Your Say

The Grey Zone: Complementary and alternative medicine (CAM)

2012-07-16T10:54:00.000-07:00

Sunnybrook ethicist Blair Henry

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Blair Henry talks about Complementary and alternative medicine (CAM).

This past month, our Grey Zone poll asked two questions: Do you use any form of CAM? Would you expect to be able to use your CAM therapy in the hospital?

Though the participant rate was low for our online survey, the result is surprisingly in line with other surveys conducted- namely, the 2007 National Health Interview Survey (NHIS)[1], which included a comprehensive survey of CAM use by Americans, showed that approximately 38 percent of adults use CAM. A similar Canadian study in 2006[2] indicated that 54% of Canadians reported using at least one CAM in the year prior to the survey, and that the most commonly used therapies were: massage, prayer, chiropractic care, relaxation techniques, herbal therapies, and acupuncture.

One of the major issues surrounding the use of CAM’s involves the level of distrust, misinformation and confusion when it comes to individual consumers interacting with many conventional western medical practitioners. Generalizations are rarely helpful, however, for the purposes of this blog, and given the breath of literature on this subject I will indulge with a few noteworthy points related to this topic:

Many different definitions are used to describe what CAM actually is- and it’s in part this heterogeneity which causes confusion between patients and their health care practitioners.

Not all CAM’s are created equal! Many forms of CAM have a long history- did you know acupuncture is thought to have been practiced over 8000 years ago! [3] Whereas the Hippocratic Oath, that signifies the birth of western medicine, was written in the 5th BC.

Many of the CAM’s are not generally considered to be part of conventional medicine (which is also known as “western” or “allopathic” medicine). This we/they split can be a source of conflict when the two modalities are interacting with each other.

Some practitioners from both camps are hoping to find a peaceful “middle ground” or what has been coined integrative care. Integrative care is a comprehensive approach to treating people. It offers the best of both complementary and conventional medicines. At some progressive health centres with integrative care, complementary therapies are offered along with conventional treatments by a team of health professionals from both fields.[4]

Flickr photo by KayVee.INC

At the heart of all definitions of CAM is the fundamental distinction between therapies that are taken in complement with western medicine and those which are pursued as an alternative to the offerings of western medicine. Being clear of your intent and communicating this with your physician is important.

Having a good relationship with your GP entails being open and honest about your health and the values that you have on how you want to manage your health care. However, as intuitive as that sounds, the 2006 Canadian study found that more than half (53%) of respondents had not discussed their use of CAMs with their doctor.

Motivation for using CAM’s can vary. Many users of CAM’s do so for preventative reasons (avoid illnesses) or to promote general wellness. Survey’s have indicated that for many consumers of CAM, the more “whole-person” approach to care practiced within that community was seen as preferable to the “disease-centric” approaches of conventional medicine. Other studies report that conventional medicine, with its focus on acute illness, is failing to address the ongoing needs of people living with chronic illnesses, and that many forms of CAM therapies are successfully providing patients with an ongoing holistic and supportive philosophy of care.[5]

Flickr photo by Pesky Library

Defining exactly what CAM is can be difficult: The field is very broad and constantly changing. However, the core of most definitions defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine as practiced by holders of M.D. (medical doctor) and by allied health professionals, such as physical therapists, psychologists, and registered nurses. Many CAM therapies address healing at the level of body, mind and spirit, and they can do this using therapies that involve energy, touch, the senses (aroma- sound-visual), physical movement, and medicines which may or may not be regulated or scientifically tested. A therapy that might involve physical manipulations (ie. Reflexology, massage, feldonkrais, etc.) or herbal and medicinal remedies (ie. Dietary supplements, teas, topical cream, etc) are often concerning when practiced in a hospital setting. Additionally practices such as colonics, cupping, excessive dosage of specific vitamins all raise a specter of concern by many conventional health care practitioners.

Many hospitals have tried to define a clear boundary between CAM and conventional medicine- and fear of the unknown has resulted in many facilities adopting a restrictive approach- preferring to not “mix” the two modalities- particularly when dealing with acute illness management.

The use and practice of CAM’s in many acute care facilities can be supported if that facility has taken the time to properly review the literature, engage in the local CAM community and developed policies that support open communication and review of potential CAM’s. Organizations that have a strong focus on staff cultural competency- typically have progressive approaches to reviewing request by patient’s to consider the use of CAM’s when a patient is in hospital (remember one person’s view of alternative can be the other’s view of traditional). Natural health products that may be ingested, absorbed or otherwise entered into the blood chemistry of the body should ideally be licensed or approved by Health Canada (they will have a NPN or DIN-HM number). This assures the consumer that the product contents- as listed, is accurate. Otherwise unregulated products may contain unknown and potentially harmful ingredients and can pose a risk to patients when combined with conventional medicines.

Remember: medicine is not an alternative to healing; it’s a complement to it! Diseases usually have multiple causes and should be amenable to multiple therapeutic interventions- it takes prudence and wisdom to decide what interventions can and should be accepted from across the multiple offering from both the allopathic (conventional) and holistic.

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

[1] McFarland, B. Bigelow, B., et al. Complementary and Alternative Medicine Use in Canada and the United States. American Journal of Public Health. October 2002; 92(10): 1616-18.
[2] http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/complementary-alternative-medicine-in-canada-2007.pdf
[3] https://www.acufinder.com/Acupuncture+Information/Detail/The+History+of+Acupuncture
[4] Integrative Cancer Therapies (http://ict.sagepub.com/)
[5] Seeff, LB.,Lindsay, KL, et al. Complementary and alternative medicine in chronic liver disease Hepatology. September 2001; 34(3):595–603

Stop Stigma: Understanding Anxiety Disorders

2012-06-12T11:37:00.001-07:00

The Grey Zone: Is Medical Repatriation Ethically Justifiable?

2012-06-08T08:48:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Sally Bean examines the ethics behind medical repatriation.

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Sunnybrook ethicist Sally Bean

In Canada, medical repatriation occurs when a health care delivery institution sends an uninsured patient back to their country of origin to receive chronic care that they would be unable to access in Canada. Recent high-profile medical repatriation cases in the U.S. involving repatriation without consent have brought heightened awareness to the issue. The prototypical medical repatriation case involves a tourist that suffers an acute onset of illness, e.g. motor vehicle accident, stroke, heart attack, etc. Once stabilized, these types of patients typically require ongoing chronic care such as rehab or home health care.

As you may recall from my prior Grey Zone posts on uninsured patients, health insurance eligibility in Canada is based on a person’s legal residency status. Therefore, persons who do not presently meet residency requirements are ineligible for health insurance. There are generally two broad categories of uninsured patients: out-of-country and resident uninsured. An out-of-country patient includes a tourist on vacation that falls ill while an uninsured resident could be an eligible person awaiting the 90 day Ontario Health Insurance Plan (OHIP) wait period or persons living in Canada without legal status. Usually, repatriated patients are out-of-country patients (e.g. tourists) that intended to return to their country of origin when they entered Canada, but potentially could be a resident uninsured patient that intended to remain in Canada indefinitely.

Based on the Canadian Medical Association’s Code of Ethics (s. 18, 2004) and the Public Hospitals Act (s. 21), legally and ethically, physicians are required to provide emergency care to uninsured persons. However, since there is no legal requirement to provide non-emergency care, treatments for chronic conditions are typically not provided unless the uninsured patient has the ability to pay for medical care. Because uninsured patients are not eligible for non-acute services, acute care facilities are left in a bind; either provide non-acute care in an inappropriate setting (i.e. hospital) or discharge the patient when they cannot access appropriate levels of care. In situations in which the patient requires complex continuing care, a safe discharge may not be able to be achieved if the uninsured patient cannot access chronic care in the community. Particularly in these types of situations, medical repatriation may be sought so that persons can access chronic care in their country of origin.

The travel method for medical repatriation, e.g. plane, train or automobile, will vary based on country of origin destination, the patient’s medical status and the corresponding medical support needed to enable a safe repatriation. A physician in the country of origin is also identified that will assume the care of the patient once they are repatriated. Typically, out-of-country patients wish to return to their country of origin and cooperate with the process.

Uninsured patients that do not wish to be repatriated fall into a grey area; is it justifiable to repatriate them without their consent? Generally, consent should be obtained prior to repatriation in order to respect the autonomy of individuals. However, in situations in which an uninsured patient with complex care needs cannot access the appropriate level of care in Canada, a safe repatriation to their country of origin may be justified without consent if repatriation would be in their general best interests. In considering general best interests, some suggested questions to consider include the following:

Can the patient access the required level of care in Canada?
Does the patient have a support system, e.g. family and friends in Canada that can assume responsibility for their care once discharged?
Is the type of care required available in the country of origin?
Can they reasonably access the appropriate level of care in their country of origin?
Does the patient have support systems in their country of origin, i.e. family and friends?
Why is the patient or proxy decision-maker resisting repatriation?

As you can see below from the Your Say poll results, a majority of participants (66%) felt that medical repatriation can be ethically justified while (33%) felt that it cannot.

Have your say: Under what circumstances you think medical repatriation would be ethically justifiable?

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

The Grey Zone: Access blocked! What do you do now?

2012-04-26T13:40:00.003-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Blair Henry talks about hospital overcrowding.

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Sunnybrook ethicist Blair Henry

Trying to care for sick people in the context of high patient volumes is a problem for all major hospitals – it’s a problem at local, national and international levels; and one that causes many people to lose sleep.

You would think the solution to access block (defined as an inability to provide incoming elective and emergency department patients access to inpatient hospital beds) as being relatively simple: Build more hospitals! And failing that: Don’t admit so many patients! (Or) Discharge the one’s you have quicker! But as you can imagine, the issue is a bit more complicated than it appears. However, both of the later options have been studied by hospital administrators and clinicians alike, and creative solutions have been made resulting in changes to our “traditional model of hospitalized care."

There are many ethical issues related to finding solutions to decreasing hospital admission rates and/or increasing discharge rates. Unfortunately we have a history of compartmentalized health services that doesn’t help the situation – the disjointed spectrum of care from primary care (seeing your own GP in the community), acute and chronic illness management, to long term care and rehabilitation care has created many pressures on the system overall. In some case, people come to hospital simply because they do not have a primary care physician who can act as a first step of triage against a potentially avoidable hospital emergency department visit. At the other end of the spectrum, the high wait times for choice long term care placement, complex continuing care, or rehabilitation services (all known as alternative levels of care) make for longer delays in discharge – and this is expected to be a growing issue as the population ages.

The above realities aside, hospital funding is tied to performance metrics – and there is an expectation that patients presenting at an emergency department (ED) will be assessed, triaged, treated and admitted within a reasonable time frame based on how seriously ill the patient is (level of acuity). If a hospital fails to maintain the expected performance standard, they can expect a direct impact to their funding.

Aside from the previously stated financial incentive to get sick people moved from the ED – we also know that access block can have a series of negative consequences on the overall system and on individuals. Studies have reported the following impacts when access block is in place: increased wait time in the ED, ED overcrowding, negative impact to quality of care, reduced efficiency, and increased adverse event occurrences to name but a few. In the past a hospital feeling overcrowded could simply ask ambulances to be redirected to another centre, but now with system wide overcrowding that strategy isn’t always available.

One option that is used in times when access block reaches a specified level of impact, is the placement of some ED patients into hallways to await an inpatient room. One physician has facetiously coined the practice of caring for patients in hallways as the Science of Corridorology – also known as Hallway Medicine!

The temporary use of hallway placement during times of access block has enabled some patients, awaiting a hospital bed, to be moved out of the ED and into a hallway on a ward to await the next available room. When pressures on the hospital are great, patients can expect to wait in a hallway anywhere from 4 to 24 hours before being placed in a room. In our last post we asked how you’d feel if you were one of these patients. Here’s how you responded:

When hospitals are full! Hospitals are frequently running at over 100% occupancy with many sick people waiting on in emergency departments to get a bed. As a short term measure, some patients are being offered a bed in the hallway. Would you be okay with that?

