Robert Sibbald

Perceptions of “futile care” among caregivers in intensive care units

Background: Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of “futile care” or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources. Methods: Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach. Results: From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines. Interpretation: ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.

Clinical ethicists’ perspectives on organisational ethics in healthcare organisations

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.

Scarcity: the context of rationing in an Ontario ICU.

Objectives:Clinicians’ perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting. Design:Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity. Setting:An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007. Subjects:We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses. Main Results:The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians’ perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts. Conclusions:ICU clinicians’ perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.

Mandate to obtain consent for withholding nonbeneficial cardiopulmonary resuscitation is misguided

The College of Physicians and Surgeons of Ontario recently revised their policy concerning decision-making at the end of life.[1][1] The revised policy includes a new requirement for physicians to obtain consent to withhold cardiopulmonary resuscitation (CPR). Regardless of the medical situation, if

Withholding and withdrawing treatment in Canada: implications of the Supreme Court of Canada's decision in the Rasouli case

The following is a summary from information in the public domain: Hassan Rasouli underwent surgery for a benign brain tumour in 2010, but a postoperative infection resulted in severe brain damage and minimal consciousness. At the time the Supreme Court of Canada released its decision, he remained at

The impact of the Rasouli decision: a Survey of Canadian intensivists

Introduction In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown. Objectives To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision. Methods We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses. Results We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups. Conclusions Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canadas ruling in Cuthbertson versus Rasouli.

Court rules that withdrawal of life support is a plan of treatment requiring consent.

Ontario doctors cannot withdraw life-sustaining treatment from patients without their consent or that of their substitute decision-makers, the province’s Superior Court of Justice has ruled. Physicians at the Sunnybrook Health Sciences Centre in Toronto, Ontario, had sought to withdraw mechanical

Standard of care and resource implications of the Cuthbertson v. Rasouli ruling

On Oct. 18, 2013, the Supreme Court of Canada released its judgment in the case of Hassan Rasouli.[1][1] The court stressed that its ruling applied only in Ontario. The main implication of the ruling is that physicians in Ontario seeking to withdraw life support over the wishes of substitute

End-of-life decision-making is difficult (problems with the Consent and Capacity Board)

To the Editor, Family members face difficult decisions when an incapable loved one is nearing death or in a state of permanent incapacity being supported by technology. It is a tragic consequence of modern medicine and current consent legislation that family members are often put in the position of weighing conflicting plans for death—one characterized by minimizing potential harms or indignities and one characterized by chronic life support and ongoing resuscitation. Physicians can face difficult decisions when families in such circumstance do not recognize that death is at the end of either choice. These families often opt for a ‘‘fight’’— against evidence, odds, and the advice of experienced clinicians—seemingly against death itself. While statements and position papers offer nuanced advice for clinicians, there are limited realistic strategies in the face of intractable conflict (i.e., conflict that endures beyond mediation, compromise, ethics consults, etc.). Physicians can make unilateral decisions to limit/withdraw treatments, often triggering legal action initiated by families, or they can acquiesce to family demands—tough decisions. In Ontario, physicians have another option through the Consent and Capacity Board (CCB), whose mission it is to provide ‘‘fair and accessible adjudication of consent and capacity issues’’. In the first seven years since the first such application was made to the CCB in 2003, each of the 16 cases taken to the CCB to resolve end-of-life conflict endorsed either limits or withdrawal of treatment to allow patients to die (typically in a matter of weeks). Nevertheless, since 2010, 18 of 39 (46%) cases were dismissed in a manner that appeared as if the CCB’s intention was to avoid difficult decisions. Consider the recent case of a 24-yr-old male who suffered irreversible brain damage following a sudden cardiac arrest with prolonged anoxia. When his physicians sought to discontinue ventilation and opt instead for palliation, the CCB dismissed the application because the consequences of a treatment decision (i.e., a requirement of consent) ‘‘had not proven to have been provided in a fulsome form to the substitute decision-maker prior to requesting a decision’’, even though they were ‘‘well addressed at the hearing’’. In a case of an infant with severe neurologic injury, the CCB expressed that the application was ‘‘premature’’, the