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The surprise question — “Would I be surprised if this patient died in the next 12 months?” — has been used to identify patients at high risk of death who might benefit from palliative care services. Our objective was to systematically review the performance characteristics of the surprise question in predicting death. We searched multiple electronic databases from inception to 2016 to identify studies that prospectively screened patients with the surprise question and reported on death at 6 to 18 months. We constructed models of hierarchical summary receiver operating characteristics (sROCs) to determine prognostic performance. Sixteen studies (17 cohorts, 11 621 patients) met the selection criteria. For the outcome of death at 6 to 18 months, the pooled prognostic characteristics were sensitivity 67.0% (95% confidence interval [CI] 55.7%–76.7%), specificity 80.2% (73.3%–85.6%), positive likelihood ratio 3.4 (95% CI 2.8–4.1), negative likelihood ratio 0.41 (95% CI 0.32–0.54), positive predictive value 37.1% (95% CI 30.2%–44.6%) and negative predictive value 93.1% (95% CI 91.0%–94.8%). The surprise question had worse discrimination in patients with noncancer illness (area under sROC curve 0.77 [95% CI 0.73–0.81]) than in patients with cancer (area under sROC curve 0.83 [95% CI 0.79–0.87; p = 0.02 for difference]). Most studies had a moderate to high risk of bias, often because they had a low or unknown participation rate or had missing data. The surprise question performs poorly to modestly as a predictive tool for death, with worse performance in noncancer illness. Further studies are needed to develop accurate tools to identify patients with palliative care needs and to assess the surprise question for this purpose.

The current novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic will likely strain Canada's health care system beyond capacity, and many people are expected to die as a result. Here, Arya et al discuss the challenges involved in providing palliative care in a pandemic.

Background Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. Methods We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. Results A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. Conclusion We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.

Medical assistance in dying (MAiD) is a controversial topic that is now legal in many jurisdictions. Policymakers are questioning what motivates people to request MAiD and whether better access to palliative care could prevent these requests. In all jurisdictions where MAiD is permitted, the requestor must have an incurable illness and either intolerable suffering or a short prognosis. The populations receiving MAiD in different jurisdictions are similar, with most recipients having a terminal illness such as cancer or ALS. Many MAiD recipients are followed by palliative care services before receiving MAiD. Some have suggested that poor quality and timing of palliative care may drive MAiD requests. However, the evidence shows that socioeconomic deprivation and service gaps statistically protect against MAiD. Palliative care is known to have limited effectiveness in relieving the type of suffering that prompts MAiD requests, which is often related to loss of autonomy or dignity. Here, Downar et al explore the role of supportive resources for people with disabilities and socioeconomic status in MAiD requests.

Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario’s early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario. We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD. A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient’s care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons). Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.

In Canada, organ donation from deceased donors is a common practice that saves or improves the lives of more than nearly 2000 Canadians every year, accounting for more than 3 of 4 of all transplanted organs. Deceased donation is permitted after either neurologic or circulatory determination of death, with the latter accounting for 25% of all organs donated in Canada in 2017.1 The current Canadian guideline recommendations for donation after circulatory determination of death, published in 2006, address the conventional scenario of an unconscious, incapable, critically ill patient not expected to survive the withdrawal of life-sustaining measures. The target audience of this guidance consists of clinicians, organ donation organizations, end-of-life care experts, medical assistance in dying providers and policy-makers. This document is intended to inform policies related to offering organ and tissue donation to patients who have made a decision that will lead to imminent death.

Downar et al respond to criticisms of their article on MAiD. As the senders of the letter sought clarification about how palliative care involvement was defined, they directed them to Appendix 2 of their article for details about what was available in medical assistance in dying database and how the information was obtained. While they acknowledged that medical assistance in dying remains a controversial subject in the medical community, the findings of their study do not resolve this controversy. But for those who are keen to address the underlying drivers of MAiD, their study offers some insight into what those might be.