Though statistically not a valid representation of any specific stakeholder group’s opinion – the survey results do indicate an interesting split in opinion about this practice. A small majority of respondents feel its an okay solution to a challenging problem and they feel thankful for admission to the hospital – even if it’s only to a gurney in a hallway. 40% indicated they would rather not be admitted under these conditions – stating they’d rather stay in the ED until a room was available and a smaller sub-section wanted to see a system wide approach to managing the access block – transferring the burden to “elective patients.”

Polls of this type can reflect a “comfortable observer” bias – since we don’t know what motivates people to answer the way they do- Have the respondents experienced hallway care? Have they experienced a cancellation of a long anticipated elective surgery at the last minute (for the second time in 6 months)?

Some researchers are currently looking at the impact of hallway patient care from a staff, patient and family perspectives – unofficial results show some predictable and surprising results. As expected, staff morale and moral distress are affected by creating surge capacity using hallway patients – with concerns over patient privacy, impact on patient dignity, worry over delays to treatments, and feeling the stress from increasing an already heavy workload to nurses and physicians. What has been surprising is how accepting most patients and families are to being placed in hallways, and how good (in most cases) the care can be.

Ethics was consulted in our hospital to help create a plan to deal with the moral distress caused by this evolving “new normal” of care – and regular staff debriefing sessions were attended to help give voice to concerns raised by staff. Initially hallway patients created conflict between ED and Ward staff – with either side seeing fault in the other when access block conditions forced surges in hallway patients to occur. ED staff were saying: Now you know what it’s like for us! And, ward staff would capitulate with: This isn’t our problem – don’t transfer this to us! However, collaboration and inter-departmental communications helped to correct misconceptions and wrong data and brought staff to a common understanding of the issues at play. Some wards felt their units were unfairly burdened with hallway patients – and a system to monitor and equalize the burden helped to create a fair process for allocation of hallway beds across the hospital. Concrete guidelines were developed to minimize risk to patients and concerns of the staff by establishing “medical criteria” for what types of patients might be acceptable for hallway care and those who should not be moved from the ED.

Access block can challenge the core mantra of how we try and define good health care: “right patient, right bed, right treatment.” Not surprisingly, going forward defining “right” will be as much a moral enterprise as a medical one!

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

***

References

Bullard, M.J., Villa-Roel, C., Bond, K., Vester, M., Holroyd, B.R., Rowe. B.H. Tracking Emergency Department Overcrowding in a Tertiary Care Academic Institution. Healthcare Quarterly, 12(3) 2009: 99-106

Cameron, P.A. Campbell, D.A. Access Block: Problems and Progress. Medical Journal of Australia 2003; 178(3): 99-100.

Freeman, J. The emerging subspecialty of Hallway Medicine. CJEM 2003;5(4):283-285. <http://www.cjem-online.ca/v5/n4/p283>

The Grey Zone: Resource allocation during a drug shortage

2012-04-04T11:56:00.001-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Sally Bean examines resource allocation during a drug shortage.

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Sunnybrook ethicist Sally Bean

Drug shortages occur due to various factors such as manufacturer’s decision to reduce production, unavailability of material ingredients required to manufacture a particular drug or class of drugs, or unexpected increase in demand. The anticipated Canada-wide shortage of injectable drugs supplied by Sandoz is reportedly due to reduced manufacturing while Sandoz’s Boucherville, Quebec plant is retrofitted to comply with North American regulatory standards. The duration of this retrofitting process is expected to last between 12-18 months. A recent fire in the Quebec-based plant has also exacerbated the already volatile situation.

In light of the Canada-wide drug shortage, there are limited drug options for both patients & providers that could negatively impact safe and effective healthcare delivery. From an ethics perspective, key questions include the following: how to safely & fairly allocate scarce resources to the target patient population, if/when decision-making limits on access to drugs are required, what will constitute a fair process and who should coordinate the response, i.e. federal, provincial, regional, municipal, or individual institutions?

There have been several studies demonstrating that the pubic endorses ethical informed priority setting.^1-2 While under ideal circumstances, priority-setting would be made well in advance of a crisis situation; advance priority-setting is not feasible in the current drug shortage. Nonetheless, a fair priority setting process can still occur with an emphasis on incorporating key principles through expeditious action and constant revision as additional information is obtained. I had the opportunity to participate in a working group of bioethicists that developed an Ethical Framework for Resource Allocation during the Drug Supply Shortage for Ontario’s Ministry of Health. The Ethical Framework outlines substantive and procedural values for allocating injectable drugs during the supply shortage. The Ethical Framework has been endorsed by the Ministry and disseminated to serve as a guideline for health care institutions facing resource allocation decisions during the drug shortage.

Here are the six overarching ethical principles outlined in the Ethical Framework for Resource Allocation during the Drug Supply Shortage:³

Principle	Definition
Beneficence	Maintain highest quality of safe and effective care within resource constraints: Ensure standard of care and best practices whenever possible Minimize pain and suffering Where evidence suggests similar clinical efficacy, use alternative drugs or treatments Inform and educate health providers about risks, benefits, and appropriate use of alternative treatments, including risk mitigation strategies Enable individuals to receive care in the most appropriate setting.
Solidarity	Build, preserve and strengthen inter-professional, inter-institutional, inter-sectoral, and where appropriate, inter-provincial/territorial collaborations and partnerships: Embrace a shared commitment to the well-being of patients regardless of care setting or geographic location. Establish, encourage, and enable open lines of communication and coordination amongst health professionals, health institutions, and health sectors. Encourage resource sharing across health sectors, health institutions, and, where appropriate, provinces/territories Support each other’s allocation decisions that are consistent with ethical framework.
Utility	Maximize the greatest possible good for the greatest possible number of individuals: Distribute drugs in short supply to those most in need and likely to benefit Share drugs within and across institutions/sectors.
Equity	Promote just/fair access to resources: Ensure burdens are not disproportionately borne by any patient, patient group, health sector, or institution Use allocation processes that do not arbitrarily disadvantage any particular patient, patient group, health sector, or institution Do not discriminate based on factors irrelevant to clinical situation (e.g., social status).
Stewardship	Use available resources carefully and responsibly: Ensure drug utilization is consistent with available evidence Postpone elective procedures/treatments that require use of drugs in limited supply Prioritize access based on urgency and severity of need Monitor drug utilization and distribution to facilitate mid-course corrections as needed.
Trust	Foster and maintain public, patient, and health care provider confidence in health system: Communicate in a clear and timely fashion Make decisions in an open, inclusive and transparent way with clearly defined decision-making authority and accountability Evaluate health system response to capture short and long-term lessons learned.

As you can see below from the Your Say poll results, in the event of a drug shortage, a majority of participants (71%) felt that persons with life-threatening medical needs should be given priority access while (28%) felt that patients experiencing severe pain and suffering should be prioritized.

Have your say. Share your suggestions or questions about resource allocation or the proposed Ethical Framework for Resource Allocation during the Drug Supply Shortage.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

We encourage you to share openly in this forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact our Office of the Patient Experience.

References

1. CanPREP. CanPREP policy Briefs. Accessible at:: http://www.canprep.ca/CanPREP_Policy_Briefs_FINAL.pdf
2. Secko DM, Preto N, Niemeyer S, Burgess MM: Informed consent in biobank research: a deliberative approach to the debate. Soc Sci Med 2009, 68(4):781–789.

3. Bean S. Chidwick P. Gibson J. et al. Ethical Framework for Resource Allocation during the Drug Supply Shortage (March 20, 2012) Accessible at: http://www.opatoday.com/files/public/documents/PublicResources/DrugShortages/Ethical%20Framework%202012-03-20%20(shared).pdf

Guess the mystery photo: March 16

2012-03-16T12:34:00.003-07:00

The Grey Zone: Research in emergency medicine

2012-03-16T07:46:00.001-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Blair Henry takes on the tough issue of consent in emergency research situations.

Emergency medicine encompasses a large part of acute care, and has been defined as “the specialty concerned with the stabilization, management, diagnosis, and disposition of individuals with acute illness and injury. It also includes the management of trauma resuscitation, advanced cardiac life support, advanced airway management, poisonings, pre-hospital care and disaster preparedness”.¹

Research in emergency medicine plays a vital role in improving the delivery of health care. Did you know that researchers in Canada were instrumental in establishing criteria to guide decisional rules for x-rays of the ankle, knee, and neck following injuries? In nearly every case, these rules have been shown to reduce the use of radiographs, reduce total costs to the health care system, and improve patient satisfaction. Similarly, researchers in Canada and elsewhere have shown that the care provided for a common problem such as asthma is not consistent within or between hospital emergency departments. As a result, emergency airway researchers in the past 10 years have successfully created, synthesized and disseminated this evidence so that care can be standardized, saving many lives in the process.²

Some emergency research will involve “capable individuals” – people who, despite their emergent condition, are able to provide their own consent to be studied when they show up for emergency care. However, not all emergency research will involve capable individuals, and that’s where the ethics becomes interesting.

Here’s what you said:

In a previous blog we discussed some of the key factors that can help ensure human subject research is ethical. Namely, this involves asking the following questions:

Does the study have societal value? Will it enhance the health of people?
Is the study scientifically valid? Will it provide the medical community with good data to base future decisions on?
Does the study allow for fair subject selection? Is it fair? Are we burdening one group over the other?
Are the risks favorable? Studies need to ensure risks are minimized and the potential for benefit exists which would ultimately outweigh the risks and are proportionate to the gains hoped for.
Has the research undergoes an independent review? In Canada all human subject research should be reviewed by a Research Ethics Board (REB) before a study can begin. The board is responsible for providing an unbiased and objective review of all aspects of a proposed study to ensure it meets the ethical standards of a good clinical trial. [Some REB members jokingly use the criteria of: “would l enroll my Mother into this study” as the ultimate litmus test of a well designed study]
Does the study entail the use of informed consent? This criteria helps to promote the interests and values of a person by allowing voluntary and informed decision making to occur where subject enrollment is considered. However, for research involving small children or adults lacking the capacity- the research needs to incorporate appropriate steps to continue their “interest and values” in the process.
Does the study involve measures that uphold respect for persons? Will a person’s privacy be protected? Is a person able to withdraw from a study without penalty? Will subjects be properly monitored during the study? Answers to all of these questions help determine the ethics of conducting a research project on human subject.

Imagine this scenario: Researchers have identified a component of the CPR process that could enhance overall survival and want to test out this theory. Initially they conduct mathematical/scientific models, which shows promise. They’ve also tested it on “resusci Anne.” They believe a test on humans is now needed to verify its actual performance. Going through the above 7 ethical considerations, it’s easy to see that item 6 (consent) will be problematic. In emergency situations, it’s not unusual to have no family or substitute decision makers present. Even if they were present, the need to act immediately will prevent the paramedics from taking the time to provide people with full informed consent. In fact, some researchers argue that trying to bring this topic up on site may cause harm, given the already tense and anxious environment present.

In these situations a process of “deferring immediate consent” is sometimes approved by REBs (research ethics boards) to enable research to be done. There are several methods used to provide some measure of protection and safety to this untenable situation:

In the U.S., regulators request that any proposed emergency research should undergo a process of what is called stakeholder engagement. This might mean that before a research protocol is reviewed the researchers must undertake a means to “communicate” the proposed research intent and methods, and its consent concerns to various communities who might have a stake in this work… If it was a project involving automobile or traumatic injuries, then patient/survivor advocacy groups should be informed and given a chance to provide their input. As you can imagine, this is a costly and time-consuming process. How can we ever be sure that the appropriate stakeholders have been given a chance to voice their concerns?
An additional safeguard is to have someone other than the person doing the procedure to review the patient to ensure they do in fact meet the “inclusion criteria” of the study. This third party would also ensure that inappropriate patients are not unnecessarily enlisted into a study due to a bias by the investigator to get enrollment targets met. This is hard to do in the field, but is commonly used in the emergency department, where an independent physician can authorize a patient to be enrolled.
REBs will often insist that – though consent was deferred because of the circumstances of the study – that every effort needs to be made at the earliest possible moment to find and inform the substitute decision maker. They should be made aware of what happened and if that person does not consent, the patient’s further involvement in the study is stopped immediately.
REBs will also insist that the patient is monitored continually. Once they regain capacity, they need to be told what happened and also be given the opportunity to rescind consent.
The REB may also want to be informed by investigators of any complaints received by the patients or the substitute decision makers. This would be used as a gauge to determine if the balance of benefit to risks was incorrectly calculated by the board.

