Re(HJ), physicians starting using the CCB when there was no other good options available, often after months of disagreement. Between 2009-2013, physicians brough 30 of these cases to the CCB, indicating a growing interest and understanding of the CCB process (and various applications). In late 2013, however, the Supreme Court of Canada chose to ignore the common law question of whether or not physicians were obligated to provide treatments they felt to be ineffective or futile, instead narrowly ruling on the applicability of the Healthcare Consent Act of Ontario in the Rasouli case. In theory, the Rasouli should have led to more applications to the CCB, but instead they plummeted. Critical Care docs in particular quietly expressed they felt let down by the legal system, especially as more and more CCB cases were being appealed as a delay tactic effectively condemning patients to suffer needlessly – the primary reason for applying to the CCB in the first place. 

It is then quite significant what has been happening this past year. Out of nowhere, there seems to be renewed interest in making applications to the CCB. I take this to be a positive sign, but there remain reasons for concern as well. Three of these cases were dismissed for reasons I won't comment on here (but you can read). Physicians should be learning from previous cases how to use the CCB so that they aren't taking cases unlikely to succeed – but that doesn't appear to be happening. Prior to Rasouli, physicians were successful* approximately 80% of the applications they filed wiht the CCB. After Rasouli, that number has fallen to roughly 50%. Of course, there could be more going on that physicians identifying the right cases and knowing how to bring them… (I will expand on this in a future post)













*The idea that an application to the CCB is a "success" has been criticized by some as a confirmation of the paternalistism at play in critical care units. They would point to the the CCB as a neutral 3rd party able to resolve of genuine uncertainty (where best interests are in question). The problem is that physicians tend not to use the CCB as a mechanism to "steamroll" families where genuine uncertainty exists. Careful reading of the cases brought forward demonstrates extreme restraint on behalf of medical teams, bringing applicaitons only in the most egrigious cases, after repeated and lengthy compromises along the way, where they feel patients are genuinely suffering for no demonstrable benefit.



http://consentqi.ca/1566-2/ Mon, 31 Oct 2016 12:56:54 +0000 http://consentqi.ca/?p=1566 View the most commonly accessed pages on this site:

1. Consent and Capacity Board decisinos that focus on end of life decision making 

2. Consent and Capacity Board decisions that focus on admission to long-term care facilities

3. Our checklist for meeting ethical and legal obilgations in treatment decisions

CMAJ piece re: CPSO policy mandating consent for DNR http://consentqi.ca/cmaj-piece-re-cpso-policy-mandating-consent-for-dnr/ Sat, 12 Mar 2016 15:44:07 +0000 http://consentqi.ca/?p=1553  

 2016 Mar 1;188(4):245-6. doi: 10.1503/cmaj.151205. Epub 2016 Jan 4.

Mandate to obtain consent for withholding nonbeneficial cardiopulmonary resuscitation is misguided.

Downar J1, Warner M2, Sibbald R2.



Clarifying roles in medical decision making (ON) http://consentqi.ca/clarifying-roles-in-medical-decision-making-on/ Mon, 29 Feb 2016 13:52:25 +0000 http://consentqi.ca/?p=1549 Our partners spearheading the PoET project, ie. Preventing of Errors in Transfers (between care settings), recently developed this very accessible explanation of the various roles in decision making for healthcare in Ontario. Please share where you think it would be useful. Hospitals might consider making this available to patients and their families.


Slow Codes Returning to Ontario? http://consentqi.ca/slow-codes-returning-to-ontario/ Thu, 17 Sep 2015 16:55:34 +0000 http://consentqi.ca/?p=1539 In wake of the recent decision by the College of Physicians and Surgeons of Ontario to approve their new policy "Planning for and Providing Quality End of Life Care" – many of us are scratching our heads trying to make sense of the actions that are now required of Ontario physicians. The following excerpt from the policy demonstrates the key problems: 

A decision regarding a no-CPR order cannot be made unilaterally by the physician. Where a physician is of the opinion that CPR should not be provided for a patient and that a no-CPR order should be written in the patient’s record, the College requires physicians to discuss this with the patient and/or substitute decision-maker at the earliest and most appropriate opportunity, and to explain why CPR is not being proposed. This discussion must occur before a no-CPR order can be written.

If the patient or substitute decision-maker disagrees and insists that CPR be provided, physicians must engage in the conflict resolution process as outlined in Section 8 of this policy which may include an application to the Consent and Capacity Board. Physicians must allow the patient or substitute decision-maker a reasonable amount of time to disagree before a no-CPR order can be written.

