Search

Multi-criteria decision analysis (MCDA) is a value assessment tool designed to help support complex decision-making by incorporating multiple factors and perspectives in a transparent, structured approach. We developed an MCDA rating tool, consisting of seven criteria evaluating the importance and feasibility of conducting potential real-world evidence (RWE) studies aimed at addressing uncertainties stemming from initial cancer drug funding recommendations. In collaboration with the Canadian Agency for Drugs and Technologies in Health's Provincial Advisory Group, a validation exercise was conducted to further evaluate the application of the rating tool using RWE proposals varying in complexity. Through this exercise, we aimed to gain insight into consensus building and deliberation processes and to identify efficiencies in the application of the rating tool. An experienced facilitator led a multidisciplinary committee, consisting of 11 Canadian experts, through consensus building, deliberation, and prioritization. A total of nine RWE proposals were evaluated and prioritized as low (n = 4), medium (n = 3), or high (n = 2) priority. Through an iterative process, efficiencies and recommendations to improve the rating tool and associated procedures were identified. The refined MCDA rating tool can help decision-makers prioritize important and feasible RWE studies for research and can enable the use of RWE for the life-cycle evaluation of cancer drugs.

The rights of patients to receive legally permissible interventions sometimes conflict with enshrined rights of providers to object, for reasons of conscience, to providing those interventions. Getting the balance right is challenging. But reasonable balance to manage these conflicting imperatives can be achieved in the design of programs for assisted death. Rather than limiting the discourse to the platform of competing individual rights, health leaders are urged to consider the broader societal benefits and impacts of valuing conscience in the practice of medicine, the creation of regulation and policy, and the delivery of healthcare. A method to determine that conscience claims are "genuine," "reasonable," and "acceptable" needs developing. A list of criteria toward this determination is offered.

Background: The Goals of Care Designation (GCD) is a medical order used to communicate the focus of a patient's care in Alberta, Canada. In this study, we aimed to determine the association between GCD type (resuscitative, medical or comfort) and resource use during hospitalization., Methods: This was a prospective cohort study of newly hospitalized inpatients in Alberta conducted from January to September 2017. Participants were aged 55 years or older with chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, cancer or renal failure; aged 55-79 years and their provider answered "no" to the "surprise question" (i.e., provider would not be surprised if the patient died in the next 6 months); or aged 80 years or older with any acute condition. The exposure of interest was GCD. The primary outcome was health care resource use during admission, measured by length of stay (LOS), intensive care unit hours, Resource Intensity Weights (RIWs), flagged interventions and palliative care referral. The secondary outcome was 30-day readmission. Adjusted regression analyses were performed (adjusted for age, sex, race and ethnicity, Clinical Frailty Scale score, comorbidities and city)., Results: We included 475 study participants. The median age was 83 (interquartile range 77-87) years, and 93.7% had a GCD at enrolment. Relative to patients with the resuscitative GCD type, patients with the medical GCD type had a longer LOS (1.42 times, 95% confidence interval [CI] 1.10-1.83) and a higher RIW (adjusted ratio 1.14, 95% CI 1.02-1.28). Patients with the comfort and medical GCD types had more palliative care referral (comfort GCD adjusted relative risk (RR) 9.32, 95% CI 4.32-20.08; medical GCD adjusted RR 3.58, 95% CI 1.75-7.33) but not flagged intervention use (comfort GCD adjusted RR 1.06, 95% CI 0.49-2.28; medical GCD adjusted RR 0.98, 95% CI 0.48-2.02) or 30-day readmission (comfort GCD adjusted RR 1.00, 95% CI 0.85-1.19; medical GCD adjusted RR 1.05, 95% CI 0.97-1.20)., Interpretation: Goals of Care Designation type early during admission was associated with LOS, RIW and palliative care referral. This suggests an alignment between health resource use and the focus of care communicated by each GCD., Competing Interests: Competing interests: Jessica Simon reports grants from Canadian Institutes of Health Research, Alberta Health, Canadian Foundation for Healthcare Improvement and Choosing Wisely Alberta via its partners: the Alberta Medical Association, Alberta Health, Alberta Health Services and the College of Physicians and Surgeons of Alberta. Dr. Simon reports speaker honoraria from Queen’s University and a role as physician consultant, Advance Care Planning and Goals of Care, Alberta Health Services, Calgary Zone. Dr. Simon also reports unpaid roles as co-chair, Advisory Committee, Advance Care Planning Alberta; advisory committee member, Advance Care Planning Canada; and committee member, Advance Care Planning International. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