These are part of the challenges researchers face in trying to advance the field of “evidence” based medicine, but we need to also remember that much of the progress we enjoy today comes on the backs of those who came before us. The great emergency treatment you may get tomorrow will be dependent on the great research conducted today!

Sunnybrook will be involved in an exciting research study to try and understand what practices are in play across the country when it comes to reviewing this type of research. The hope is to standardize the process so that fair and transparent research ethics principles are applied across the board.

Have your say: Should emergency patients be allowed to be enrolled in studies without their consent? Should substitute decision makers be able to consent for them? Do you agree with the ethics guidelines to be followed when enrolling emergency patients?

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact our Office of the Patient Experience.

References
1. Yale University website( accessed March 11, 2012.) http://medicine.yale.edu/emergencymed/whatis.aspx
2. Canadian Association of Emergency Physicians (Accessed March 12, 2012) http://caep.ca/advocacy/romanow-commission/research-emergency-medicine
3. https://roc.uwctc.org/tiki/tiki-index.php
4. E. Emanuel, D Wendler, C Grady. What makes clinical research ethical? Journal of the American Medical Association, 2000: 283(20); 2701-2711.

The Grey Zone: E-mailing to discuss health-related questions?

2012-03-01T12:09:00.001-08:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In this post, Sally Bean discusses the pros and cons of moving physician-patient communication from the doctor's office to email.

Previously, Grey Zone readers unanimously voted that they would like to be able to communicate with their physician whenever they have a health-related question. However, research has indicated that physicians are less amenable to the idea of e-mailing with patients as an alternative to face-to-face communication. Who’s right?

Some of our savvy Grey Zone readers commented on some of the potential reasons a gap may exist between physician and patient acceptance of e-mail communication: physician workload management, work-life imbalance leading to physician burnout, physicians unable to respond immediately to patient’s questions, privacy and confidentially concerns and legal liability, etc.

In the present day internet-based communication environment, virtually everyone—businesses and individuals alike—have an e-mail address. Most e-mail addresses can frequently be located on-line through a basic Google search. Is it reasonable for patients to assume that because a physician’s e-mail is accessible, it is okay to e-mail a potential or existing physician about health-related questions? Is there an ethical obligation for physicians to respond to unsolicited e-mails? These are all important questions worth considering.

While e-mails are available on-line for arguably a wide range of purposes such as contact by colleagues, does the fact that a physician’s e-mail is available indicate that e-mailing with patients is a viable option? Given medicine’s long history of predominantly face-to-face medical care, it would be unusual to communicate with a physician about health related questions unless an agreement to that effect has been previously established. While this may change in the near future, for the time being, it is more appropriate to call your physician’s office to make a face-to-face appointment.

But let’s say you are a maverick that likes to push the envelope… Should a physician respond to your e-mails posing health-related questions? According to Gunther Eysenbach, a response should always be given but the content of the reply arguably differs based on whether there is a pre-existing patient-physician relationship or not. Eysenbach’s six principles for giving tele-advice on the Internet when there is no pre-existing physician-patient relationship:

Physicians responding to patients' requests on the Internet should act within the limitations of telecommunication services and be mindful of potential limitations to confidentiality.
Not every aspect of medicine requires face-to-face communication or physical examination, thus tele-advice may be appropriate in some cases.
Unsolicited patient e-mail questions, should not be ignored, but responded to with a clear message.
Informed consent requires should include disclaimers and disclosures (as required).
Health professionals and information custodians must maintain patient confidentiality.
Health professionals should define internal procedures and perform quality control measures.

Eysenbach’s six principles generally parallel the recommendations made by the Canadian Medical Protective Association to physicians regarding legal risks associated with e-mailing patients. Namely: 1) confidentiality, privacy and security issues 2) promptness of physician reply and 3) clarity of overall communication.¹

In light of these principles and recommendations, physicians may want to consider crafting a standard template response to use to respond to patient questions. The script should likely be different for existing patients versus patients with no pre-existing relationship. The script should ideally redirect existing patients to the preferred mode of contact. It should inform patients with no pre-existing relationship if they are currently accepting patients or need to refer to another resource to identify another physician. In the latter case, the College of Physician and Surgeons of Ontario’s website may be used to locate a family physician.

As you can see below from the results from two previous Your Say polls, a majority of participants felt that receiving test results over e-mail without the physician present to explain them may cause worry about what the results might mean. This may be an indicator that conveying information such as a test result would best be accomplished in person.

When asked if patients would support a decrease in clinic hours to off-set the additional time required for physicians to e-mail patients, half of the voters said they would not support a decrease. Just under a third indicated they would support a reduction. Not surprisingly, many of us seem to want our cake and eat it too!

Have your say: Share your suggestions or questions about e-mailing with your physician. Would you prefer to e-mail your doctor, or meet face-to-face?

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

Eysenback G. Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre-existing patient-physician relationship — systematic review and expert survey. J Med Internet Res. 2000 Jan-Mar; 2(1): e1. Accessible at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761847/?report=printable

The Grey Zone: How far would you go to enhance your abilities?

2012-01-26T07:42:00.000-08:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In previous posts, Ethicists Sally Bean and Blair Henry addressed advanced directives and assisted suicide. In this post, Blair Henry discusses the key concepts underpinning the debate around human enhancement through technology. How much would you allow technology to help you become smarter or stronger, or live longer?

We live in a world that constantly seeks to improve or make things better – and medicine is no different in that regard. Medicine and health care embrace ideals such as wellness, curing, and making better. The questions we need to ask ourselves are: At what cost do we want to pursue this goal? What and who defines any limitations to making it “better”–should we try to see if we could increase our lifespan to 150 years? What means might justify the ends of achieving the goals we set out to accomplish? All the stuff of ethics!

Taking a step back, a lot of the attention given to the field of human enhancements has been driven in part by advances in biomedical technology. The more we develop and create, the more we begin to see that what was once an unmoveable, basic fact of our human condition may now (or in the very near future, as long as we spend our money on research) be subject to change!

In this week’s blog we asked readers to consider the following question: If given the chance to undertake a special operation that would install a chip in your brain with the promise to make you the smartest person in the world, would you?

Ultimately this one question asks us to consider several embedded questions: What do you value? How much do you value it? And, what would you be willing to do to achieve it?

Imagine if I changed the question and asked: If you could take a pill to make you the smartest person in the world, would you do it? Or if I changed the outcome and made the claim the intervention could increase your mental smarts by 30%, would that have changed people’s responses?

None of those who responded to this survey left comments, but I wonder what motivated them to respond the way they did. In asking a close friend of mine this questioned, she was quick to say: “No, I wouldn’t take the surgery. Can you imagine how alone and isolated you’d feel?” Perhaps the cult of individualism has its detractors. Seeking a place of community and belonging are still strong human drives, and being “different”–even if it means better–isn’t always what we aspire to.

Courtesy of startrek.com

When technology lagged farther behind our imaginations, the ideal of human enhancement came to life in the world of science fiction. Many will recall when Captain Picard became assimilated into the fictional pseudo-race of cybernetic organisms know as the Borg! This gave him incredible sensory, mental (questionable to Star Trek fans) and physical enhancements considered super human and therefore suspect.

However, in the world of evolving enhancements, the picture below outlines a form of scientific/human enhancement enabling this surgeon to do incredibly precise work previously unheard of as a human capacity. In this case, the researcher is dissecting the neuronal circuitry on the retina of rabbits, which in addition to being therapeutically curative will also be minimally invasive, and will offer safer and more effective surgical options to patients in the future.


Researcher tweaks the brains of rabbits with advanced technology

Our appetite and acceptance of human enhancement continues to grow and in more mainstream areas of our lives. The photo below shows double amputee sprinter Oscar Pistorius running with bladelike prosthesis (brand name is Cheetahs!). Oscar became a double lower leg amputee when he was 1 year old, and his ultimate dream was to run in the 400 meter event at the Beijing Olympics against other able-bodied athletes. However, the International Association of Athletics Federation ruled that he incurred unfair advantage from his prosthesis, and could not compete. At some level the implications of this decision are staggering. Our old world paradigm that saw disability as disadvantage was now being challenged and perhaps in some situations it could be seen as reversing: disability becoming ability and disadvantage becoming advantage!

Learn more about Pistorius here

The field of human enhancement is a complex and fascinating one. Applied ethics look at world of human enhancements from 5 particular areas: lifespan extension, physical enhancement, mood and personality enhancement, cognitive enhancement, and pre- and perinatal enhancements. Each area provides its own unique challenges and ethical dilemmas.

Have your say: Are you encouraged by the thought of scientific progress that might enable us to go beyond our mere mortal capacities? If so then maybe you’re a transhumanist or post-humanist in your thinking! Does this technological leap sound suspicious and cause you to experience more dread than Interested? Then, perhaps you have a bioconservative leaning!

Whatever your preference might be I hope you agree that this is an extremely interesting and complex topic. For those interested in learning more, I’ve listed interesting web-based sources below. Enjoy!

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

Patient and Family Experience Survey

2012-01-24T07:40:00.000-08:00

Sunnybrook is committed to ensuring that patients and their family members have the best possible health care experience. To help us improve the patient and family experience at Sunnybrook, we would like to ask you a few questions. Fill out our online survey — it will take about 5 minutes to complete. We will use this information to make changes to improve our care and service.

This survey is voluntary and will not affect the care you are currently receiving by members of the health care team. You do not have to put your name on the survey.

Start the Patient and Family Experience Survey

The Grey Zone: Ethical questions Canadians should consider in 2012

2012-01-05T11:26:00.000-08:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean discussed a new frontier of doctor-patient communication and took on the euthenasia debate from an Ethicist's perspective. In this post, Sally Bean meditates on two controversial topics likely to dominate Canadian ethical debates this year.

In his December 31, 2011 Toronto Star ethics column, Ken Gallinger wrote about the top 10 ethical questions Canadians should answer in 2012.

In the spirit of the New Year, I will postpone my next blog on the physician perspective of e-mailing with patients to raise some key ethical questions I think Canadians should consider rather than answer in 2012.

This is the Grey Zone, after all.

The subject you may be avoiding

Two very important judicial rulings on end-of-life care will be issued in 2012, with far-reaching implications. The ongoing right to assisted suicide case is currently before the British Columbia Supreme Court and the Rasouli case, examining whether consent is required to withdraw life support that is deemed to provide no medical benefit, will be heard by the Supreme Court of Canada sometime this year.

Regardless of how the courts decide both cases,the New Year is a good time to consider your wishes around end-of-life care and share those wishes with your family and friends. Communication of your end-of-life wishes is an essential, but often overlooked, step that is necessary to insure that your values are upheld to the extent possible. End-of-life planning is not exactly an uplifting topic to consider and discuss, so many of us procrastinate or avoid the topic all together.

Some individuals who don’t take the initiative to do advanced care planning may use vague language in their written advanced directives. Phrases like “I do not want any heroic measures” provide little guidance to substitute decision-makers as to what would constitute a heroic measure in a given circumstance. Oral advanced directives are equally binding under the law, so the important part is to reflect on your values and communicate them to loved ones and re-visit them throughout your life as your wishes may change over time.

A few questions to ask yourself this year:

Who would I want to make my healthcare decisions if I am unable to make them myself?
Does my substitute decision-maker(s) know how I would like them to act on my behalf in different circumstances?
Under what type of circumstances (e.g. if the treatments would be required temporarily, for an indefinite period of time or permanently) would I want to have life-sustaining treatments such as a breathing machine, feeding tube or dialysis?
Would I want to receive cardiopulmonary resuscitation (CPR) if I would survive but remain permanently unconscious?
What is my realistic idea of a “good death?”

