“Everything has been tried and his heart can’t recover…”: A Descriptive Review of “Do Everything!” in the Archive of Ontario Consent and Capacity Board

Background

In end-of-life situations, the phrase “do everything” is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase “do everything” in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician–patient conflicts in order to explore its potential meanings.

Methods

We systematically searched the CCB’s online public archive from its inception to 2018 for any references to “do everything” in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes.

Results

Of 598 cases in the archive, 41 referred to “do everything” in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related “doing everything” to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients’ quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to “do everything” legally but followed existing laws by deferring to patients’ prior wishes whenever known, or to concepts of “best interests” when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients’ “well-being” and “best interests.”

Conclusions

In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to “do everything” highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient’s death, whereas physicians identified moral distress related to the prolongation of patients’ suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients’ goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care.

Trial Registration

Not applicable.

An undergraduate medical education framework for refugee and migrant health: Curriculum development and conceptual approaches

BACKGROUND

International migration, especially forced migration, highlights important medical training needs including cross-cultural communication, human rights, as well as global health competencies for physical and mental healthcare. This paper responds to the call for a 'trauma informed' refugee health curriculum framework from medical students and global health faculty.

METHODS

We used a mixed-methods approach to develop a guiding medical undergraduate refugee and migrant health curriculum framework. We conducted a scoping review, key informant interviews with global health faculty with follow-up e-surveys, and then, integrated our results into a competency-based curriculum framework with values and principles, learning objectives and curriculum delivery methods and evaluation.

RESULTS

The majority of our Canadian medical faculty respondents reported some refugee health learning objectives within their undergraduate medical curriculum. The most prevalent learning objective topics included access to care barriers, social determinants of health for refugees, cross-cultural communication skills, global health epidemiology, challenges and pitfalls of providing care and mental health. We proposed a curriculum framework that incorporates values and principles, competency-based learning objectives, curriculum delivery (i.e., community service learning), and evaluation methods.

CONCLUSIONS

The results of this study informed the development of a curriculum framework that integrates cross-cultural communication skills, exploration of barriers towards accessing care for newcomers, and system approaches to improve refugee and migrant healthcare. Programs should also consider social determinants of health, community service learning and the development of links to community resettlement and refugee organizations.

Mobile interventions targeting common mental disorders among pregnant and postpartum women: An equity-focused systematic review

INTRODUCTION

Pregnant and postpartum women face major psychological stressors that put them at higher risk of developing common mental disorders, such as depression and anxiety. Yet, their limited access to and uptake of traditional mental health care is inequitable, especially during the COVID-19 pandemic. Mobile interventions emerged as a potential solution to this discontinued healthcare access, but more knowledge is needed about their effectiveness and impact on health equity. This equity-focused systematic review examined the effectiveness and equity impact of mobile interventions targeting common mental disorders among pregnant and postpartum women.

METHODS AND RESULTS

We systematically searched MEDLINE, EMBASE, PsychINFO and 3 other databases, from date of database inception and until January 2021, for experimental studies on mobile interventions targeting pregnant and postpartum women. We used pooled and narrative synthesis methods to analyze effectiveness and equity data, critically appraised the methodological rigour of included studies using Cochrane tools, and assessed the certainty of evidence using the GRADE approach. Our search identified 6148 records, of which 18 randomized and non-randomized controlled trials were included. Mobile interventions had a clinically important impact on reducing the occurrence of depression (OR = 0.51 [95% CI 0.41 to 0.64]; absolute risk reduction RD: 7.14% [95% CI 4.92 to 9.36]; p<0.001) and preventing its severity perinatally (MD = -3.07; 95% CI -4.68 to -1.46; p<0.001). Mobile cognitive behavioural therapy (CBT) was effective in managing postpartum depression (MD = -6.87; 95% CI -7.92 to -5.82; p<0.001), whereas other support-based interventions had no added benefit. Results on anxiety outcomes and utilization of care were limited. Our equity-focused analyses showed that ethnicity, age, education, and being primiparous were characteristics of influence to the effectiveness of mobile interventions.

CONCLUSION

As the COVID-19 pandemic has increased the need for virtual mental health care, mobile interventions show promise in preventing and managing common mental disorders among pregnant and postpartum women. Such interventions carry the potential to address health inequity but more rigorous research that examines patients' intersecting social identities is needed.

A student-led curriculum framework for homeless and vulnerably housed populations

BACKGROUND

Medical student demands for competency based homeless health education is increasing. Indeed, humans living homeless is a treatable health and social emergency. This innovation report outlines the initial development of an education framework for homeless health.

