What are the views of Quebec and Ontario citizens on the tiebreaker criteria for prioritizing access to adult critical care in the extreme context of a COVID-19 pandemic?

BACKGROUND: The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario's protocols were presented to the public in a democratic deliberation during the summer of 2022. OBJECTIVES: (1) To explore the perspectives of Quebec and Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. METHODS: This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. RESULTS: A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value - a less acceptable tiebreaker. CONCLUSION: Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria.

Physician and administrator experience of preparing to implement Ontario's intensive care unit Triage Emergency Standard of Care during the COVID-19 pandemic: a qualitative study.

BACKGROUND: As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics. METHODS: We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis. RESULTS: We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard). INTERPRETATION: The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.

Leader as CARER: An ecological approach to designing a resilient MAiD program.

In this article, I use a personal narrative case study approach to describe how the evolution of the Medical Assistance in Dying (MAiD) program at one Canadian hospital is informed by the model of a "care ecology," and how we designed our program to generate resilience and sustainability systemically and structurally, rather than relying on the self-care efforts of individuals. I will also reflect on the leader behaviours required to enable a care ecology, and how this challenges traditional approaches to leadership. This model may be adapted to other high-stress teams to promote longitudinal well-being for healthcare professionals and leaders, as well as quality care for patients and families.

MAiD to Last: Creating a Care Ecology for Sustainable Medical Assistance in Dying Services.

This paper depicts a case study of an organizational strategy for the promotion of ethical practice when introducing a new, high-risk, ethically-charged medical practice like Medical Assistance in Dying (MAiD). We describe the development of an interprofessional program that enables the delivery of high-quality, whole-person MAiD care that is values-based and sustainable. A "care ecology" strategy recognizes the interconnected web of relationships and structures necessary to support a quality experience of MAiD for patients, families, and clinicians. This program exemplifies a care ecology approach that addresses common barriers to entry to MAiD practice, and also meets the needs of a variety of stakeholders through the creation of patient and family resources, team supports, standards of practice, professional development opportunities, organizational infrastructure, and community partnerships. We also describe how a thriving care ecology evolves to remain resilient, and to enable integration as the needs of the organization, team and program change over time. The design and development of this program may be adapted to other jurisdictions and organizations where MAiD is introduced, or where new patient populations become eligible for MAiD. This care ecology model may also be applicable to the creation of sustainable programs that provide other morally controversial or novel clinical services.

Introducing Medical Assistance in Dying in Canada: Lessons on Pragmatic Ethics and the Implementation of a Morally Contested Practice.

Medical Assistance in Dying (MAiD) in Canada has had a tumultuous social and legal history. In the 6 years since assisted dying was decriminalized by the Canadian Parliament in June 2016, the introduction of this practice into the Canadian healthcare system has been fraught with ethical challenges, practical hurdles and grass-roots innovation. In 2021, MAiD accounted for approximately 3.3% of all Canadian deaths annually, and more patients are seeking MAiD year over year as this option becomes more widely know. Unfortunately, some patients who want MAiD are unable to access it in a timely manner because of a lack of willing MAiD providers. This introduction describes statistics about the uptake of MAiD in Canada and the challenges presented by Canadians' rapid acceptance of this end of life care option. In this special edition of HEC Forum about the implementation of MAiD in Canada, authors depict a range of ethical challenges and strategies to address issues related to MAiD access and quality, organizational engagement, clinician recruitment and retention, and support for a morally diverse workforce. In each article, the authors reflect on the question: What are the practical ethics involved in introducing assisted dying into a new healthcare context, and how can ethicists and ethics resources collaborate with stakeholders to ensure the integration of ethical considerations as this practice continues to evolve?

Access Isn't Enough: Evaluating the Quality of a Hospital Medical Assistance in Dying Program.

Following an initial study of the needs of healthcare providers (HCP) regarding the introduction of Medical Assistance in Dying (MAiD), and the subsequent development of an assisted dying program, this study sought to determine the efficacy and impact of MAiD services following the first two years of implementation. The first of three aims of this research was to understand if the needs, concerns and hopes of stakeholders related to patient requests for MAiD were addressed appropriately. Assessing how HCPs and families perceived the quality of MAiD services, and determining if the program successfully accommodated the diverse needs and perspectives of HCPs, rounded out this quality evaluation. This research implemented a mixed-methods design incorporative of an online survey with Likert scale and open-ended questions, as well as focus groups and interviews with staff and physicians, and interviews with MAiD-involved family members. There were 356 online surveys, as well as 39 participants in six focus groups with HCP, as well as fourteen interviews with MAiD-involved family members. Participants indicated that high-quality MAiD care could only be provided with enabling resources such as policies and guidelines to ensure safe, evidence-based, standardized care, as well as a specialized, trained MAiD team. Both focus group and survey data from HCPs suggest the infrastructure developed by the hospital was effective in delivering high-quality MAiD care that supports the diverse needs of various stakeholders. This study may serve as a model for evaluating the impact and quality of services when novel and ethically-contentious clinical practices are introduced to healthcare organizations.

Getting Beyond Pros and Cons: Results of a Stakeholder Needs Assessment on Physician Assisted Dying in the Hospital Setting.

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015-16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study's qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization.

Implementation of Medical Assistance in Dying as Organizational Ethics Challenge: A Method of Engagement for Building Trust, Keeping Peace and Transforming Practice.

