Shame, health literacy and consent.

This paper is particularly concerned with shame, sometimes considered the 'master emotion', and its possible role in affecting the consent process, specifically where that shame relates to the issue of diminished health literacy. We suggest that the absence of exploration of affective issues in general during the consent process is problematic, as emotions commonly impact upon our decision-making process. Experiencing shame in the healthcare environment can have a significant influence on choices related to health and healthcare, and may lead to discussions of possibilities and alternatives being closed off. In the case of impaired health literacy we suggest that it obstructs the narrowing of the epistemic gap between clinician and patient normally achieved through communication and information provision. Health literacy shame prevents acknowledgement of this barrier. The consequence is that it may render consent less effective than it otherwise might have been in protecting the person's autonomy. We propose that the absence of consideration of health literacy shame during the consent process diminishes the possibility of the patient exerting full control over their choices, and thus bodily integrity.

Courts, rights and the critically brain-injured patient.

The reality of current clinical practice in the UK is that where a patient's family refuses to agree to testing for brain stem death (BD), such cases will ultimately end up in court. This situation is true of both adults and children and reinforced by recent legal cases. While recourse to the courts might be regrettable in such tragic cases, if public trust in the medical diagnosis of BD is to be maintained all aspects of the process must be conducted in a way that is transparent and open to scrutiny. This is not an 'ineffective expenditure' of resources, but an essential element of a human rights-compliant legal system.

Consent to testing for brain death.

Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that 'UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent'. This is supplemented by the claim that recent court decisions in the UK similarly confirm that consent is not required, referencing two judgements in Battersbee We disagree with the authors' interpretation of the law on consent in the UK and argue that there is nothing in Battersbee to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required.

Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices.

BACKGROUND: Perioperative medication errors (MEs) are complex, multifactorial, and a significant source of in-hospital patient morbidity. Anesthesiologists' awareness of error and the potential for harm is not well understood, nor is their attitude to reporting and disclosure. Anesthesiologists are not routinely exposed to medication safety training. METHODS: Ten clinical vignettes, describing an ME or a near miss, were developed using eDelphi consensus. An online survey instrument presented these vignettes to anesthesiologists along with a series of questions assessing error awareness, potential harm severity, the likelihood of reporting, and the likelihood of open disclosure to the patient. The study also explored the influence of prior medication safety training. RESULTS: Eighty-nine anesthesiologists from 14 hospitals across Ireland (53.9% were residents, and 46.1% were attendings) completed the survey. Just 35.6% of anesthesiologists recalled having had medication safety training, more commonly among residents than attendings, although this failed to reach significance (P < 0.081). Medication error awareness varied with the vignette presented. Harm severity assessment was positively associated with error awareness. The likelihood of patient disclosure and incident reporting was both low and independent of harm severity assessment. CONCLUSIONS: Perioperative ME awareness and assessment of potential harm by anesthesiologists is variable. Self-reported rates of incident reporting and error disclosure fall short of the standards that might apply in an environment focused on candor and safety. An extensive education program is required to raise awareness of error and embed appropriate reporting and disclosure behaviors. Vignettes, designed by consensus, may be valuable in the delivery of such a curriculum.

The use of Lean Methodology to reduce personal protective equipment wastage in children undergoing congenital cardiac surgery, during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has compounded many existing healthcare delivery challenges including long waiting lists and cost containment. New challenges have arisen, such as demand on supply of personal protective equipment (PPE) and the implications of social distancing on staff, patients, and their families. Despite the pandemic, the need to deliver safe, urgent congenital cardiac surgery has remained. OBJECTIVE: To demonstrate how Lean methodology can improve PPE supply chain demand and reduce staff exposure to children with unknown SARS-CoV-2 status undergoing congenital cardiac surgery, during the COVID-19 pandemic. METHODS: We implemented the define, measure, analyze, improve, and control method (DMAIC) and Value Stream Maps to eliminate waste steps during testing for SARS-CoV-2 for children undergoing congenital cardiac surgery. RESULTS: Following a 3-week period of implementation of this new value stream map, we reduced PPE set usage from 13 to 1 per patient, resulting in an annual saving of over €36,000 and reducing single-use plastic waste by nearly 70 000 pieces per annum. We reduced numbers of staff exposed to patients with an unknown SARS-CoV-2 status from 13 to 1. CONCLUSION: The use of Lean methodology can reduce waste of PPE and plastic, resulting in cost savings, while reducing staff exposure when testing patients with congenital cardiac disease for SARS-CoV-2. By preventing admission of SARS-CoV-2-positive patients, we can reduce use of isolation beds and prevent cancellation of surgery, improving patient flow and departmental efficiency. Other departments in our institution are implementing similar admission pathways to allow surgical services to restart during the ongoing pandemic.

Health-related shame: an affective determinant of health?