Once you consider the answer, be sure to share your thoughts with your substitute decision maker, both verbally and in writing. For additional information, consult Ontario’s free Guide to Advance Care Planning.

Have your say: Have you put advanced directives in place? If so, what pushed you to take the initiative? If not, what's holding you back? Share your thoughts in the comments section.

The subjects you've read about

Another big topic in 2012 will be balancing the ongoing tension between religious freedom and expression. How will we attain balance within Canadian values codified in existing legislation such as the Charter and Criminal Code, or activities that are historical Canadian traditions or customs? In particular, what are reasonable limitations on religious expression, particularly in a country in which diversity is valued and embraced?

The 2011 British Columbia Supreme Court ruling that upheld Canada’s ban on polygamy is a recent example of judicial considerations of limits on religious expression. Canadian Immigration also issued a recent ban on Muslim women wearing face coverings such as burkas or niqabs (two types of veils that cover the face) while taking the oath during the citizenship ceremony. Notably, in December 2011, the Supreme Court of Canada heard the case of a Muslim sexual assault victim that wished to testify against the defendants while wearing her niqab. A Supreme Court of Canada ruling is expected sometime over the next few months.

2012 will prove to be a year packed with lots of interesting ethical issues, so keep reading and feel free to suggest potential future topics in the comments section.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact our Office of the Patient Experience.

Our next post: Blair Henry returns with a new perspective on a hot health care topic. Stay tuned!

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

The Grey Zone: Should physician-assisted suicide be legal in Canada?

2011-12-21T06:45:00.000-08:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and discussed advanced directives from an Ethicist's perspective. Today, Blair Henry gives you a detailed overview of physician-assisted suicide and the history of the debate in Canada. With a landmark Supreme Court ruling due in late December of this year or early January 2012, conversation around the topic is heating up.

Before beginning this post, I quickly scanned the literature and various blogs on the topic of assisted dying. To illustrate the breadth of opinion on the topic, I decided to cherry-pick some of the more popular idiomatic expressions that one encounters when trying to understand the motivation behind those advocating for or against the legalization of assisted dying in Canada.

As a reader of this article, I wonder which of these statements most resonate with your lens on this issue?

Click to expand the graphic below to find your match.

While euthanasia is currently a hot topic, and seems quite contemporary, the debate around assisted dying goes back a long time. In fact, it’s been in existence as far back as early antiquity! Excerpts from credible sources note that during the period between the 5^th Century BC to around the 1^st century BC the ancient Greeks and Romans supported euthanasia:

"The ancients stressed the voluntary nature of the dying, provided that it was done for the right reasons; for example, to end the suffering of a terminal illness. Indeed, in classical Athens, the city magistrates kept a supply of poison for anyone who wished to die."

When we asked our readers for their opinion on the issue in a poll, we received the following results:

Though the sample size was small, the results are not unlike those that have been consistently reported when Canadians have been polled. In 1994, 65% of Canadians favored the legalization of physician-assisted suicide. In 2009, that figure was 71%. In a 2010 Angus Reid poll, 67% of Canadians polled were in favor of legalizing voluntary euthanasia. Despite what would appear to be strong public opinion on the matter, this sentiment has not (as of yet) resulted in a change in law: currently in Canada assisted suicide illegal. The Canadian Federal Criminal Code no longer prohibits a person from attempting or committing suicide, however, it still upholds a prohibition on third parties from assisting a person to commit suicide (with knowledge or means). It was this section of the law that was challenged by Sue Rodriguez in 1993.

Sue Rodriguez’s legal battle was based on a Charter of Rights and Freedoms argument, which stated that a prohibition on assistance in dying was discriminatory to those with a physical disability. Sue argued that it in effect deprived her of liberty and security of the person guaranteed under Sections 7, 12, and 15 of our Charter. If a non-disabled person could take their own life without legal penalty, the argument went, then assistance should be extended to those who cannot undertake this due to their own disability, unless we were a country who supported discriminatory practices against those with a disability]. However, in September 1993 the Supreme Court of Canada rendered its landmark decision in a close 5 to 4 split, denying her request.

Understanding terminology is important in understanding the issues at stake. A local Toronto philosopher and professor emeritus at the University of Toronto put forth the following definitions in his recent book on assisted death:

“[Physician] Assisted suicide is the self-administration by a patient of a lethal medication where: a) the patient intends the medication to cause his death as a means of relieving his suffering; b) the patient’s death is actually cause by the medication, and c) the medication is provided by a physician for the purpose of facilitating the patient’s suicide.”

“Euthanasia is the administration of a lethal medication to the patient by a physician where: a) the physician intends the medication to cause the patient’s death as a means of alleviating suffering and b) the patient’s death is actually caused by the medication.”

The underlying subtext here is the voluntary versus involuntary distinction, which was brought home in the Tracey Latimer case in 1993. Tracey’s father (Robert) killed his disabled 12-year-old daughter by placing her in the family truck and then piping exhaust fumes into it. Tracy had a severe form of cerebral palsy, and could not walk, talk or feed herself. She had suffered considerable pain; Mr. Latimer told the police that “his priority was to put her out of her pain.” This was portrayed as a “mercy killing”, however, Latimer was convicted of second-degree murder by a jury, and sentenced to life imprisonment with no possibility of parole for 10 years (he was granted full parole in Dec 2010).

Of recent interest is the Right to Die case being brought forward in British Columbia . The case is currently before the Supreme Court with a ruling expected in either late December or early January 2012.

“One of my greatest fears is to have to rely on others for all my needs. I do not want to live in a bedridden state, stripped of my dignity and independence. I have decided I want to die when I no longer have quality of life”

- Gloria Taylor, Co-Plaintiff in the fight for the Right to Die

Gloria is in the advanced stages of ALS, and her case is not unlike the one presented by Sue almost 20 years ago. The BC Civil Liberties Association is representing Ms. Taylor, hoping that the changes in International laws and growing public opinion will weigh in favorably as the SCC reconsiders the arguments presented.

We’d like to continue to hear your thoughts on this important topic! Have your say: should physician-assisted suicide should be made legal in Canada? If not, why not? If so, how should it be regulated? Share your thoughts in the comment section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact our Office of the Patient Experience.

-Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

[i] Michael Manning, MD Euthanasia and Physician-Assisted Suicide: Killing or Caring?, 1998
[ii] Wayne Sumner, Assisted Death: A Study in Ethics and Law. Oxford University Press, 2011.
[iii] http://www.cbc.ca/thecurrent/episode/2011/08/31/the-right-to-die-gloria-taylor/

The Grey Zone: Should patients communicate with their doctors through email?

2011-11-24T05:47:00.000-08:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and illustrated the importance of advanced directives from an Ethicist's perspective. Today, Sally Bean continues her series on telemedicine by discussing changes to doctor-patient communication already underway.

Imagine that you are recovering from a sinus infection and were seen by your family doctor, who prescribed a course of antibiotics. After taking a week of antibiotics, your symptoms do not seem to be improving. Instead of going back to your doctor’s office, you simply e-mail your physician and describe your status to see if he or she thinks you need to be re-evaluated. Your doctor promptly responds to your e-mail later that day.

Should face-to-face therapeutic encounters with your family doctor be supplemented with e-mail or other communication modalities such as Skype? In an influential consensus report on health systems for the 21^st Century released in 2001, the Institute of Medicine, suggested that the therapeutic framework shift to include traditional face-to-face visits supplemented by e-mail and other telecommunication modalities.

This is the second installment of Grey Zone posts dedicated to exploring issues on the changing communication dynamics in medicine. This particular topic, e-mailing your doctor, was suggested by a Grey Zone reader who has experienced mixed responses from physicians regarding which e-mailing practices are currently permissible between patients and physicians. Research supports that our reader’s experience is not an isolated event. There is a demonstrated gap between patients’ desires to communicate with their physician via e-mail and physician’s willingness to use e-mail as a communication method.¹ The reasons for physician reluctance appear to be complex.

As a result of limited time with their physician, many patients prioritize their most pressing health issues to discuss and save other concerns for another appointment. One study examining patient’s experience in communicating with their physician through e-mail, found that due to easy access to a physician through e-mail communication, the threshold for contacting the physician was lowered as patients felt that there was ample opportunity to address concerns as they arose.²

The Canadian Medical Protective Association (CMPA), which provides legal defense to Canadian physicians, notes that there are three legal risks associated with e-mailing patients:

Confidentiality, privacy and security issues
Promptness of physician reply
Clarity of overall communication

Naturally, there are inherent risks of communicating personal health information over the internet and since the physician is not there is contextualize any information, cannot insure that the information or message intended was the one received and understood by the patient. Due to these associated risks in communicating via e-mail, it is generally recommended that express consent be obtained from the patient to insure that they understand and accept these risks prior to initiating health-related e-mail communications. Additionally, establishment of parameters around what information is appropriate to communicate to the physician via e-mail and an expected response time frame would help keep e-mail communications focused and appropriate.

As you can see below from the results of the Your Say poll, there was 100% agreement (a first in our Your Say polls) that patients would like to be able to communicate with their family physicians when they have a health related question. While a selection bias of participants that participated in an on-line poll in favor of e-mailing physicians would be expected, the resulting unanimous response is striking. Maybe we should rename this blog series the Black and White Zone, or something.

Have your say: Do you currently communicate with your family physician via e-mail? Has your experience to date been positive? Would potential confidentiality breaches deter you from e-mailing your physician? What measures would you expect your physician to take to insure secure and timely e-mail communications?

As always, please leave comments or suggestions for future blog topics.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: Blair Henry returns with a new perspective on the assisted suicide debate heating up in Canada. Do you believe it should be legal? What is the basis of your choice? What limits would you like to see imposed if it did become law? Comment and vote in the sidebar poll to share your thoughts.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

1. Andreassen H.K. Trondsen M. Kummervold P.E. et al. Patients Who Use E-mediated Communication with Their Doctor: New Constructions of Trust in the Patient-Doctor Relationship. Qualitative Health Research. 2006; 16(2): 238-248.

2. Id (Same as above).

The Grey Zone: Advaned care planning, where belief rarely matches reality

2011-11-01T08:04:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and discussed the future of telemedicine from an Ethicist's perspective. Today, Blair Henry examines advanced directives. Why don't more Canadians have them in place?

The statistics may be somewhat dated (2004), but here’s what we do know about Canadians appetite and practice around using advanced care plans^[i]:

80% of Canadians agreed that people should start planning for end of life when they are healthy.
Yet only 9% reported to have had an end-of life care discussion with their physician.
Fewer than 44% have discussed end-of-life care with family.
70% had not prepared a living will or Advance Directive.
47% have not designated a substitute decision maker to make healthcare decisions for them if they are unable.

For those of you thinking these statistics may be an anomaly, think again! In fact, the literature supports these findings. A recent review of the literature found that while 60 to 90% of the general public (people in the US, Canada, and Australia) is supportive of advance care planning, only 10 to 20% of the have completed an advance care plan document of any kind.^{[ii], [iii], [iv], [v], [vi]} In an attempt to encourage Canadians to consider advance care planning, Sunnybrook has launched a video campaign:

When I asked readers to respond to our online poll, here’s how you answered to the following: How prepared are you for future events dealing with your medical and financial affairs in the event of your illness and death?

Though not a strong level of response, the survey does show that our readers are “in line” with what has been observed in other studies. Only 15% of respondents actually completed some form of advanced directive! So why is it that an idea–which everyone conceptually agrees is a good one–does not see any form of real uptake in practice?

