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Levels of Intervention: How Are They Used in Quebec Hospitals?

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Abstract

In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called “Levels of Intervention” (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form’s use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.

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References

  • Adams, J.A., D.E. Bailey, Jr., R.A. Anderson, and S.L. Docherty. 2011. Nursing roles and strategies in end-of-life decision making in acute care: A systematic review of the literature. Nursing Research and Practice 2011. doi:10.1155/2011/527834.

  • Bach, V., J. Ploeg, and M. Black. 2009. Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research 31(4): 496−512.

    Article  PubMed  Google Scholar 

  • Beach, M.C., and R.S. Morrison. 2002. The effect of do-not-resuscitate orders on physician decision-making. Journal of American Geriatric Society 50(12): 2057−2061.

    Article  Google Scholar 

  • Beauchamp, T.L., and J.F. Childress. 2009. Principles of biomedical ethics, 6th ed. Oxford University Press.

  • Becker, G., R. Sarhatlic, M. Olschewski, C. Xander, F. Momm, and H.E. Blum. 2007. End-of-life care in hospital: Current practice and potentials for improvement. Journal of Pain and Symptom Management 33(6): 711−719.

    Article  PubMed  Google Scholar 

  • Beckstrand, R.L., L.C. Callister, and K.T. Kirchhoff. 2006. Providing a “good death”: Critical care nurses’ suggestions for improving end-of-life care. American Journal of Critical Care 15(1): 38−45.

    PubMed  Google Scholar 

  • Bédard, C., D. Major, P. Ladouceur-Kègle, M.-H. Guertin, and J. Brisson. 2006. Soins palliatifs de fin de vie au Québec: Définition et mesure d’indicateurs. Edited by Direction systèmes de soins et services. Institut national de santé publique, Gouvernement du Québec.

  • Berger, J.T. 2003. Ethical challenges of partial do-not-resuscitate (DNR) orders: Placing DNR orders in the context of a life-threatening conditions care plan. Archives of Internal Medicine 163(19): 2270−2275.

    Article  PubMed  Google Scholar 

  • Blondeau, D., M. Lavoie, P. Valois, E.W. Keyserlingk, M. Hébert, and I. Martineau. 2000. The attitude of Canadian nurses towards advance directives. Nursing Ethics 7(5): 399−411.

    Article  CAS  PubMed  Google Scholar 

  • Bomba, P.A., M. Kemp, and J.S. Black. 2012. POLST: An improvement over traditional advance directives. Cleveland Clinic Journal of Medicine 79(7): 457−464.

    Article  PubMed  Google Scholar 

  • Canadian Hospice Palliative Care Association. 2013. A model to guide hospice palliative care: Based on national principles and norms of practice. Revised and condensed edition. Ottawa, ON, Canada.

  • Cohen, J., D.M. Wilson, A. Thurston, R. MacLeod, and L. Deliens. 2012. Access to palliative care services in hospital: A matter of being in the right hospital. Hospital charts study in a Canadian city. Palliative Medicine 26(1): 89−94.

    Article  PubMed  Google Scholar 

  • Curtis, J.R. 2005. Interventions to improve care during withdrawal of life-sustaining treatments. Journal of Palliative Medicine 8 (supplement 1): s-116−131.

  • Detering, K.M., A.D. Hancock, M.C Reade, and W. Silvester. 2010. The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ 340. doi: 10.1136/bmj.c1345.

  • Ellershaw, J., and C. Ward. 2003. Care of the dying patient: The last hours or days of life. BMJ 326(7379): 30−34.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ells, C. 2010. Levels of intervention: Communicating with more precision about planned use of critical interventions. The American Journal of Bioethics 10(1): 78−79.

    Article  PubMed  Google Scholar 

  • Frost, D.W., D.J. Cook, D.K. Heyland, and R.A. Fowler. 2011. Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: A systematic review. Critical Care Medicine 39(5): 1174−1189.

    Article  PubMed  Google Scholar 

  • Hammes, B.J., B.L. Rooney, J.D. Gundrum, S.E. Hickman, N. Hager. 2012. The POLST program: A retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. Journal of Palliative Medicine 15(1): 77−85.

    Article  PubMed  Google Scholar 

  • Heyland, D.K., D. Groll, G. Rocker, et al. 2005. End-of-life care in acute care hospitals in Canada: A quality finish? Journal of Palliative Care 21(3): 142−150.

    PubMed  Google Scholar 

  • Heyland, D.K., P. Dodek, G. Rocker, et al. for the Canadian Researchers End-of-Life Network. 2006. What matters most in end-of-life care: Perceptions of seriously ill patients and their family members. Canadian Medical Association Journal 174(5): 627−633.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hickman, S.E., C.A. Nelson, A.H. Moss, S.W. Tolle, N.A. Perrin, and B. J. Hammes. 2011. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. Journal of the American Geriatrics Society 59(11): 2091−2099.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hui, D., A. Con, G. Christie, and P.H. Hawley. 2009. Goals of care and end-of-life decision making for hospitalized patients at a canadian tertiary care cancer center. Journal of Pain and Symptom Management 38(6): 871−881.

    Article  PubMed  Google Scholar 

  • Johnson, C.E., A. Girgis, C.L. Paul, and D.C. Currow. 2008. Cancer specialists’ palliative care referral practices and perceptions: Results of a national survey. Palliative Medicine 22(1): 51−57.

