Blair Henry

Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

Framework for Continuous Palliative Sedation Therapy in Canada

BACKGROUND Canada does not have a standardized ethical and practice framework for continuous palliative sedation therapy (CPST). Although a number of institutional and regional guidelines exist, Canadian practice varies. Given the lack of international and national consensus on CPST, the Canadian Society for Palliative Care Physicians (CSPCP) formed a special task force to develop a consensus-based framework for CPST. OBJECTIVE Through a preliminary review of sedation practices nationally and internationally, it was determined that although considerable consensus was emerging on this topic, there remained both areas of contention and a lack of credible scientific evidence to support a definitive clinical practice guideline. This led to the creation of a framework to help guide policy, practice, and research. METHODS This framework was developed through the following steps: 1) literature review; 2) identification of issues; 3) preparation of a draft framework; 4) expert consultation and revision; 5) presentation at conferences and further revision; and 6) further revision and national consensus building. RESULTS A thorough literature review, including gray literature, of sedation therapy at the end of life was conducted from which an initial framework was drafted. This document was reviewed by 30 multidisciplinary experts in Canada and internationally, revised several times, and then submitted to CSPCP members for review. Consensus was high on most parts of the framework. CONCLUSION The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.

Factors Affecting Family Satisfaction with Inpatient End-of-Life Care

Background Little data exists addressing satisfaction with end-of-life care among hospitalized patients, as they and their family members are systematically excluded from routine satisfaction surveys. It is imperative that we closely examine patient and institution factors associated with quality end-of-life care and determine high-priority target areas for quality improvement. Methods Between September 1, 2010 and January 1, 2012 the Canadian Health care Evaluation Project (CANHELP) Bereavement Questionnaire was mailed to the next-of-kin of recently deceased inpatients to seek factors associated with satisfaction with end-of-life care. The primary outcome was the global rating of satisfaction. Secondary outcomes included rates of actual versus preferred location of death, associations between demographic factors and global satisfaction, and identification of targets for quality improvement. Results Response rate was 33% among 275 valid addresses. Overall, 67.4% of respondents were very or completely satisfied with the overall quality of care their relative received. However, 71.4% of respondents who thought their relative did not die in their preferred location favoured an out-of-hospital location of death. A common location of death was the intensive care unit (45.7%); however, this was not the preferred location of death for 47.6% of such patients. Multivariate Poisson regression analysis showed respondents who believed their relative died in their preferred location were 1.7 times more likely to be satisfied with the end-of-life care that was provided (p = 0.001). Items identified as high-priority targets for improvement included: relationships with, and characteristics of health care professionals; illness management; communication; and end-of-life decision-making. Interpretation Nearly three-quarters of recently deceased inpatients would have preferred an out-of-hospital death. Intensive care units were a common, but not preferred, location of in-hospital deaths. Family satisfaction with end-of-life care was strongly associated with their relative dying in their preferred location. Improved communication regarding end-of-life care preferences should be a high-priority quality improvement target.

How Toronto and Montreal (Canada) Respond to Heat

It is only during the last five years that Canadian cities have begun to develop formal programs to protect the public’s health from the effects of summertime heat. Toronto’s (Ontario) Hot Weather Response Plan followed recommendations from advisory committees for seniors and for the homeless. The public health department was confronted with a rain-storm on the first day, in 1999, that it issued a heat alert. Toronto has since instituted a two-level alert and emergency response with action levels based on the estimation of mortality impacts through a synoptic model developed at the University of Delaware. Key to the program is media alerts and community partnerships to aid vulnerable people. Montreal’s (Quebec) approach has been to issue public advisories based on real and apparent temperature thresholds elaborated in collaboration with the Canadian Meteorological Service. Montreal has instituted a program of research and action designed to inform the population and to identify and mitigate population vulnerabilities in order to make residents more resistant to the effects on health of heat. Priority areas for health protection include hospitals and nursing homes, few of which are now air-conditioned; rather than retrofit air conditioning, relative air-cooling and air dehumidification have been proposed where feasible. In the community, local health centers target their vulnerable elderly clients requiring follow-up during heat waves based on the identification of factors such as dehydrating medications, social isolation, and lack of access to a nearby cooling room. A heat wave emergency response plan, based on the mobilization and updating of existing programs, is coordinated by civil defense authorities, advised by the city’s public health department.