Researchers have tried to better understand this phenomena, the most notable dating back to the SUPPORT study in 1995^[vii], which concluded: advanced directives are oftentimes not completed properly, they are often not derived with consideration of the actual clinical scenario being experienced, rarely do they get added to medical records or they are lost along the way, and even more infrequently do they appear to actually influence medical care! Some counter the findings of the SUPPORT study by suggesting we should put aside the use of advanced care documents. In this view, most patients want their substitute decision maker (SDM) to use their own judgment rather than being bound by specific “living wills." They believe patients have faith that SDMs will know how to act in their best interest. Despite this optimism, research to date on surrogate performance hasn’t proven to be all that promising^[viii]. The research suggests:

Patient’s rarely discuss their treatment preferences with their surrogates
Surrogates routinely underestimate the patient’s preference for less aggressive treatments (perhaps due to guilt and concern from other family members)
The surrogate personal values influence their predictions of others preferences
Surrogate anxiety, grief, depression alter decision making accuracy

Fortunately, the challenges identified above have not deterred further work on this important topic and over the past 3 years a Canadian multi-professional Task Force has been working on this project. The Task Force took up the call issued by the Canadian Senate in their 2000 report updating Quality End-of-Life Care: The Right of Every Canadian, which identified that there were many problems with preparing advance directives in Canada. Mainly, that the difficulties were primarily with the singular focus on advance directives. The report suggested moving towards the process of conversation or advance care planning, and argued that advance directions should be seen as part of an overall planning and communication process that helps people prepare for death in the context of being supported by, or making decisions with, their loved ones. The report stated,

“The preparation of an advance directive can facilitate discussions between people and their family, and provide guidance and support for substitute decision makers who must make the difficult decisions regarding life-sustaining treatment. If loved ones and medical professionals have engaged in a process of serious communication, the problems associated with the interpretation and application of advance directives are much less likely to occur. The passage to death is eased, the level of comfort rises, and the burden of care is lightened for the substitute decisions-maker.”^[ix]

This understanding of the role of advanced directives falls more in line with the principles of shared decision making that needs to be at the centre of all patient, family, health care team encounter.

Share your thoughts: Why do you think so few Canadians have considered advanced directives? If you have any questions or comments about advanced care planning, leave us a message and we will try to respond with information and resources.

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

[i] Ipsos, Reid. Hospice Palliative Care Study. Study commissioned by GlaxoSmithKline and the Canadian Hospice Palliative Care Association. 2004.
[ii] Royal College of Physicians. Advance Care Planning: National Guidelines. February 2009. http://www.rcplondon.ac.uk/pubs/contents/9c95f6ea-c57e-4db8-bd98-fc12ba31c8fe.pdf
[iii] Schiff, R., C. Rajkumar, and C. Bulpitt. Views of elderly people on living wills: interview study. BMJ 2000; 320(7250):1640-1.
[iv] Blondeau, D., et al. Comparison of patients’ and health care professionals’ attitudes towards advance directives. J Med Ethics 1998; 24(5): 328-35.
[v] Sahm, S., R. Will, and G. Hommel. What are cancer patients; preferences about treatment at the end of life, and who should start talking about it? A comparison with healthy people and medical staff. Support Care Cancer 2005; 13(4):206-14
[vi]Morrison, RS., and DE. Meier. High rates of advance care planning in New York City’s elderly population.
Arch Intern Med 2004; 164(22):2421-6.
[vii] The SUPPORT Investigators. A controlled trial to improve care for seriously ill hospitalized patients in the Study to Understand Prognoses and Preferences for Outcomes and Risk of Treatments. JAMA. 1995;274:1591-1598.
[viii] Collins LG, Parks SM, Winter L. The state of advance care planning: one decade after SUPPORT. Am J Hosp Palliat Care. 2006 Oct-Nov;23(5):378-84.
[ix] Subcommittee to update “Of Life and Death”, & Standing Senate Committee on Social Affairs, Science and Technology. 2000, Part 1, B5 - Advance Directives section, para. 2.

The Grey Zone: Is health care communication up in the air?

2011-10-25T10:11:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and examined private services within public health care from an Ethicist's perspective. Today, Sally Bean looks at health care communication innovations. Would you want to talk to your doctor via Skype? Get a diagnosis over email?

In the movie Up in the Air, George Clooney’s character Ryan Bingham is a corporate downsizing expert who travels across the Unites States to fire soon-to-be downsized employees. To save money, his company begins using video conferencing similar to Skype to convey the unfortunate “pink slip” news. This shift in practice is much to Bingham’s chagrin because he believes that firing someone should be done in person.

Similarly, an episode of Sex and the City involved a story line in which one of Carrie Bradshaw’s (Sarah Jessica Parker) boyfriends infamously breaks up with her on a post it note. Carrie is incredulous at the medium used and presumes it is a reflection of his perceived value of their relationship.

If pressed to think about it, each of us can probably recall a time in which someone communicated bad news to us via e-mail, telephone, etc. in which you thought, “why didn’t they have the decency to do it in person?” Are there some activities that fundamentally should be done in person, whether to foster optimal communication or to demonstrate respect for another? If a physician were conveying bad news to you, would you want it to be done in person? Would you consider the discussion to be “in person” if this news were conveyed remotely via Skype? The next few of my blog posts will explore these types of issues on the changing communication dynamics in medicine.

Telemedicine translated literally means medicine practiced from a distance. In telemedicine, the healthcare provider and patient can be located in distinct geographical locations and interact either in real or delayed time. For example, in real time a burn surgeon in Toronto may remotely examine the healing progress of a post-operative wound of a patient living in northern Ontario, versus the scanning and sending an x-ray of the same northern Ontarian’s injured ankle to be read by a Radiologist. With the rise in affordable telemedicine modalities, the former is likely to become a more routine way of providing care.

Currently in Ontario, telemedicine is successfully used to give persons in remote geographical areas access to specialists through the expansive Ontario Telemedicine Network infrastructure. Reducing geographical access disparities is an excellent justice-based benefit of telemedicine. However, are there some therapeutic encounters that should only be done in person? If so, how would we identify them and based on what criterion?

The fastest implementation of telemedicine has largely occurred in more diagnostically oriented fields such as Radiology and Pathology in which health data may be sent for remote interpretation and analysis. The College of Physician & Surgeon’s of Ontario’s (CPSO) 2007 policy on Telemedicine outlines expectations for physicians engaging in the practice of Telemedicine. Three particular requirements are noted in the policy:

Telemedicine meets clinical practice standards
Technology used is of sufficient quality to enable provision of quality care
Confidentiality of patient health information is ensured

The requirements help guarantee that telemedicine interactions and outcomes are comparable to those in face-to-face medicine.

Have your say: What other aspects of telemedicine do you think should be addressed by the CPSO? My next post will examine e-mail communications between patients and clinicians. Would you like to see this practice embraced? What are some of the pros and cons? Share your thoughts in the comment section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: Blair Henry will address advanced directives. Do you have a living will? What happens when a patient hasn't chosen a power of attorney? Vote in the sidebar poll and check back for Blair's post to have your say on the issue.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

The Grey Zone: Should uninsured services be offered within public health care institutions?

2011-10-05T12:20:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and weighed in on rationing health care costs from an Ethicist's perspective. Today, Sally Bean will examine the issue of uninsured medical treatments within the publicly insured health care system.

Do you think uninsured services–like expensive cancer drugs, or a fibreglass rather than plaster cast–should be offered within the public health care system?

The degree of controversy involved in deciding whether to offer uninsured health services within publicly funded healthcare institutions varies. Public reaction depends both on the particular uninsured service under consideration and whether there is an available insured treatment alternative.

For example, supplementary services such as private nursing or accommodations and services that increase comfort but are unlikely to influence health outcomes, such as a fibreglass cast, have been relatively uncontroversial. Uninsured IV cancer drugs within hospitals, on the other hand, have been highly contentious.

One key difference between the fibreglass cast and the uninsured IV cancer drugs is that there is an insured alternative to the fibreglass cast, but in some instances, there may not be an insured alternative for a particular IV cancer drug. Decisions made around particular services can have widespread repercussions not only for individual patients but throughout our healthcare system. Therefore, thoughtful deliberation about the potential risks and benefits to future and existing patients should occur. Ultimately, the question is should we permit the provision of uninsured services within our hospital if the patient is willing to pay for those services privately? If yes, under what conditions?

The Canada Health Act guarantees reasonable access to publicly funded healthcare resources without financial or other barriers. Our publicly funded healthcare system is currently structured to provide reasonable access to insured drugs and services that are deemed "medically necessary." This is where the controversy begins: no definition of "medically necessary" is supplied so at the Provincial level, decision-makers must make tough choices about what services will be offered with public funds.

The federal government typically defers to Provincial determinations of what services and drugs are deemed medically necessary (and therefore insured) under Provincial health care plans such as OHIP. Access to uninsured services is not addressed in legislation. However, legal scholars considering the provision of uninsured IV cancer drugs in a public hospital have opined that the practice is legally permissible in the publicly funded out-patient hospital setting. Their reasoning? The drugs are not considered "medically necessary" under the Canada Health Act.^[1]

In Chaoulli v. Quebec, the Supreme Court of Canada held that Canadians can access insured services in the private market, but public institutions cannot accept or require private payment for insured services. This means I can pay out-of-pocket to go to a private imaging clinic but my hospital or physician cannot charge me to access that insured service in a publicly funded hospital.

On Oct. 4^ththe Toronto Star published an article on the use of biologic mesh for abdominal wall reconstructions. The procedure was recently approved for use by Health Canada, but is currently not insured. The article chronicles one patient's journey, Peter Landers, to become the second patient in Canada to receive this particular type of biologic mesh. According to the article, Mr. Landers waited seven months to receive the mesh. He sought to cover the cost of the mesh ($5000) over the standard synthetic mesh ($1000) that is commonly used in routine hernia repairs. What are your thoughts as to whether Mr. Landers should be able to pay out-of-pocket for the biologic mesh and have it surgically inserted in a publicly funded hospital?

From an ethics perspective, in considering requests to pay for uninsured services when there is an insured alternative, there are two key considerations: 1) Patient safety and 2) Procedural & substantive impacts on insured services for current and future patients. In considering patient safety, the goal would be to balance patient choice with potential risks and benefits. At the same time, procedural and substantive considerations would focus on an equity analysis. To work out whether or not a request to pay for an uninsured service when there is an insured alternative, we should consider the following questions:

Has the drug or product been approved by Health Canada?
Does the clinician possess the required degree of knowledge and experience?
Are the risks and benefits needed to provide informed consent known?
What is the precedential value of allowing/disallowing this case?
Are there alternative treatments available (including standard of care) that are equally or more effective? Do the alternatives involve less risk to the patient?
Would OHIP patients be displaced or disadvantaged?
How would the healthcare institution monitor the impact of allowing private payment?
Are more health services required than with the standard treatment?

As you can see from the results of our poll, readers had mixed opinions regarding whether it is appropriate to allow the provision of uninsured services within publicly funded hospitals. A majority of voters supported this practice while a minority disagreed or were unsure about this practice.

What do you think about offering uninsured services alongside insured options within public health care institutions? Have your say: What should be done if there are no insured alternatives? How does the issue of patient equity fit into the debate? Join our discussion in the comment section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On Thursday, October 20, Blair Henry will address advanced directives. Do you have a living will? What happens when a patient hasn't chosen a power of attorney? Vote in the sidebar poll and check back for Blair's post to give your say on the issue.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

References:

[1] Flood C. Hardcastle L. THE PRIVATE SALE OF CANCER DRUGS IN ONTARIO'S PUBLIC HOSPITALS: TOUGH ISSUES AT THE PUBLIC/PRIVATE INTERFACE IN HEALTH CARE. McGill Health Law Journal (2007); 1: 5-21. http://mjlh.mcgill.ca/pdfs/vol1-1/flood-hardcastle.pdf

The Grey Zone: Should health care costs be rationed? Implications on paper will mean tough decisions at the bedside

2011-09-26T07:42:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves and examined the treatment of uninsured patients in Canada from an Ethicist's perspective. Today, Blair Henry will look at the tough issue of high-tech, costly medical care, and whether or not it should be limited.

An article in the August 18, 2011 edition of The Chicago Tribune, entitled "Short lives, troubling questions"^[i] raised some very serious issues regarding the impact increased technology can have on the choices available to clinicians and patients, and on the consequences of providing these services on an already heavily budget-restricted health care system. The story described conjoined twins Kameron and Kaydon, who were joined at the chest and shared a liver and a defective heart. Their condition was discovered during a regular ultrasound examination early in the pregnancy, and doctors advised the parents to consider termination, saying the twins would most likely be delivered stillborn or, at best, survive only a few hours or days after delivery.