A request for hastened death can mean many things, from an emotional plea for help with unmet needs to a request for legal provision of chemically induced hastened death. Regardless of whether the clinician supports legally available hastened death, knowing how to respond to requests for hastened death is important. Responding in an empathic and open manner will strengthen the therapeutic relationship between the patient and clinician. Suggested scripts on how to respond are provided. A framework for assessing the patient's preparation at various stages in the decisional journey is suggested. Additional factors including caring for the family and involving other healthcare providers are discussed. Last, there is some exploration of ethics considerations and a summary of legal chemically induced hastened death availability internationally., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: In 2014, the province of Alberta, Canada implemented a province-wide policy and procedures for advance care planning (ACP) and goals of care designation (GCD) across its complex, integrated public healthcare system. This study was conducted to identify and operationalise performance indicators for ACP/GCD to monitor policy implementation success and sustainment of ACP/GCD practice change., Methods: A systematic review and environmental scan was conducted to identify potential indicators of ACP/GCD uptake (n=132). A purposive sample of ACP/GCD stakeholders was invited to participate in a modified Delphi study to evaluate, reduce and refine these indicators through a combination of face-to-face meetings and online surveys., Results: An evidence-informed Donabedian by Institute of Medicine (IOM) framework was adopted as an organising matrix for the indicators in an initial face-to-face meeting. Three online survey rounds reduced and refined the 132 indicators to 18. A final face-to-face meeting operationalised the indicators into a measurable format. Nine indicators, covering 11 of the 18 Donabedian×IOM domains, were operationalised., Conclusions: Nine ACP/GCD evidence-informed indicators mapping to 11 of 18 Donabedian×IOM domains were endorsed, and have been operationalised into an online ACP/GCD dashboard. The indicators provide a characterisation of ACP/GCD uptake that could be generalised to other healthcare settings, measuring aspects related to ACP/GCD documentation, patient satisfaction and agreement between medical orders and care received. The final nine indicators reflect the stakeholders' expressed intent to strike a balance between comprehensiveness and feasibility within a large provincial healthcare system., Competing Interests: Competing interests: JS is the Physician Consultant for Advance Care Planning and Goals of Care, Calgary Zone, Alberta Health Services. TLWM. was the Provincial Lead for Palliative End of Life Care Practice Development, Alberta Health Services at the time of this work., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Advance care planning (ACP) encompasses both verbal and written communications expressing preferences for future health and personal care and helps prepare people for healthcare decision-making in times of medical crisis. Healthcare systems are increasingly promoting ACP as a way to inform medical decision-making, but it is not clear how public engagement in ACP activities is changing over time., Methods: Raw data from 3 independently conducted public polls on ACP engagement, in the same Canadian province, were analysed to assess whether participation in ACP activities changed over 6 years., Results: Statistically significant increases were observed between 2007 and 2013 in: recognising the definition of ACP (54.8% to 80.3%, OR 3.37 (95% CI 2.68 to 4.24)), discussions about healthcare preferences with family (48.4% to 59.8%, OR 1.41 (95% CI 1.17 to 1.69)) and with healthcare providers (9.1% to 17.4%, OR 1.98 (95% CI 1.51 to 2.59)), written ACP plans (21% to 34.6%, OR 1.77 (95% CI 1.45 to 2.17)) and legal documentation (23.4% to 42.7%, OR 2.13 (95% CI 1.75 to 2.59)). These remained significant after adjusting for age, education and self-rated health status., Conclusions: ACP engagement increased over time, although the overall frequency remains low in certain elements such as discussing ACP with healthcare providers. We discuss factors that may be responsible for the increase and provide suggestions for healthcare systems or other public bodies seeking to stimulate engagement in ACP., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The moral divide between proponents and opponents of medical assistance in dying is wide and can be ascribed to a number of dichotomous beliefs. This article addresses a particular and less commonly described platform for the divide: human acquiescence to physical decline and death as an important stage of life, versus presumptive human mastery over the timing and manner of some peoples' death. Practical ideas are then offered for health systems that wish to bridge the divide, to provide both robust palliative end-of-life care and medical assistance in dying programs for their patients, while keeping health workers whole.

Methadone can be an effective drug for cancer pain but it can also be difficult to use safely. It has been recommended that rotation to methadone from other opioids be undertaken in a hospital setting. The purpose of the study was to characterize the safety, toxicities, and outcomes of outpatient rotation to methadone for severe cancer pain in a heavily pretreated cohort of cancer patients. Data were collected through a retrospective review of consecutive patients from a tertiary level cancer pain clinic. Twenty-nine patients were rotated to methadone, 13 (45%) due to opioid toxicity and 16 (55%) because of either cost or difficulty swallowing their prior opioid. Eleven of 29 patients (38%) failed methadone due to rapidly progressive cancer, dose-limiting side effects, or other reasons, but the other patients were successfully rotated to methadone. Pain usually improved following rotation to methadone, but drowsiness from methadone was common. On average, it took 32 days to successfully rotate to methadone in the outpatient setting. Cancer patients with advanced disease and severe pain can be safely and effectively rotated to methadone in the outpatient setting. It takes considerably longer to stabilize these patients than patients on lower doses of opioid or those titrated in the inpatient setting. A careful monitoring system is needed to screen for evidence of toxicity.