Ethical challenges in conducting research on dying patients and those at high risk of dying.

Clinical research to improve care across the broad spectrum of health care has led to better quantity and quality of life for many patients. However, imposing arbitrary restrictions that might result in the exclusion from clinical research of patients who are at the end of life, or patients with a high risk of dying, is undesirable. Such exclusions may violate the principle of justice, by denying these patients a valid opportunity to make an important socio-medical contribution, and could make it difficult or impossible to advance clinical knowledge about the care of these patients. This article reviews issues relevant to the conduct of research on dying patients and those who are at high risk of dying, and outlines special considerations for ensuring that such research is ethical. In particular, precautions should be taken to ensure that informed consent is obtained from patients who are capable (or their substitute decision maker if the patient is not capable), free from coercion, and not harboring false expectations about the likelihood of benefiting from the study intervention. The unique circumstances surrounding the timing of this research (at the end of life or potentially there) may warrant that some patients be considered vulnerable, requiring special protective measures. Adhering to these principles will help ensure that dying patients or patients at high risk of dying can still participate in research that has the potential to advance knowledge and improve future care.

Justifying Different Levels of Palliative Sedation

TO THE EDITOR: We read with great interest the article by Quill and colleagues (1), which presented and discussed 3 categories of palliative sedation: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). One notion shared by these practices, and by all attempts to justify sedation, is that the degree of sedation should match the symptoms— proportionality. The prominence of proportionality in this and other discussions of palliative sedation suggests a simpler and ethically clearer classification. Instead of “ordinary,” “proportionate,” and “unconscious” sedation, we suggest that all palliative sedation be classified as PPS. This is not a confusion of types of palliative sedation, as Quill and colleagues suggest, but a helpful reconception. Under the notion of proportionality, all types of palliative sedation are given only to the extent demanded by symptoms. Low demands imply minimal sedation, and higher demands imply greater sedation. In this way, prognosis does not change the rationale or the practice of sedation, but it places limits on the degree of acceptable sedation. The closer the patient is to death, the higher the level and duration of acceptable sedation (although low levels of sedation will sometimes still be sufficient). The classification presented by Quill and colleagues is reasonable and helpful, but our amendment improves simplicity and ethical clarity. Considering all palliative sedation as PPS avoids the inevitable difficulties of distinguishing among ordinary, proportionate, and unconscious sedation, particularly when palliative sedation is titrated to the point of near or total unconsciousness. Classifying some sedation as PSU also risks blurring the importance of intention to the practice of palliative sedation (2). Considering all palliative sedation as proportionate underscores the ethical imperative that the intention in using sedation is to palliate and not to hasten death.

Minding the gap: access to palliative care and the homeless

BackgroundWith an ever increasing number of individuals living with chronic and terminal illnesses, palliative care as an emerging field is poised for unprecedented expansion. Today’s rising recognition of its key role in patients’ illnesses has led to increased interest in access to palliative care. It is known that homelessness as a social determinant of health has been associated with decreased access to health resources in spite of poorer health outcomes and some would argue, higher need. This article aims to discuss the current state of affairs with regards to accessing palliative care for the homeless in Canada.DiscussionRecent review of the literature reveals differential access to palliative care services and outcomes with differing socio-economic status (SES). Notably, individuals of lower SES and in particular, those who are homeless have poorer health outcomes in addition to poor access to quality palliative care. Current palliative care services are ill equipped to care for this vulnerable population and most programs are built upon an infrastructure that is prohibitive for the homeless to access its services. A preliminary review of existing Canadian programs in place to address this gap in access identified a paucity of sporadic palliative care programs across the country with a focus on homeless and vulnerably-housed individuals. It is apparent that there is no unified national strategy to address this gap in access.SummaryThe changing landscape of the Canadian population calls for an expansion of palliative care as a field and as many have put it, as a right. The right to access quality palliative and end of life care should not be confined to particular population groups. This article calls for the development of a unified national strategy to address this glaring gap in our healthcare provision and advocates for attention to and adoption of policy and processes that would support the homeless populations’ right to quality palliative care.