However, the mother was adamant her babies should be given every chance possible. With the power of hope and the backing of extensive technology developed to support the growing field of neonatology, the twins were delivered and exceeded everyone's expectations of survival. They struggled, and died 16 months after their birth. By some accounts this was heralded as a medical miracle; however, the medical bill for their short but intensively cared for lives amounted to USD $5.6 mil.

The case raised some interesting and troubling questions: How much should be done, and at what cost, when it comes to prolonging life? These questions are pertinent at all stages of life – particularly at the end of life when treatments perceived as futile are requested. These kinds of questions are also at the heart of many ethical deliberations: when we know what we "can" do, the question then becomes one of whether we "should" we being doing it.

We polled readers who visit the Your Say blog on this case and asked whether we should limit costly high-tech care provided to patients. We had the following response:
This small sampling shows how polarizing and divisive this issue can be. As reported, voting on the conjoined twins' case won't settle these types of troubling questions, but it can inform the debate. The twins survived longer than almost anyone imagined, and the medical establishment no doubt gained some valuable lessons from their short and intense lives. But it's hard to set limits based on this type of scenario. In legal circles there is a saying that tough cases make bad laws. It's also known that reviewing high profile cases can bring out an "identifiable victim effect"^[ii], which can create a dangerous bias in our thinking.

So, how can we look at the issue of setting limits on health care spending? How can we do so to find an ethically justifiable way to determine who will get access to what medical care in the future?

Daniel Callahan^[iii], an American philosopher/bioethicist, has written widely on this topic. His views are considered controversial by many, but his courage to ask the tough questions and propose tough solutions is welcomed by others.

Callahan sees American medicine as a direct reflection of American culture, defined by a love of technology and the fight against death as a central goal of medicine. He writes:

"Our whole health care system is based on a witch's brew of sacrosanct doctor-patient autonomy, a fear of threats to innovation, corporate and (sometimes) physician profit-making, and a belief that, because life is of infinite value, it is morally obnoxious to put a price tag on it."

Callahan has been known to advocate a "fair innings" approach to health care decisions and rationing, and he is a strong proponent of "age-based" health care rationing that would focus on quality not quantity of life in old age. For those of you interested in his ideas,

Callahan's Taming the Beloved Beast

I'd suggest his book: Taming the Beloved Beast^[iv] wherein he suggests that nothing short of a full scale transformation of our thinking will be needed to properly address this problem.

Given the example of Kameron and Kaydon, we can see how challenging these sorts of decisions have become in our modern world. We may feel that to challenge this trend is to challenge what is at the heart of what we define as the "good" in health care.

Another strong voice that has weighed into the debate is the controversial Princeton Professor, Dr. Peter Singer^[v]. In 2009 Dr. Singer published an editorial in the NY Times, commenting on a drug used to slow the progression of advanced kidney cancer. A diagnosis of advanced kidney cancer comes with a prognosis of 1 to 2 years, however, treatment with a chemotherapy agent called Stutent, slows down its spread and adds an additional 6 months of life. The cost for the delivery of Stutent is $54,000. Is this cost justifiable?

That depends: How much do you think 6 months of added life is worth? In your mind is there a number that makes you say: "No! An extra six months isn't worth that much"? According to Singer, once you've been able to land on a dollar value, you've reached a point where you believe health care needs to be rationed.

The real challenge isn't the acceptability of rationing, but deciding who will "set that limit". A patient or close family member will have a very different focus than a politician or even a tax payer, who may or may not be able to relate to the emotional and psychological factors that are at the centre of such difficult decisions.

An image from Dr. Peter Singer's NY Times piece

In Dr. Peter Singer's account "rationing" has become a dirty word, yet the task of health care bureaucrats has traditionally been to get the best value for the resources allocated. Singer advocates the utilitarian approach to rationing decisions: do so such that the greatest good can be delivered to the greatest number.

Sometimes that can be relatively easy to decide. For example, if two drugs offer the same benefits and have similar risks of side effects, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. In the U.K. this task has been assigned to a group called the National Institute of Health and Clinical Excellence (NICE)^[vi], which focuses on the methods that should be used to establish cost-effective practices for the British health care system.

Another controversial image
from Dr. Singer's NY Times
editorial

However, as the reports from NICE indicate, the problem arises when the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question, but an ethical one.

Health is a shared public good and has associated rights that demand fair and just distribution of the resources allocated towards its promotion. However, good stewardship of this resource is perilous and subject to political scrutiny; it's a hot button item in most political campaigns, making open discussion around the tough rationing decisions a challenge. Many economists bemoan that health care is also a complex construction that few tax payers really understand.

For example, are health care dollars are best served in the field of preventative medicine (funding to support the known pre-determinants of health such as poverty, education, social injustices)? If so, that may mean we will need to divert more money away from innovation at the bedside and direct it towards public health and social equity efforts. Should they instead be spent in the fields of acute, chronic or critical illness? Who has the expertise to answer these questions?

Balancing the real and pressing needs of current patients against the impact on mitigating health concerns for the future entails a strong vision of what it truly means to live in community and to make decisions based on the good of that community. Ethics has a role in this effort by advocating for a strong process, based on a model of deliberative democracy that can engage all citizens in having these important conversations.

In the spirit of engaging all citizens, what are your thoughts on health care rationing? Should limits be placed on high-cost treatments? Who should determine those limits? Join our discussion in the comments section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On Thursday, October 6, Sally Bean will discuss uninsured services within the public health care system. Should some treatments, such as unfunded cancer drugs, be available for private payment within publicly funded health care institutions? Vote in the sidebar poll and check back for Sally's post to share your thoughts.

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

References:

[i] http://articles.chicagotribune.com/2011-08-18/news/ct-edit-twins-20110818_1_troubling-questions-medical-team-decisions
[ii] http://www.andrew.cmu.edu/user/gl20/GeorgeLoewenstein/Papers_files/pdf/identifiable-victim.pdf
[iii] http://www.kaiserhealthnews.org/Checking-In-With/Daniel-Callahan-Limits-On-Health-Care.aspx
[iv] http://press.princeton.edu/titles/9016.html
[v] http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=all
[vi] http://bmb.oxfordjournals.org/content/81-82/1/51.full

The Grey Zone: Uninsured Patients Seeking Access to Health Care

2011-09-08T10:10:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves, discussed sedation for palliative patients and examined pandemics in movies in honour of TIFF from an Ethicist's perspective. Today, Sally Bean will look at the treatment of illegal immigrants in Canadian hospitals – specifically, the case of Nell Toussaint.

In my July 14^th post, I explored the issue of uninsured patients in Canadian hospitals and whether healthcare professionals should provide treatment. In this post, I'll explore uninsured patients seeking access to care, in particular, the recent Federal Court of Appeals case involving Nell Toussaint, a citizen of Grenada who came to Canada as a visitor in 1999 and has remained in Toronto without legal status since her arrival, and her legal plight to seek access to healthcare.

Not surprisingly, uninsured patients face many barriers in accessing care in Canada. The access challenges are magnified for persons without legal status, like Nell Toussaint, for whom it would be very unlikely to ever obtain Ontario Health Insurance Plan (OHIP) coverage due to her non-status and the requirement to pass an immigration medical physical. Due to access barriers, uninsured patients often present for care with a higher severity of late stage cancer, unmanaged chronic diseases, no pre-natal care and mental health issues. Additionally, uninsured patients may receive sub-standard care if are unable to pay for their healthcare.

The legal foundation for our current healthcare system, the Canada Health Act, states, “the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” By basing health insurance eligibility on a person’s residency status, there will be persons who do not meet residency requirements and are therefore currently ineligible for health insurance. Each Province establishes its residency requirements for Provincial health insurance eligibility.

In Ontario, for example, OHIP coverage is currently based on legal residency standard which has two components: 1. Person resides in Ontario for 1 of 10 different qualifying conditions AND 2. Person meets physical presence requirements, i.e. 90 day wait period and resides in Ontario for 153 days in a 12 month period.[i] In terms of characterizing those who do not currently meet residency standards, there are generally two broad categories of uninsured patients, out-of-country and resident uninsured. An out-of-country patient includes a tourist on vacation that falls ill while an uninsured resident could be an eligible person awaiting the 90 day OHIP wait period or persons living here without legal status. Nell Toussaint, for example, would be considered a resident uninsured patient and as a person without legal status, she would be unable to fulfill one of the 10 qualifying conditions that would make her eligible for OHIP coverage.

While most health insurance for Canadian residents is administered by the Provinces and Territories, Citizenship and Immigration Canada provides medical coverage under its Interim Federal Health Program. The Interim Federal Health Program (IFHP) provides emergency and essential health care coverage to eligible individuals who do not qualify for private or public health coverage and who demonstrate financial need. IFHP targets four groups of recipients that have legally been admitted to Canada: Refugee claimants; Resettled Refugees; Persons detained under the Immigration and Refugee Protection Act; and, Victims of Trafficking in Persons. Nell Toussaint was deemed to not fall within any of the four groups and was denied healthcare through the IFHP. Toussaint appealed this finding and argued that the terms of the IFHP infringed her Charter rights (sections 7 & 15) "rights to life and security of the person." Ultimately, the Federal Court of Appeals disagreed and dismissed her appeal noting that if she had prevailed, "Canada’s immigration laws would be undermined and that Canada could become a health care safe haven."

As you can see from the results of our poll, readers were divided on the court’s ruling. A majority of our voters agreed with the court’s ruling that Nell Toussaint has no right to federal healthcare while a little more than a third thought that the court got it wrong. The division among our poll participants reflects that this is a challenging issue that sparks strong reactions from both supporters and opponents alike.

What are your thoughts on health care for immigrants without legal status? Should patients like Nell Toussaint be allowed access to acute care or long term care? If so, who should pay? Join our discussion in the comments section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On Thursday, September 22, Blair Henry will address the issue of high-tech, high-cost medical care, and who should pay. Should hospitals or governments set limits on the expensive, cutting-edge health care provided to people? Vote in the sidebar poll and check back in two weeks to join the conversation. An editorial published by the Chicago Tribune in August on the tragic case of a set of conjoined twins will give you food for thought on the subject.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

References:

[i] MOHLTC OHIP Eligibility Fact Sheet (April 2009); Regulation 522 of Ontario’s Health Insurance Act (April 2009).

The Grey Zone: Bioethics at the Movies

2011-08-31T11:35:00.000-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves, addressed the treatment of uninsured patients and discussed sedation treatment for palliative patients from an Ethicist's perspective.

In the spirit of the 36^th annual Toronto International Film Festival (TIFF), which begins in just two days, this special Grey Zone post will be dedicated to exploring movies that contain bioethics themes and plots lines. Sally Bean will examine whether or not pandemics are portrayed accurately in movies, and explain how medical ethics would guide a reaction to a global medical catastrophe in the real world.

The new Steven Soderbergh pandemic action-thriller “Contagion” opens September 9, 2011 and follows a team of international doctors responding to threats posed by a deadly airborne virus. With the tagline “nothing spreads like fear,” "Contagion" taps into the modern day global world in which information is characterized as spreading like a virus, for example, when we say a YouTube video has gone “viral.” Here's Soderbergh's take on how the world might react to a pandemic, from the movie's official synopsis:

"One contact. One instant. And a lethal virus is transmitted. [...] The numbers quickly multiply: one case becomes four, then sixteen, then hundreds, thousands, as the contagion sweeps across all borders, fueled by countless human interactions that make up the course of an average day. A global pandemic explodes. At the U.S. Centers for Disease Control and Prevention, researchers mobilize to break the code of a unique biological pathogen as it continues to mutate. As the death toll escalates and people struggle to protect themselves and their loved ones in a society breaking down, one activist blogger [...] claims the public isn't getting the truth about what's going on, and sets off an epidemic of paranoia and fear as infectious as the virus itself."

That's the movie version. How might health care providers react to a global pandemic in real life?

Courtesy of
contagionmovie.warnerbros.com.