In the past few years, Ontario has made international news because of a series of landmark legal cases involving end-of-life conflicts. On Aug 20, 2019, the Ontario Superior Court of Justice dismissed a key medical malpractice case brought by Joy Wawrzyniak against 2 physicians who wrote a do-not-resuscitate (DNR) order in her father's medical record without consent and refused to start cardiopulmonary resuscitation (CPR) when she requested it. The plaintiff's father, an 88-year-old man with multiple comorbidities, had multiorgan system failure after a bilateral above-knee amputation for gangrene. In 2013, the Supreme Court of Canada, in the Rasouli case, determined that consent was required under the act to withdraw life-sustaining therapies even if the treating physician deemed them nonbeneficial, because withdrawing life support entails physical interference with the patient's body and is closely associated with the provision of palliative care.

Many bereaved family members (FMs) of intensive care unit decedents experience symptoms of complicated grief (CG) or social distress, but there is no standard screening or follow-up for these individuals. We determined the desirability and need for an intensive care unit–based bereavement screening and support program for these FMs. We surveyed bereaved FMs to measure symptoms of CG, prolonged grief disorder, and social difficulties and the desire for support; and staff physicians and nurses at 2 teaching hospitals in Toronto, Canada, to determine comfort and interest in providing routine bereavement support. We could not contact 69% of FMs largely because of inaccuracies in the patient record. Of the 64 who were contacted, 32 (50%) agreed to be surveyed a mean (SD) of 7.4 (2.2) months after the loss of their relative. Among eligible staff, 57 (61%) of 94 completed the questionnaire. Nine (28%) FMs met subthreshold criteria for CG or prolonged grief disorder, and 7 (22%) met criteria for social distress. Only 10 (31%) had received professional support for emotional symptoms, and 2 (6%) received professional assistance for their social difficulties. Fifty-eight percent supported routine screening, and 68% wanted to receive (or receive more) support. Fifty-five percent of FMs expressed a strong willingness to meet with the medical team to review events surrounding the death of the patient, which was the type of support that the health care staff were most comfortable providing. Most staff (85%) reported providing emotional support at the time of death, but few provided any support afterwards. Fifty-six (98%) of 57 would be willing to support or participate in a formal bereavement screening and support program. Respondents cited the need for training and dedicated time to carry out such a program. An ICU-based bereavement screening and support program for FMs of ICU decedents is both needed and desirable, although there are important needs and barriers. Future studies should evaluate the effectiveness for such a program at improving outcomes among bereaved FMs.

Since Canadian Blood Services (CBS) developed policy guidance in 2019 for organ and tissue donation after medical assistance in dying (MAiD), the federal government has made changes to legislation related to MAiD. This document provides updated guidance for clinicians, organ donation organizations, end-of-life care experts, MAiD providers and policy-makers on the impact of these changes. Canadian Blood Services assembled a group of 63 experts from critical care, organ and tissue donation, health care administration, MAiD, bioethics, law and research to review the legislative changes in the Organ and Tissue Donation After Medical Assistance in Dying – Guidance for Policy forum. Two patients who had requested and been found eligible for MAiD and 2 family members of patients who had donated organs after MAiD were also included as participants. In a series of 3 online meetings from June 2021 to April 2022, forum participants addressed a variety of topics in small and large groups. These discussions were informed by a comprehensive scoping review using JBI methodology. We used an adapted form of nominal group technique to develop the recommendations, which were approved by consensus of the participants. Management of competing interests was in accordance with Guideline International Network principles. Although many of the recommendations from the guidance developed in 2019 are still relevant, this guidance provides 2 updated recommendations and 8 new recommendations in the following areas: referral to an organ donation organization, consent, directed and conditional donation, MAiD procedures, determination of death, health care professionals and reporting. Policies and practices for organ and tissue donation after MAiD in Canada should align with current Canadian legislation. This updated guidance will help clinicians navigate the medical, legal and ethical challenges that arise when they support patients pursuing donation after MAiD.