While the conflict resolution process is underway, if an event requiring CPR occurs, physicians must provide CPR. In so doing, physicians must act in good faith and use their professional judgment to determine how long to continue providing CPR.

While a no-CPR order should require consent in some instances, it seems inappropriate to extend that to all situations. In some instances, physicians believe it is not medically indicated to offer CPR to a patient – and thus consent wouldn't apply. A patient with metastatic cancer who is already intubated in an ICU is typically not a canditate for CPR, because it would be ineffective and only cause harm. Taking the disagreement to the Consent and Capacity Board may not provide the resolution the CPSO was looking for. The CCB is only able to ajudicate where consent is clearly at issue (ie. the physician has proposed a treatment plan).  But more troubling is in the final paragraph where physicians are instructed to begin CPR (ie. disregard their clinical judgment about the ineffectiveness of such an action), but then only provide CPR for a period of time considered approrpiate by use of the same professional judgment. This almost sounds like an instruction to implement the "slow codes" that have been repeatedly dismissed as unethical. 

The Trouble With Conflict in Paediatric Cases http://consentqi.ca/the-trouble-with-conflict-in-paediatric-cases/ Thu, 25 Jun 2015 17:09:29 +0000 http://consentqi.ca/?p=1534 The delicate balance between medical paternalism and patient directed medicine (in the name of autonomy) has recently shown signs of weakness. For the most part, physicians are content to allow patients to direct their own care, so long as the decisions can be justified by medical standards of care. Sometimes, they can't – and physicians are then forced to either compromise their professional integrity or challenge a patient. This is an incredibly rare event, as most capable patients will tend to agree with what is in scope at least, in terms of treatments available to them. 

It is somewhat more challenging when patients aren't speaking for themselves as is often the case in both critical illness (adult ICU) and pediatrics broadly. In these cases, there are two scenarios where physicians are ethically obliged to challenge family/surrogate decision makers. The first scenario is where surrogates are making decisions that contravene wishes the patient had previously expressed while capable. This is more of an adult problem, though it should be noted that even young children may have opinions about their care, that while not legally directive, have great influence on the ethically appropriate care we provide. But the second scenario includes situations where treatments that are requested by family are either outside the medical standard of care, or are not in keeping with other treatment plans that are in the patient's best interest. Even here, physicians rarely challenge families relative to the reported incidence of perceived inappropriate end of life care. 

In pediatrics, physicians long ago accepted the orthodoxy of 'family-centred care'. The problem is that family-centredness may sometimes be at the expense of patient-centredness. But how can a child's interests be separate from their family-unit? This is a significant problem for pediatric medicine, and one which we rarely take time to aknowledge. What we do know is that the courts have made it clear that a child's interests can be separated from those of their family-unit, for example in cases where families who are Jehovah's Witnesses, request that live saving blood products not be used to save their children. However, these cases are so rare, and more often we find reasons to support families and their values, irrespective of whether they should rightly be understood to be held by their children. But there are a handful of cases where medical staff have felt compelled to act, in the interests of their patient, over the interests of the family. These cases are rare, but are likely not occuring at the same rate as perceptions of inappropriate care (incidence of perceived inappropriate treatment at the end of life in pediatrics is currently being studied).

What do these cases look like? Well, for one, we hear about most of them through the media. It has become a standard legal tactic to appeal to the media and share stories of physicians who don't value life (and worse). But this is an inherently unfair tactic as physicians are publicly tried, though unable to defend theirselves against their acusers, who don't provide consent to share patient information. Nevermind that it is likely a legal violation for the parents to share that same personal informaiton if it is not in the childs best interests to do so. But the media approach works – and physicians are weary of challenging families even where they feel the alternative is to treat the child in a manner inconsistent with their best interests. What is needed is a legal order not to use the media to campaign against physicians, especially where there is a specific legal process designed to address the matter. It is in the interests of justice, that these cases are heard in private – though their lessons may be made public after the fact. 



How Terminology Matters http://consentqi.ca/terminology-matters/ Wed, 11 Feb 2015 15:01:35 +0000 http://consentqi.ca/?p=1514 In consent, terminology matters a lot. I was recently asked whether we should be providing antibiotics to a 95 yo patient who arrived from Long Term Care with an “advanced directive” that indicated he was DNR, and did not wish to be transferred to hospital for any life ending complications. He wished only comfort measures for the remainder of his life. Initially, I wondered why the patient was in hospital in the first place, but upon inspection of the “advanced directive”, I noted that the patient hadn’t created it at all – his wife did. As members of the team were busy debating whether the “advanced directive” should apply to antibiotics, no one questions that the wishes might not have been expressed by the patient. There is no standard definition of what constitutes an “advanced directive”, but most tend to assume that they would express the prior capable wishes of an individual, about him/herself. Without careful attention to how this language is used, we are setting ourselves up for trouble.