Similar to triaging that occurs after a mass casualty, during a pandemic or outbreak in which demand for healthcare resources such as ventilators, vaccines, anti-viral, etc. exceeds the available supply to care for those in need, limited resources are often directed toward those with the best chance for survival. This shift in focus from individual decision-making to collective or group well-being is an illustration of the moral theory of utilitarianism, i.e. maximizing good for the greatest number. Conversely, under normal circumstances for managing seasonal flu, those who are most vulnerable or susceptible to the detrimental effects of flu are prioritized for vaccination which generally tends to be children and seniors. The downside to utilitarian-based decision-making during a pandemic is that frequently those most susceptible to the disease are marginalized or disadvantaged individuals: they may be further disadvantaged by basing decision-making solely on anticipated patient outcomes.

Aside from access to and allocation of limited healthcare resources, another issue that may arise during a pandemic or outbreak is the practice of quarantine. This means a person infected with the particular virus is isolated from others so that further transmission does not occur. While the degree and length of quarantine will vary depending on the nature and transmission of a given virus, quarantine places restrictions on an individual’s liberty which could last for an indefinite amount of time. Quarantine is another illustration of utilitarian theory in which one person’s freedom may be limited to protect the broader public. As we have seen in the past with other communicable diseases, stigmatization of the infected individuals may also unfortunately occur, which further isolates an infected individual.

Do you think pandemics are portrayed ethically in movies like "Contagion"? Do you agree with the real world utilitarian approaches to epidemics outlined above? How would you deal with an epidemic in real life? Join the conversation by posting in the comment section below.

With recent memories of SARS and H1N1 still in our collective conscience, "Contagion" will no doubt be an unsettling yet captivating film. If "Contagion" sounds like a must see, then consider viewing precursor deadly virus movies including the film adaptation of Michael Crichton’s novel The Andromeda Strain (1971) and Outbreak (1995).

Have you already bought advanced tickets for "Contagion"? Are you a big fan of "Gattaca"? Here are a few other suggested films that contain bioethics themes and issues:

Organ donation issues (procurement, marketing, donation, etc.):

End-of-life (suicide, euthanasia, personhood, withdrawing treatment, etc.) issues:

The Diving Bell and the Butterfly (2007)
The Sea Inside (2004)
Million Dollar Baby (2004)
Talk to Her (2002)
Wit (2001)

Issues associated with human reproduction (abortion, cloning, assisted reproduction, etc.):

Justice and access to healthcare issues:

Sicko (2007)
John Q (2002)

Issues associated with human subject research:

The Constant Gardener (2005)
Extreme Measures (1996) & (2010)
Ms. Evers’ Boys (1997)
Awakenings (1990)

Our next post: On September 8, The Grey Zone will tackle the case of uninsured Canadian patient Nell Toussaint. Vote in the sidebar poll and post your comments this Thursday to join the conversation.

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

The Grey Zone: Should sedation be a treatment option to manage suffering for patients at the end of life?

2011-08-25T10:03:00.001-07:00

Welcome to The Grey Zone, our ethics blog series on Your Say. In our previous posts, Ethicists Blair Henry and Sally Bean introduced themselves, addressed the treatment of uninsured patients and discussed clinical trials for end-stage cancer patients from an Ethicist's perspective. In this post, Blair Henry examines palliative patients and sedation as a treatment option, which leads to a state of unawaress, as in a deep sleep. Should patients be able to decide for themselves? Should the treatment option be allowed at all?

The practice of palliative sedation has been around for many years but it was only in 1990 that it garnered “public” attention when a Physician who wrote about its use in end-of-life care.^[i] At the time it had the dubious name of “terminal sedation” – an unfortunate label that stuck until 2005. The problem with the name terminal sedation was the confusion around how one was to interpret the word “terminal”: was it meant to indicate the patient’s condition before the treatment or as a result of the treatment?!?

Now we use the expression palliative sedation therapy, PST for short. PST is the deliberate lowering of consciousness in a terminally ill patient for the treatment of intolerable and refractory (not responding to the usual therapies) symptoms at the very last stages of life. Depending on the level of sedation, palliative sedation therapy makes the patient unaware or unconscious, in a state comparable to being in a deep sleep.

The philosophy behind palliative care has been around since the beginning of medicine: do no harm, relieve suffering, and attend to the needs of the dying. However, the birth of the modern hospice and palliative care movement really got its start in the 1960’s with Dr. Cicely Saunders in the UK.^[ii] Since then it has grown as an important field of medicine, but it’s a topic that’s still filled with much confusion.

The term palliative means to “relieve or make easier one’s” suffering, and in reality this has a role at all stages of a person’s illness. However, most people associate palliative care with dying only, which is unfortunate, since it can play an important role much earlier on. So, some centres use different terms to provide the same thing: instead of saying “palliative care” you might see a sign that says “supportive care." It feels less threatening for some patients who don’t like the association between dying and palliative.

However, at the very end of life, when cure is either no longer achievable and the patient wants to focus on quality versus quantity of life, the goals of care begin to change. Acute types of interventions fall away and the palliative types of interventions become central; the goal of treatment becomes comfort, whole-person and family-centred care. The enemies of comfort and dignity become pain and suffering and good, specialized palliative care focuses on addressing these issues -- but within the limits of 1) having the consent of the patient or substitute decision-maker, 2) that the intervention will not deliberately shorten life, and 3) the intervention is proportionate to the distress being managed.

I don’t know what people expect at the end of life. I suspect most of us just hope to go to sleep some night and just never wake up -- to go peacefully and without event. But statistically that’s not going to be the reality for a majority of us. Not to depress you or anything, but most of us at the end of life will experience a slow, progressive, degenerative illness -- with acute and chronic phases -- that may last weeks to years leading up to our death. So how we are cared for during that time is of crucial importance.

Before coming to the hospital setting I worked at a hospice for many years, and I know that people can have many fears along the final journey of life: fears of pain, fears of loss, fears of being a burden on others... and the list goes on! To help in caring for the person experiencing these fears requires skill, compassion and multiple disciplines from medicine, social work, chaplaincy, nursing, psychology, and the allied fields. The number one issue on most people’s list is pain and distress: if I have trouble breathing, if the pain is too much, if I feel sick and nauseous, will you be able to help me? These are some of the most common requests in hospice care.

Having been involved with many patients receiving good end-of-life care, I can say with confidence that these fears can be successfully addressed. But -- and yes there’s always a but! -- some symptoms can be challenging to manage, and at some point sedation may be a necessary option. Without a doubt the use of sedation at the end of life is considered both a legal and ethical option. The issue becomes: How long should we sedate? What about eating and drinking when sedation is being used? Does sedation result in a shortening of life?

These are important issues that need to be clarified to help understand what the aim of the sedation really is. We know that pain is a complex entity! At one level it can physical in nature, and in some cases it can be emotional (also known as “existential distress”). For the past two years I have worked with a group of palliative care physicians across Canada to develop guidelines on the use of palliative sedation therapy. In my next post I will share some of the key points of interest I've found, but until then I’d like to hear you thoughts on these questions:

What do you think? Should sedation be allowed, even if it lowers consciousness? Who should make the decision, and when should it be made? Share your thoughts on the complex issue in the comment section, and use the social buttons in our sidebar to share this post with friends.

We encourage you to share openly in this new forum on health care. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On September 8, Sally Bean will continue her investigation of the treatment of uninsured patients. She'll look at the case of Nell Toussaint, an illegal immigrant and long-time Canadian worker who took her battle for health care coverage to the courts. Vote in the sidebar poll and check back in September for her post to join the conversation. Thanks for reading!

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

References:
[i] http://www.deepdyve.com/lp/sage/drug-induced-terminal-sedation-for-symptom-control-f0fdemmaxx
[ii] http://www.cicelysaundersfoundation.org/about-palliative-care

The Grey Zone: Should patients with "unrealistic optimism" be allowed to enroll in early phase drug trials?

2011-07-27T15:16:00.000-07:00

Welcome to The Grey Zone, our new blog series on Your Say. In our last three posts, Ethicists Blair Henry and Sally Bean introduced themselves, discussed hospital visiting hours and addressed the treatment of uninsured patients from an Ethicist's perspective. In today's post, Blair Henry takes on the issue of the enrollment of hopeful patients in early phase drug trials--even if the trials may do more harm than good. Should patients be allowed to sign up if they have unrealistic expectations?

We’ve all seen the movie version: a haggard lone scientist working away in the middle of a stormy night accidentally knocks over a test tube filled with a mysterious liquid into a stray coffee cup. The next day an innocent lab assistant takes a drink from the cup (I know, so metaphorical!) and then ZAP! An amazing transformation occurs that has wide spread implications for humanity; the exact nature of that implication depends of course on the genre of the film you happen to be watching.

When it comes to actual medical research, the scenario described above couldn’t be further from the truth. In fact, most scientific advances occur are typically the result of long hard years of work by large teams of scientist. It’s been estimated that it cost over $800,000,000 (USD) to bring a single drug from the lab bench to the shelves of a pharmacy - and that process can take anywhere between 5 to 10 years to complete. For every 5 drugs currently being tested in clinical trials, only about 1 will make it through the intense testing and evaluation process. The reality of medical discovery isn't exactly movie material. So how does research work?

Initially, basic research starts with what is often referred to as bench side science and pre-clinical trials (testing not done on humans) to determine if the original idea or concept has merit. This can take the form of in vitro testing (test tube test) or in silico testing (computer simulation), but ultimately it will entail in vivo testing (on living organism). Initially in vivo testing usually involves animal testing, because human cells contain many of the same building blocks and chemical pathways as most other living things. When it comes to animal testing, scientist try to determine how the drug is absorbed, distributed, metabolized and eliminated in the body, as well as any toxic effects. Finding these answers is commonly known as ATMET testing.

If the new drug is promising at this stage, then it’s ready for human testing. And here’s where it get interesting! In order to get approval to begin human testing, a series of regulatory requirements must be met. The sponsor of the new drug (usually a pharmaceutical company) must apply to Health Canada, which thoroughly reviews the trial. Once a letter of No Objection has been given, enrollment of human subjects can begin. Even then, testing on humans involves three unique phases (Phase 1, 2 and 3), so that harms are minimized and good scientific data can be obtained. Additionally, all research involving human subjects needs to be reviewed by a research ethics board (REB) at each of the sites where the research is conducted.

The first phase for any human testing is called Phase 1 (also called First in Human studies) and is usually conducted on anywhere between 20 and 80 healthy volunteers, usually paid to participate. The goal of a Phase 1 study is to determine the drug’s most frequent side effects, how the drug is metabolized, and how it gets excreted in humans (commonly called safety and dosing studies). The scientific goal of a Phase 1 study is not to determine if it’s effective at treating the underlying disease, since in most cases only healthy volunteers are used. However, when it comes to research on a known toxic medication (like many chemotherapy drugs), sick patients from the disease group of interest can be recruited.

So the question is: Should a sick patient be allowed to enroll in this type of study if they harbor “unrealistic optimism” about the benefits they will derive from the new drug? In our preliminary poll we asked you to choice one of the following responses:

Yes, they should have the right to enroll, unrealistic hope aside.
No, informed consent means being informed about the study. If they refuse to believe what’s told to them about the poor chance of benefit, they need to be protected from harm.
Maybe. I'll share my thoughts in the comments section.

As it turns out, 16 out of 18 people voted Yes: cancer patient should be allowed to enroll irrespective of unrealistic hope.

Everyone involved in research, but most specifically the research ethics board, is tasked with making sure the conduct of research is ethical. One of the most important elements involves informed consent. We want to make certain that all participants know the purpose, the risk and the potential benefits about the research. They need to know that their participation is voluntary, what will happen to them during the study, and that if they no longer want to participate they can stop at any time.

We know of all types of influences that can impact a patient’s decision to enter or not enter into a study. Some of these involve therapeutic misconception: they don’t understand the goals of research and confuse it with actual treatment that is aimed at making them better. We know that some patients may feel uncomfortable saying no to their trusted physician when they ask them to enter a study. We want to be certain that patients are mentally able to understand, appreciate and decide for themselves whether or not to enroll in a study. We expect people to have the right information and to have their eyes wide open; their judgement shouldn't be clouded, for example, by pop culture perceptions of scientists creating miraculous treatments overnight.