METHODS

A medical student task force and educators conducted a mixed method study, including a scoping review of homeless health curriculum and competencies, a cross-country survey of medical students, and unique clinical guidelines. The task force collaborated with persons with lived experience and clinical guideline developers from the Homeless Health Research Network. The students presented at the Toronto Homeless Health Summit and refined the framework with feedback from homeless health experts.

RESULTS

The main outcome was an evidence-based Homeless Health Curriculum Framework. It uses seven core competencies; with communication, advocacy, leadership, and upstream approaches playing the strongest roles. The framework integrated the new clinical guideline (housing, income assistance, case management and addiction). In addition, it identified approaches to support mental health care with trauma informed and patient centered care. It identified public health values, clinical objectives, and case studies. The framework aims to inform the design, delivery, service learning and evaluation for medical school curriculum.

CONCLUSIONS

This student-led curriculum framework can support the design, implementation, delivery and evaluation of homeless health within the undergraduate medical curriculum. The framework can lay the foundation for new doctors, research and development; support consistency across programs; and support the creation of national learning and evaluation tools.

Conference Proceeding for the 6th Annual Action Global Health Network Conference: A Student-led Movement Encouraging Advocacy, Research and Outreach

On September 30th, 2017, medical students from the University of Ottawa organized and attended the 6th annual Action Global Health Network Conference (AGHN), in collaboration with the Faculty of Medicine. This full-day event aimed to challenge perceptions about global health and development, and encouraged participants to explore global health and social medicine as an avenue to improve equity. This conference proceeding recounts the key components of the 6th annual AGHN Conference, including keynote speakers, workshop speakers, and the research symposium. Core themes, learning takeaways, and future planning are also discussed in hopes of inspiring similar student-led initiatives across campuses.

Respect for Intimacy Among Persons Whose Privacy Is Compromised

This invited commentary addresses an article by Joy and Weiss and their views on the potential use of sexual advanced directives "… as a theoretical mechanism to assert sexual desire past incapacity …." Their article focuses on the importance of the sexual rights of individuals with neurocognitive disorders, principally dementia, in which there is a progressive decrease in executive functioning leading to impaired communication, understanding, and judgment. Individuals with dementia may be increasingly challenged to maintain autonomy in life, such as in cases of financial decision-making, self-care, end-of-life care, and, as Joy and Weiss point out, decisions pertaining to sexual relations. They highlight a possible trend of placing increasing restrictions on the freedom of aging patients to have sexual intimacy, to ensure their safety, and to prevent the potential of sexual abuse or other forms of harm. They propose the development of a "hypothetical sexual advance directive" for those at risk for incapacity, in collaboration with forensic psychiatrists. Although we agree that sexual rights should be legally protected by the established principles of the right to govern one's own body, rights of privacy, and autonomy, we are concerned that the requirement to have a signed and witnessed sexual advance directive may have unintended consequences that decrease, rather than enhance the sexual rights of people with dementia and other types of intellectual disabilities. We propose an alternative in which established and consensual sexual intimacy is treated as an aspect of the right to bodily self-determination that should not require an advance directive.

Central Nervous System and Head and Neck Histiocytoses: A Comprehensive Review on the Spectrum of Imaging Findings

The histiocytoses are a rare group of varied but related disorders characterized by abnormal tissue proliferation of macrophages and dendritic cells within tissues. The purpose of this article was to review the imaging findings in patients presenting with CNS and with head and neck manifestations of these disorders. Histiocytoses include but are not limited to Rosai-Dorfman disease, Erdheim Chester disease, Langerhans cell histiocytosis, histiocytic sarcoma, and juvenile xanthogranuloma. A review of the literature was performed to determine the sites of disease involvement. This article includes the demographics, histopathologic criteria for diagnosis, and imaging features of these histiocytoses, and describes the manifestations in locations known to harbor disease: intraaxial and extra-axial intracranial regions, the calvaria, skull base, hypothalamopituitary axis, orbits, paranasal sinuses, spine, and the head and neck region. Histiocytoses have variable imaging appearances in the CNS and in the head and neck region, and radiologists should be aware of the spectrum of findings to avoid mistaking them for other disease processes.

Learning Objective

To understand the general pathophysiology, clinical presentation, and typical imaging characteristics of the most common histiocytoses; comprehend the morphologic and immunohistochemical characteristics of these histiocytoses and the hallmark findings on pathology; and be able to differentiate between these disorders based on their most common presentations.