It isn’t just with technical, and legal jargon where language matters in healthcare. It is with our most controversial debates, including the one resurfacing around physician assisted death (following the historic Supreme Court of Canada decision last week). While I am proud of the court for reaching the conclusion that they did, the debate has suffered on both sides from appeal to emotional language that has imprecise meaning. I noticed a statement from the pro-PAD camp recently, that “there is no virtue in suffering“. This claim is interesting, because it attempts to universalize the judgement – coming from a group that also argues, it should be individuals who determine what quality of life, and manner of death are virtuous. While rare, I have encountered patients who felt suffering was a virtue, for whom experiencing their death was so meaningful, they refused many medications that would have relieved their obvious pain. Who am I to judge that for someone else, this isn’t virtuous? And on both sides of the debate, we see an attempt to own a universal interpretation of the phrase “dignity”. On this topic, I refer to Stephen Pinker’s excellent response to the Presidents Commission on Bioethics report on Human Dignity.

CPSO Drafts Problematic EoL Policy http://consentqi.ca/cpso-drafts-problematic-eol-policy/ Tue, 03 Feb 2015 15:28:53 +0000 http://consentqi.ca/?p=1510 Toward the end of 2014, the College of Physicians and Surgeons of Ontario (CPSO) released a draft policy entitled “Planning for and Providing Quality End of Life Care“. This was to be an update of an earlier End of Life Policy that by all accounts was overly vague regarding the precise obligations of physicians in situations where they felt unilateral withholding and/or withdrawal of treatments was the most appropriate course of action. But the draft policy contained something that surprised and upset many clinicians. While the policy says that “Physicians are not obliged to propose or provide life-saving or life-sustaining treatments that are not within the standard of care.“, consistent with its earlier policy, it goes on to say that “The College requires physicians to obtain consent for a Do Not Resuscitate order“.  Not only do these statements potentially conflict with one another, the Rasouli case decided by the Supreme Court only a year earlier already made it clear that with respect to withdrawal of LST at least, physicians could be required to provide treatments that are not consistent with the standard of care. But it gets worse; the second statement was explained by referencing a Tribunal decision of the Health Professions Appeals and Review Board (HPRAB) – and this is where the story gets interesting.

In 2008, doctors at Sunnybrook hospital caring for a Mr.Douglas DeGuerre wrote a DNR in his chart when it was determined he was too sick to benefit from CPR. After his death, Mr.DeGuerre’s daughter, Joy Wawrzyniak  filed suit against the physicians and hospital, and also filed a complaint with the CPSO. After considering the case, the CPSO determined the physicians had done nothing wrong, though acknowledged that there could have been better communication. Wawrzyniak then appealed this decision to HPRAB. In 2012, HPRAB concluded that the CPSO should reconsider their decision and make explicit reference to the question of whether or not the DNR order required consent from Mrs. Wawrzyniak. In the meantime, the Rasouli case was before the Supreme Court of Canada, and was poised to answer this very question (spoiler: it did no such thing).  So the CPSO reconsidered the case, and for a second time found the physicians had done nothing wrong, in particular, by not seeking consent for the DNR. Undeterred, Mrs. Wawrzyniak again appealed to HPRAB. By now, the Rasouli decision had been released, and it should have been clear that it did not address the question of whether consent was required for a DNR in Ontario. The Supreme Court in fact went to lengths to ensure its decision was not construed so as to apply to cases with circumstances different to those of Mr.Rasouli. Amazingly, HPRAB in its second hearing of this case, referenced the Rasouli case and argued that it had in fact settled the matter regarding the need for consent to a DNR order. They instructed the CPSO to review and revise their policies on end of life to ensure they were consistent with the requirements of the Health Care Consent Act – in other words to ensure that consent was required for a DNR.

Since the release of the draft policy, physicians, hospitals, and other organizations have been organizing a response to the College pointing out their concerns in order to prevent the draft policy from becoming a formal position. The CPSO is taking feedback on the draft policy until Feb 20th, 2015.