There have been some interesting studies conducted on research participants, particularly cancer patients entering into early phase clinical trials. Even when they were “informed about the study”, when asked, they said they still believed that they were more likely to benefit from the new drug and/or less likely to experience risks than others enrolled in the same study.

Based on these study results, is “unrealistic optimism” a true indication that some patients don’t have the capacity to decide? If so, should they be “protected” from harm by being denied entry into a study? I suspect those questions are not quite so easily answered – and that we’d need a lot more data to support that level of paternalism! As the poll shows, most of our voters would agree.

We know some patients who have tried conventional therapies with no luck will want the opportunity to enroll in research involving new drugs. These patients may be particularly vulnerable to any offer of hope (real or false), and so we need to be clear that we are not using that vulnerability to entice patients to participate in research. They need to be given the facts in a professional and non-coercive manner, and given an opportunity to ask questions and receive truthful information.

There is a “cult of the rational” that does exist in scientific circles, where things like emotions and feelings are viewed suspiciously. But let’s face it: how rational have we been in making many of our major life decisions like choosing a life partner, or even taking a job, or buying a home? We all rely on an odd amalgam of hopes, dreams, and rationality, and we need to be mindful of that when screening potential candidates for entry into research.

What do you think? Should patients, particularly those in the end-stages of their diseases, be allowed to enroll in early clinical trials? What if those trials are Phase 1, and therefore not even designed to assess a drug's benefit? Join our discussion in the comment section, and use the social buttons in our sidebar to share this post with friends.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On ~~August 11~~ August 24 (UPDATE: Sally is away until August 22, and will post the following on August 24; Blair Henry will post another piece on August 18), Sally Bean will continue her investigation of the treatment of uninsured patients by examining the case of Nell Toussaint, an illegal immigrant and long-time Canadian worker who took her battle for health care coverage to the courts. Vote in the sidebar poll and check back in on August 11 to join the conversation. Thanks for reading!

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

From Acute Care to Recovery: St. John’s Rehab & Sunnybrook Team Up

2011-07-22T08:22:00.000-07:00

St. John’s Rehab Hospital and Sunnybrook have signed a memorandum of understanding, an important step in seeing the two organizations merge voluntarily to become a comprehensive health care provider.

Each hospital has complementary programs for patients with complex health issues including acute interventions and rehabilitation for people with cancer, cardiovascular disease, orthopaedic and arthritic conditions, neurological issues such as stroke, and traumatic injuries such as major burns.

>> Read more in our Q&A on the proposed merger

We’d like to hear from you. What do you think about St. John’s Rehab and Sunnybrook joining forces to maintain the reputation of excellence in patient care, research, and education that each hospital has developed over the years? Please feel free to post a comment or email yoursay@sunnybrook.ca

The Grey Zone: Should healthcare professionals provide treatment to uninsured patients?

2011-07-14T11:49:00.001-07:00

Welcome to The Grey Zone, our new blog series on Your Say. In our last two posts, Ethicists Blair Henry and Sally Bean introduced themselves and discussed hospital visiting hours from an Ethicist's perspective. In today's post, Sally Bean takes on the issue of uninsured patients in Canadian hospitals. Should healthcare professionals provide treatment?

Healthcare providers are frequently faced with decisions regarding whether an uninsured patient--a person currently without Provincial health insurance coverage, like OHIP--will be given access to non-urgent, chronic healthcare. In deciding whether to provide care, decision-makers must consider multiple competing factors. This post will focus on exploring the legal and ethical landscape healthcare providers must navigate when deciding whether to treat uninsured patients. In future posts, I will explore the uninsured patient's experience in seeking access to healthcare.

Based on the Canadian Medical Association’s Code of Ethics (s. 18, 2004) and the Public Hospitals Act (s. 21), it is clear that legally and ethically, physicians are required to provide emergency care to uninsured persons. However, since there is no legal requirement to provide non-emergent care, treatments for chronic conditions that over time could even become life-threatening are typically not provided unless the uninsured patient has the ability to pay for medical care. Inability to pay can lead to devastating consequences for the patient who is unable to access healthcare.

However, providing free care to uninsured patients may have negative consequences for Ontarians seeking access to medical care: it could prolong wait times. Additionally, physicians are often expected to provide care to uninsured patients without compensation. Finally--as if healthcare providers did not have enough to consider--they must also weigh potential liability implications. An uninsured patient obtaining care in Ontario could, for example, return to their home country to sue the healthcare provider in a foreign legal jurisdiction.

Considering uninsured patients seeking non-urgent care from an ethics perspective entails weighing of competing duties and obligations. We have to balance the needs of the uninsured patient and the broader healthcare system, and ensure that a fair and open process is undertaken in reaching a decision. That process starts with the physician.

A healthcare provider must first use their professional clinical judgment to ascertain whether urgent or non-urgent care is required. If it is urgent, they are legally and ethically bound to provide care irrespective of a patient’s ability to pay. If it is the non-urgent, then difficult decisions regarding whether to provide care must be made. Increasingly, some healthcare organizations have institutional protocols governing if and under what circumstances non-urgent uninsured patients can receive access to care. Institutional policy ideally promotes fair and consistent treatment of uninsured patients and alleviates the burden of healthcare professionals having to decide either without guidance or on a case by case basis.

On one hand, deciding solely on a patient’s ability to pay for services will further disadvantage many already vulnerable persons. It adds a new and uncomfortable element into the therapeutic relationship, i.e. the ability to pay for health services. On the other hand, decision-making based only on a patient’s medical need could encourage system abuse and threaten ongoing sustainability of our healthcare system.

As you can see from the results of our poll, the majority of our voters believe an uninsured person’s access to non-urgent care should be decided based on their medical need. This thinking aligns with legal and ethical principles governing access to urgent care. The second largest response (approximately one-third of votes) indicated that non-urgent care should be offered to uninsured persons only if it does not disadvantage Ontarians. This position takes into consideration competing duties and obligations of Ontarians seeking access to care.

Envision the following hypothetical case: a 45 year old male arrives at the emergency room and is diagnosed with a tear in his bowel caused by previously undetected colon cancer. Urgent surgery is provided to fix the tear and a follow up course of chemotherapy is recommended. The patient has lived in Canada for twenty years without legal status and has worked as a laborer since his arrival. He does not have the financial ability to pay for his recommended cancer therapy, but will most certainly die soon if treatment is not provided. The patient does not have any family in his country of origin and does not wish to return there. The patient is distraught as he wants the chance to fight his cancer and continue to live where he has made his home for the last 20 years, without incurring substantial debt.

Should the patient receive treatment? If you were the physician or hospital executive deciding whether cancer treatment should be provided to the patient, and if yes whether it should be for free, how would you decide and why? Imagine your decision would form the basis of a policy that would inform how all future uninsured patient cases would be decided. Join the discussion and post your thoughts in the comment section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On July 28, Blair Henry will discuss the issue of advanced cancer patients enrolling in early stage clinical trials. Should the patients be allowed to enter a clinical trial, even when they have unrealistic hope? Vote in the sidebar poll and check back on July 28 to give us your thoughts. Thanks for reading!

- Sally Bean, Ethicist, Sunnybrook Health Sciences Centre

The Grey Zone: Should hospital visiting hours be restricted or unrestricted?

2011-06-30T09:55:00.000-07:00

Welcome to The Grey Zone, our new blog series on Your Say. In the previous post Ethicists Blair Henry and Sally Bean introduced themselves and listened to your thoughts on hospital visiting hours, and below Blair has responded to the issue from an Ethicist's perspective.

Ethics, at its core, is about trying to help people determine what we “should or ought” to do in certain situations, by helping them to think about the core values at stake, and applying principles to complex situations.

Contrary to popular belief, we don’t want to be too philosophical or abstract in how we go about determining what the right thing to do is. In other words, in trying to find a solution to the question of visiting hours, I could start out by asking the question: Who’s visiting who in hospitals? Maybe as staff we’ve got it all wrong and it’s the health care professionals coming into a patient’s room that are the real visitors, not family or friends! Though a helpful way to reframe the situation, in reality, ethicists also try to be pragmatic in their thinking about issues. We work in a scientific world and we want to ask: what evidence exists to support or guide our thinking on this issue?

History is an important consideration in any deliberation, and it's informative to understanding the greater “cultural” factors that may have influenced how we got to where we are. Restricted hospital visiting hours began in the late 19^th century as an attempt by hospital staff to establish order in large multi-bed general wards. Below, a photo of a typical 24-bed ward at Sunnybrook after the Second World War:

This practice started to shift when private and semi-private rooms became available (however, it only favored those with the finances to afford these rooms). By the 1960s, the shift was back to restricted hours at the request of staff as a means to “protect patients and families” from exhaustion.^[i]

The current trend is back to less restrictive visitation practices often referred to as open visitation. One open visitation approach requires the creation of a customized visitation plan developed by the patient in collaboration with the healthcare team. Several recent studies have demonstrated the benefits of open visitation.^{[ii] [iii]} A lower incidence of cardiovascular complications, lower blood pressure and a lower heart rate were observed in patients in ICUs with open visitation policies compared to those with restrictive policies. Open visitation was also associated with less anxiety in patients and their families.

Other studies have demonstrated that open visitation actually promotes patient rest since visitors are more likely to come back another time rather than waking the patient. Open visitation has also been shown to increase the educational opportunities for family members who can help in the provision of patient care both in hospital and upon discharge. Despite all this positive evidence, misperceptions about open visitation persist among many healthcare workers, making open visitation a controversial topic among hospital staff.

The results from the poll we posted on the blog last week are in line with current thinking on the issue. Our readers had a variety of opinions on the ideal hospital visiting hours policy:

What are your thoughts on visiting hours? Does a critical look at the evidence help point towards a very different perspective on this issue? The evidence presented comes largely from the intensive care population. Do you think they apply to the other areas of the hospital? Should visitation be strictly controlled, completely unrestricted or something in between? Should patients be allowed to determine their own visitation hours? What’s been your experience? Join the discussion in the comment section below.

We encourage you to share openly in this new forum on healthcare. If you have any specific concerns about your Sunnybrook experience and need support or advice, please contact Patient Relations.

Our next post: On July 14, Sally Bean will discuss the controversial issue of providing non-urgent treatment to uninsured patients. How should we decide if uninsured patients (a person currently without Provincial health insurance coverage) will receive access to care? Vote in the sidebar poll and check back in on July 14 to give us your thoughts. Thanks for reading!

- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre

References:
[i] Rosenberg CE. The care of strangers: The rise of America’s hospital system. Baltimore MD: John Hopkins UP; 1987.
[ii] Sims JM et al. A Look at Critical Care Visitation, Dimens Crit Care Nurs, 2006; 25(4):175-180
[iii] Fumagalli S. Reduced Cardiocirculatory Complications with unrestricted visiting policy in an intensive care unit results from a pilot, randomized trial. Circulation. February 21, 2006; 113:946-952.

Strategic Planning 2011

2011-06-21T07:04:00.000-07:00

Sunnybrook is conducting a Strategic Planning process to define the role the Hospital will continue to play in serving our community and the larger health care system. We've developed an e-presentation to give our partners, community members and other stakeholders information about the proposed Strategic Plan.

Watch our e-presentation:

The plan builds on the work from Strategic Focus 2008 by taking further steps toward developing Sunnybrook’s specialized areas of care called Strategic Priorities. There are four Strategic Priorities at Sunnybrook including: Trauma, Cancer, Heart and Stroke and High-Risk Maternal and Newborn. These select areas of Sunnybrook’s activity are world-renowned for the patient care provided, the research conducted and the educational opportunities provided.

We welcome you to review the presentation and share your feedback with us. There are a couple of ways to let us know what you think about our Strategic Plan:

Share your comments here on 'Your Say'
Email us at yoursay@sunnybrook.ca. Comments sent via email will not be made public.

A final version of our Strategic Plan will be made publicly available in October 2011. Thank you for your participation and interest in Sunnybrook Health Sciences Centre.