Despite shame being recognised as a powerful force in the clinical encounter, it is underacknowledged, under-researched and undertheorised in the contexts of health and medicine. In this paper we make two claims. The first is that emotional or affective states, in particular shame, can have a significant impact on health, illness and health-related behaviours. We outline four possible processes through which this might occur: (1) acute shame avoidance behaviour; (2) chronic shame health-related behaviours; (3) stigma and social status threat and (4) biological mechanisms. Second, we postulate that shame's influence is so insidious, pervasive and pernicious, and so critical to clinical and political discourse around health, that it is imperative that its vital role in health, health-related behaviours and illness be recognised and assimilated into medical, social and political consciousness and practice. In essence, we argue that its impact is sufficiently powerful for it to be considered an affective determinant of health, and provide three justifications for this. We conclude with a proposal for a research agenda that aims to extend the state of knowledge of health-related shame.

Adherence to imatinib among patients attending Saskatchewan Cancer Agency Pharmacies.

RATIONALE: Chronic use of imatinib confers an important survival benefit for individuals with chronic myeloid leukemia. In Saskatchewan, the provincial cancer agency addresses important barriers to adherence by providing imatinib at no cost through specialized cancer centers. OBJECTIVE: To describe adherence to imatinib dispensed through the Saskatchewan Cancer Agency. STUDY DESIGN AND METHODS: We conducted a retrospective analysis of electronic pharmacy dispensation records from the Saskatchewan Cancer Agency. All dispensations for imatinib classified for hematologic malignancies were electronically abstracted by cancer center personnel and securely forwarded to investigators with all meaningful patient identifiers removed. All subjects receiving a new dispensation (i.e. using a 6-month washout period) for imatinib between 1 June 2004 and 31 December 2011 were included. The primary endpoint was optimal adherence to imatinib during the first year of therapy, defined as a medication possession ratio ≥ 80%. RESULTS: Ninety-one subjects were started on imatinib during the observation period. During the first year of therapy, 82.4% (75/91) maintained a medication possession ratio ≥ 80%. The percentage of individuals maintaining optimal adherence decreased only slightly when the observation period was extended to 2 (78.4%) or 3 years (78.8%). CONCLUSIONS: Non-adherence to imatinib is relatively infrequent when provided by the Saskatchewan Cancer Agency.

Integrating pharmacists into primary care teams: barriers and facilitators.

OBJECTIVES: This study evaluated the barriers and facilitators that were experienced as pharmacists were integrated into 23 existing primary care teams located in urban and rural communities in Saskatchewan, Canada. METHODS: Qualitative design using data from one-on-one telephone interviews with pharmacists, physicians and nurse practitioners from the 23 teams that integrated a new pharmacist role. Four researchers from varied backgrounds used thematic analysis of the interview transcripts to determine key themes. The research team met on multiple occasions to agree on the key themes and received written feedback from an external auditor and two of the original interviewees. KEY FINDINGS: Seven key themes emerged describing the barriers and facilitators that the teams experienced during the pharmacist integration: (1) relationships, trust and respect; (2) pharmacist role definition; (3) orientation and support; (4) pharmacist personality and professional experience; (5) pharmacist presence and visibility; (6) resources and funding; and (7) value of the pharmacist role. Teams from urban and rural communities experienced some of these challenges in unique ways. CONCLUSIONS: Primary care teams that integrated a pharmacist experienced several common barriers and facilitators. The negative impact of these barriers can be mitigated with effective planning and support that is individualized for the type of community where the team is located.

Solidarity, children and research.

While research on children is supported by many professional guidelines, international declarations and domestic legislation, when it is undertaken on children with no possibility of direct benefit it rests on shaky moral foundations. A number of authors have suggested that research enrolment is in the child's best interests, or that they have a moral duty or societal obligation to participate. However, these arguments are unpersuasive. Rather, I will propose in this paper that research participation by children seems most reasonable when considered as an act of solidarity; a form of identification with, and provision of practical assistance to, those who are less well off. This is an articulation of the view that many children, and their parents, seem to take seriously the suffering of others, and wish to assist in advancing other children's wellbeing. Perhaps, by fostering an environment in which children are encouraged to take solidarity seriously, participation in research which holds out substantial hope of benefit to those less well off would come to be perceived as a behavioural norm rather than an exceptional practice.

'The good that is interred in their bones': are there property rights in the child?

Bone marrow donation between siblings is a common medical procedure. In some instances, the donor will be a young child incapable of providing either consent or assent, and the intervention is made lawful through the consent of the parent(s). Although a number of justifications have been formulated to cover this act with legitimacy, these fail to describe accurately the transaction that takes place. In the absence of the child authorising his parents to act as his proxy, it is unclear why parental consent is sufficient to permit the redistribution of his biological wealth. Instead, where the donor is such a young child, the whole procedure may be construed as the appropriation of bodily tissue from one unconsenting human and its conveyance to a third, albeit related, party. This paper argues that if the parentally authorised transfer of biological material from an unconsenting human to another is legally permissible, it must be on the basis of an implicitly acknowledged property right in the child.