Does warfarin use impact hospital length of stay? A retrospective study looking at patients treated for atrial fibrillation.

Abstract The authors received anecdotal practice information from clinicians indicating that when warfarin was initiated in the hospital setting, it may be associated with an increased length of stay (LOS): specifically to achieve a desired minimum international normalized ratio (INR) of 2.0 before discharge in a subset of patients where clinicians perceived follow-up after discharge was not deemed optimal. Given that oral thromboprophylactic anticoagulation with warfarin is the mainstay treatment for the prevention of stroke in atrial fibrillation (AF), the authors decided to look at hospitalized patients from this population to determine if a subset of these patients experienced an increased LOS. The study design entailed a retrospective chart review of consecutive patients admitted to a large, tertiary care, academic center. Patients were included if they were admitted with a primary, secondary, or most responsible diagnosis of paroxysmal or chronic AF. Medical records were audited over an 18-month period (February 1, 2009, to July 31, 2010) to determine the average LOS and to identify patients with a documented prolonged LOS secondary due to subtherapeutic INR at the time of potential discharge. Our final study cohort of 189 patients had an average LOS of 5.2 days (SD = 5.2). However, for eight (4.2%) of these patients discharge was delayed an additional 2.25 days (SD = 1.3) for reasons solely attributed to achieving a therapeutic INR.

A systematic literature review on the ethics of palliative sedation: an update (2016)

Purpose of reviewPalliative sedation has been the subject of intensive debate since its first appearance in 1990. In a 2010 review of palliative sedation, the following areas were identified as lacking in consensus: inconsistent terminology, its use in nonphysical suffering, the ongoing experience of distress, and concern that the practice of palliative sedation may hasten death. This review looks at the literature over the past 6 years and provides an update on these outstanding concerns. Recent findingsGood clinical guidelines and policies are still required to address issues of emotional distress and waylay concerns that palliative sedation hastens death. SummaryThe empirical evidence suggests some movement toward consensus on the practice of palliative sedation. However, a continued need exists for evidence-informed practice guidelines, education, and research to support the ethical practice of palliative sedation at the end of life. Until that time, clinicians are advised to adopt a framework or guideline that has been expert driven to ensure consistent and ethical use of palliative sedation at the end of life.

Development of a decision-making tool for reporting drivers with mild dementia and mild cognitive impairment to transportation administrators

BACKGROUND Driving in persons with dementia poses risks that must be counterbalanced with the importance of the care for autonomy and mobility. Physicians often find substantial challenges in the assessment and reporting of driving safety for persons with dementia. This paper describes a driving in dementia decision tool (DD-DT) developed to aid physicians in deciding when to report older drivers with either mild dementia or mild cognitive impairment to local transportation administrators. METHODS A multi-faceted, computerized decision support tool was developed, using a systematic literature and guideline review, expert opinion from an earlier Delphi study, as well as qualitative interviews and focus groups with physicians, caregivers of former drivers with dementia, and transportation administrators. The tool integrates inputs from the physician-user about the patients clinical and driving history as well as cognitive findings, and it produces a recommendation for reporting to transportation administrators. This recommendation is translated into a customized reporting form for the transportation authority, if applicable, and additional resources are provided for the patient and caregiver. CONCLUSIONS An innovative approach was needed to develop the DD-DT. The literature and guideline review confirmed the algorithm derived from the earlier Delphi study, and barriers identified in the qualitative research were incorporated into the design of the tool.