A Different Approach to ACP http://consentqi.ca/different-approach-acp/ Mon, 19 Jan 2015 20:52:24 +0000 http://consentqi.ca/?p=1504 I was going through the documents of several websites that offer tools on advanced care planning. In Canada, the leading site is SpeakUp. And while I applaud the efforts I’ve seen on these websites, I can’t help but struggle with the missed opportunity. We seem to have transitioned over the past few years from the POLST approach that is physician driven and depending on the jurisdiction may contain excruciating detail to the point of becoming incomprehensible to a patient to the SpeakUp approach that is patient driven and asks questions that are perhaps overly broad and general to the point of not being useful to clinicians. As I think about this problem, I have often wondered what the reasonable middle ground looks like. And based on the kinds of cases where patients wishes are absent, but would crucially assist family and physicians in key decision points – I have some ideas.

What I mean by key decision points are the decisions that lead to (a) admission to hospital at the end of life, (b) initiation of artificial feeding through the gut, (c) or tracheostomy/mechanical ventilation. What makes these decisions different than all others is their irreversibly. Technically, sure, we can send patients back home to palliate, cease artificial nutrition, or discontinue ventilation but practically speaking these decisions tend to be points of no return. Why? admission to hospital from Long-Term Care typically leads clinicians to presume that patients would want ‘everything’ in the absence of additional information. Often the patient is in dialysis or some other form of life support before anyone thinks to ask the question “did the patient want any of this?”. And regarding artificial feeding, I have seen far too many families protest that they cannot participate in a decision that would amount to “starving” their loved one to death (irrespective of the fact that their loved one had already been dying for weeks or more). And finally, while there are some very strong individuals who can accept that their loved ones  will never leave an ICU environment, the success of critical care today too frequently leads to a false sense of hope. Everyone involved in these kinds of decision would benefit from hearing the patients perspective – in their voice and not through the interpretation of a husband, wife, child, or other family member in shock at the situation and only able to think about the ‘good times’ when asked how the patient might have chosen. So how can we ask patients, when they still have their wits about them, to consider these key decision points in a way that will be useful to us?

I think we need to ask people to consider more than “what matters most to them” and focus on scenarios that clinicians can actually speak to. Two scenarios come to mind. First, the treatment in question is going to be needed for as long as the patient is living. That is, there is no realistic prospect that the patient will return home, eat on their own, or leave the ICU. These are special circumstances that doctors will be able to reliably forecast (I am not saying that physicians can predict such outcomes with certainty as many families ask of them). The other scenario that must be considered is the identity of the patient him/herself. What if they will never again be able to make their own decisions, recognize themselves, or even be conscious? Identity is of vital importance to decisions as significant as are required at the end of life.

Where does this leave us? Well, I would envision asking patients, who have a life limiting illness or for whom death is a realistic probability in the few years ahead to consider what they would want in the following situations:

1. If transition to hospital meant that you would die there because you were too sick to return to home or hospice, but you would live weeks or more than had you not come to hospital in the first place, would you want to be admitted?

2. If you lost the ability to swallow such that it was irreversible, would you want a permanent tube inserted directly into your gut to prolong your life?

3. If you were sick enough to require mechanical ventilation, but it was felt that you would never recover to the point of leaving the ICU, what would you want?

And for each of these questions I would pose the question “would it make a difference if you were not able to recognize yourself? or if you were permanently unconscious?”

There you have it. I’m sure it is flawed – but these are the essential questions that I think provide greater utility to patients and clinicians caring for them at the end of life.

Evidence Based Advance Care Planning http://consentqi.ca/evidence-based-advance-care-planning/ Thu, 05 Jun 2014 13:19:42 +0000 http://consentqi.ca/?p=1462 If we recognize that as difficult as end of life discussions are, that the vast majority of them are adequately navigated in a manner that everyone can accept – then we can focus on the ‘problem’ cases where conflict arises, differences of opinion are not settled, and interpretations of patient values are questionable. These cases often become the new stories and in ON are generally resolved at the Consent and Capacity Board where we have been carefully doing our research.

Based on the cases that lead to conflict, we have drafted a list of questions that would be most helpful in preventing these “conflict” cases, had the patient taken the time to have answered them.

Question 1.
If you were incapable of consent to treatment, would you want a feeding tube if you would be dependent on it for the remainder of your life? (what if you were unable to meaningfully interact with those around you?)
Question 2.
If you were incapable of consent to treatment, would you want to be kept on a ventilator if you would be dependent on it for the remainder of your life? (what if you were unable to meaningfully interact with those around you?)
Question 3.
How do you interpret ‘meaningful interaction’? (e.g. expression through eyes/touch only… ability to speak and communicate personal feelings)
Question 4.
If (a) you are unable to communicate and unlikely to ever regain that ability; and (b) your SDM and the physicians disagree about how much harm (pain/suffering) you are experiencing and whether treatments should be continued to sustain your life – how would you like to see them resolve their conflict?