    Article  CAS  PubMed  Google Scholar 

  • Jonsen, A.R, M. Siegler, and W.J. Winslade. 2006. Clinical ethics: A practical approach to ethical decisions in clinical medicine: McGraw Hill, Medical Publication Division.

  • Kaldjian, L.C., and A. Broderick. 2011. Patient and family involvement developing a policy for do not resuscitate orders within a framework of goals of care. Joint Commission Journal on Quality and Patient Safety 37(1): 11−1AP.

  • Kaldjian, L.C., R.F. Weir, and T.P. Duffy. 2005. A clinician’s approach to clinical ethical reasoning. Journal of General Internal Medicine 20(3): 306−311.

    Article  PubMed  PubMed Central  Google Scholar 

  • Laplante, A., H. Bergeron, D. Boucher, et al. 2012. Rapport de la Commission spéciale sur le mourir dans la dignité. Assemblée nationale du Québec.

  • Lee, M.A., K. Brummel-Smith, J. Meyer, N. Drew, and M.R. London. 2000. Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. Journal of American Geriatric Society 48(10): 1219−1225.

    Article  CAS  Google Scholar 

  • Marco, C.A., and R.M. Schears. 2002. Societal opinions regarding CPR. The American Journal of Emergency Medicine 20(3): 207−211.

    Article  PubMed  Google Scholar 

  • McIlfatrick, S. 2007. Assessing palliative care needs: Views of patients, informal carers and healthcare professionals. Journal of Advanced Nursing 57(1): 77−86.

    Article  PubMed  Google Scholar 

  • McMillen, R. E. 2008. End of life decisions: Nurses perceptions, feelings and experiences. Intensive Critical Care Nursing 24(4): 251−259.

    Article  PubMed  Google Scholar 

  • Morrell, E.D., B.P. Brown, R. Qi, K. Drabiak, and P.R. Helft. 2008. The do-not-resuscitate order: Associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act. Journal of Medical Ethics 34(9): 642−647.

    Article  CAS  PubMed  Google Scholar 

  • Oberle, K., and D. Hughes. 2001. Doctors’ and nurses’ perceptions of ethical problems in end-of-life decisions. Journal of Advanced Nursing 33(6): 707−715.

    Article  CAS  PubMed  Google Scholar 

  • Robinson, F., M. Cupples, and M. Corrigan. 2007. Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: Qualitative study. Palliative Medicine 21(4): 305−312.

    Article  PubMed  Google Scholar 

  • Rosenwax, L.K., and B.A. McNamara. 2006. Who receives specialist palliative care in Western Australia—And who misses out. Palliative Medicine 20(4): 439−445.

    Article  CAS  PubMed  Google Scholar 

  • Saint-Arnaud, J. 2009. L’éthique de la santé. Guide pour une intégration de l’éthique dans les pratiques infirmières. Edited by Les Éditions de la Chenelière. Montréal.

  • Sanders, A., M. Schepp, and M. Baird. 2011. Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes? Critical Care Medicine 39(1): 14−18.

    Article  PubMed  Google Scholar 

  • Shalowitz, D.I., E. Garrett-Mayer, and D. Wendler. 2006. The accuracy of surrogate decision makers: A systematic review. Archives of Internal Medicine 166(5): 493−497.

    Article  PubMed  Google Scholar 

  • Statistique Canada. 2012. Tableau 102-0509—Décès en milieu hospitalier et ailleurs, Canada, provinces et territoires, annuel, CANSIM (base de données). http://www5.statcan.gc.ca/cansim/a26?lang=fra&id=1020509. Accessed August 28, 2016.

  • Sulmasy, D.P., J.R. Sood, and W.A. Ury. 2008. Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. Journal of Medical Ethics 34(2): 96−101.

    Article  CAS  PubMed  Google Scholar 

  • Torke, A.M., G.A. Sachs, P.R. Helft, et al. 2011. Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. Journal of the American Geriatrics Society 59(7): 1326−1331.

    Article  PubMed  PubMed Central  Google Scholar 

  • Tremblay, C. 2009. Niveaux de soins et mesures de réanimation. Pour le comité de bioéthique. CSSS de Chicoutimi.

  • Tulsky, J.A. 2005. Beyond advance directives: Importance of communication skills at the end of life. Journal of the American Medical Association 294(3): 359−365.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors thank Mrs. Jane Chambers-Evans for being a crucial collaborator on this research project. The authors also want to recognize Mrs. Maude Laliberté and Dr. Zachary Weinstein for their respective contributions to the article.

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Authors and Affiliations

  1. Public Health School (local 3035), University of Montreal, C. P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada

    Marjolaine Frenette

  2. Department of Social and Preventive Medicine, Public Health School, University of Montreal and Center for Research in Ethics (CRÉ), President Clinical Ethics Committee, Sacré-Coeur Hospital, Montreal, QC, Canada

    Jocelyne Saint-Arnaud

  3. Sacré-Coeur Hospital and University of Montreal, Montreal, QC, Canada

    Karim Serri

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  1. Marjolaine Frenette
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  2. Jocelyne Saint-Arnaud
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Correspondence to Marjolaine Frenette.

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Frenette, M., Saint-Arnaud, J. & Serri, K. Levels of Intervention: How Are They Used in Quebec Hospitals?. Bioethical Inquiry 14, 229–239 (2017). https://doi.org/10.1007/s11673-017-9778-9

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