I am delighted to introduce guest blogger, Ruth Trinier, CACCN Treasurer to share information about the Critical Care Canada Forum held in Toronto from November 9 to 12, 2013.
Every year the Critical Care Canada Forum in Toronto offers professionals an opportunity to attend informative and interactive sessions focusing on the care of critically ill patients. The three-day conference, hosted by an international faculty, presents leading-edge science, research, practice innovations, products and services. Again this year, members of the Canadian Association of Critical Care Nurses, including members of the Board of Directors, attended the conference in addition to participating in the curriculum and some special meetings.
Of the many excellent sessions, we would like to report on two that we considered particularly relevant to members of CACCN.
In September, the National Board of Directors received an invitation to participate in a consensus meeting for the development of a Canadian document to guide health care providers on the procedure of withdrawal of life-sustaining treatment. The meeting, arranged by doctors Lisa Kenny, James Downar, Jesse Delaney and Laura Hawryluck of the Canadian Critical Care Society, was to be held during the CCCF. CACCN members attending the Forum were asked to participate in order that the unique knowledge and perspective of nurses was an active part of the evolving document.
The goal of the project is to develop interprofessional consensus guidelines including preparation of patients and families, symptom control, withdrawing specific therapies, and supporting family members and the healthcare team throughout the process. The end product will be a report entitled “The Canadian Critical Care Society’s Guidelines on the Procedure of Withdrawal of Life-Sustaining Therapy”.
After a brief overview of the literature, the law, and ethics in this area, participants met in one of four working groups:
- Preparation and support for patients, substitute decision makers / families and the health care team throughout the procedure of withdrawal of life support.
- Pharmaceutical management of distress.
- Assessment of distress.
- Withdrawal of life-sustaining therapies.
Some groups were unable to complete their work in the limited time available, and the large group was not able to reconvene as planned at the end of the session. It is anticipated that the work of this group will continue into the new year.
The Board of Directors would like to thank the following CACCN members for providing their time and expertise to this important initiative:
- Greater Edmonton Chapter
- Tereza Coughlin
- London Regional Chapter
- Brenda L Morgan
- Manitoba Chapter
- Marie Edwards, CACCN Director, Publications/Research
- Nova Scotia Chapter
- Kirk Dawe, CACCN Director, Website
- Toronto Chapter
The second session that we would like to report on, “Obligations for End-of-Life (EOL) Care in ICU as of November 2013” concerned the implications from the decision of the Supreme Court of Canada in the case of Mr. Hassan Rasouli v. Sunnybrook Health Sciences Centre, Dr. Brian Cuthbertson and Dr. Gordon Rubenfeld, for which CACCN had been granted intervener status. (For information on CACCN’s role in this action please see CACCN Media.
The session, moderated by doctors Peter Cox and Brian Kavanagh, included an overview of the case by Dr. Stephen Lapinsky and the legal team of Erica Baron and Andrew McCutcheon. Dr. Andrew Baker presented an overview of the possible implications of the decision. This was followed by clarification by the legal team, questions from the audience, as well as suggestions for moving forward.
Some of the points made included:
- The majority of EOL situations will continue without controversy as they do now.
- It is not yet clear what the ruling will mean – it will take further cases/discussion.
- It is not yet clear what the ruling will mean outside of Ontario where there is no Consent and Capacity Board.
- In most instances, the decision will not make things materially different than what is being done now.
- Clear notes should be written noting that consent has been sought for withdrawal at EOL.
- Legally, informed consent needs to be obtained, but practically assent is likely acceptable in those cases where a SDM agrees with the decision but is unable to make it themselves (for whatever reason).
- It is likely a good idea to obtain a signature for consent.
- Because writing a DNR order does not involve touching the patient, it is likely that it does not require consent, however, there was no suggestion that not requesting consent would be the best route to follow. There are cases currently before the Canadian courts addressing the need for consent for a DNR order.
- The SDM has to be “rational”, i.e.: the argument of “I believe in miracles” is not rational, however, a confirmed religious belief of “life at all costs” may be valid.
- Consent for terminating CPR is not needed in the case of an unsuccessful code – it was felt that no court would uphold such a request, as it would be considered ridiculous.
- This case was not taken to the Consent and Capacity Board as it was felt that it was not a question of consent, it was felt to be a question of the meaning of treatment (further information concerning the reason this case was brought forward can be found on the Sunnybrook Hospital website.
Suggestions for the future included:
- Seeking legal consultation early in any situations that might be similar to the Rasouli case and forwarding it to the Consent and Capacity Board if the situation arises in Ontario.
- Sending all cases in Ontario to the Consent and Capacity Board to force clarification of the role of the CCB. This was seen to be impractical due to the impact of the delay in those situations that do not require the board.
- Going to law review to have the law clarified. This was seen as impractical as it would require agreement among all Canadian physicians.
We will continue to represent you, our members, as organizations across Canada look to CACCN as the “Voice for excellence in Canadian Critical Care Nursing”. Your comments, suggestions and feedback for all issues that are relevant to you will facilitate that representation.
Speaking with Conviction!