This paper focuses on the ethics of how to approach the introduction of MAiD as an organizational ethics challenge, a focus that diverges from the traditional focus in healthcare ethics on the ethics of why MAiD is right or wrong. It describes a method co-designed and implemented by ethics and medical leadership at a tertiary hospital to develop a values-based, grassroots response to the decriminalization of assisted dying in Canada. This organizational ethics engagement method embodied core tenants that drew inspiration from a variety of sources, including poetic ones. These tenants are: make the problem bigger; focus on values; cultivate open moral spaces; and trust emergence. The paper describes how these tenants were put into practice in order to create a rigorous and sustainable MAiD program that delivers high-quality care to patients and families while honoring the moral diversity of the hospital workforce. One of the goals in sharing this method is to provide a roadmap for healthcare organizations in Canada and other jurisdictions around the world that are facing the challenge of responding to patient requests for MAiD following the decriminalization of this care option.

A framework for critical care triage during a major surge in critical illness.

During the COVID-19 pandemic, many jurisdictions experienced surges in demand for critical care that strained or overwhelmed their healthcare system's ability to respond. A major surge necessitates a deviation from usual practices, including difficult decisions about how to allocate critical care resources. We present a framework to guide these decisions in the hope of saving the most lives as ethically as possible, while concurrently respecting, protecting, and fulfilling legal and human rights obligations. It was developed in Ontario in 2020-2021 through an iterative consultation process with diverse participants, but was adopted in other jurisdictions with some modifications. The framework features three levels of triage depending on the degree of the surge, and a system for prioritizing patients based on their short-term mortality risk following the onset of critical illness. It also includes processes aimed at promoting consistency and fairness across a region where many hospitals are expected to apply the same framework. No triage framework should ever be considered "final," and there is a need for further research to examine ethical issues related to critical care triage and to increase the extent and quality of evidence to inform critical care triage.

RéSUMé: Pendant la pandémie de COVID-19, de nombreuses régions ont connu une augmentation de la demande de soins intensifs qui a mis à rude épreuve ou dépassé la capacité de réponse du système de santé existant. Lors de toute augmentation importante de cette demande, un écart par rapport aux pratiques habituelles est nécessaire, y compris la prise de décisions difficiles sur la façon d'allouer les ressources en soins intensifs. Nous présentons un algorithme pour guider ces décisions dans l'espoir de sauver le plus de vies possibles et ce, de la manière la plus éthique possible, tout en respectant, en protégeant et en remplissant les obligations légales et en matière de droits de l'homme. Cet algorithme a été élaboré en Ontario en 2020-2021 dans le cadre d'un processus de consultation itératif avec divers participants, mais a été adopté dans d'autres juridictions avec quelques modifications. L'algorithme comprend trois niveaux de triage en fonction du degré d'augmentation de la demande, ainsi qu'un système permettant de prioriser les patients en fonction de leur risque de mortalité à court terme après l'apparition d'une maladie grave. Il comporte également des processus visant à promouvoir l'uniformité et l'équité dans une région où de nombreux hôpitaux vont appliquer le même algorithme. Aucun algorithme de triage ne devrait jamais être considéré comme « définitif ¼, et il est nécessaire d'approfondir les recherches pour examiner les questions éthiques liées au triage aux soins intensifs et accroître l'étendue et la qualité des données probantes afin d'éclairer le triage aux soins intensifs.

How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study.

BACKGROUND: Medical assistance in dying has been available in Canada for 5 years, but it is unclear which practices contribute to high-quality care. We aimed to describe patient and family perspectives of quality of care for medical assistance in dying. METHODS: We conducted a multi-centre, qualitative descriptive study, including face to face or virtual one-hour interviews using a semi-structured guide. We interviewed 21 english-speaking patients found eligible for medical assistance in dying and 17 family members at four sites in Canada, between November 2017 and September 2019. Interviews were de-identified, and analyzed in an iterative process of thematic analysis. RESULTS: We identified 18 themes. Sixteen themes were related to a single step in the process of medical assistance in dying (MAID requests, MAID assessments, preparation for dying, death and aftercare). Two themes (coordination and patient-centred care) were theme consistently across multiple steps in the MAID process. From these themes, alongside participant recommendations, we developed clinical practice suggestions which can guide care. CONCLUSIONS: Patients and families identified process-specific successes and challenges during the process of medical assistance in dying. Most importantly, they identified the need for care coordination and a patient-centred approach as central to high-quality care. More research is required to characterize which aspects of care most influence patient and family satisfaction.

Becoming a medical assistance in dying (MAiD) provider: an exploration of the conditions that produce conscientious participation.

The availability of willing providers of medical assistance in dying (MAiD) in Canada has been an issue since a Canadian Supreme Court decision and the subsequent passing of federal legislation, Bill C14, decriminalised MAiD in 2016. Following this legislation, Hamilton Health Sciences (HHS) in Ontario, Canada, created a team to support access to MAiD for patients. This research used a qualitative, mixed methods approach to data collection, obtaining the narratives of providers and supporters of MAiD practice at HHS. This study occurred at the outset of MAiD practice in 2016, and 1 year later, once MAiD practice was established. Our study reveals that professional identity and values, personal identity and values, experience with death and dying, and organisation context are the most significant contributors to conscientious participation for MAiD providers and supporters. The stories of study participants were used to create a model that provides a framework for values clarification around MAiD practice, and can be used to explore beliefs and reasoning around participation in MAiD across the moral spectrum. This research addresses a significant gap in the literature by advancing our understanding of factors that influence participation in taboo clinical practices. It may be applied practically to help promote reflective practice regarding complex and controversial areas of medicine, to improve interprofessional engagement in MAiD practice and promote the conditions necessary to support moral diversity in our institutions.

How We Can Improve the Quality of Care for Patients Requesting Medical Assistance in Dying: A Qualitative Study of Health Care Providers.

CONTEXT: Since Canada decriminalized medical assistance in dying (MAID) in 2015, clinicians and organizations have developed policies and protocols to implement assisted dying in clinical practice. Five years on, there is little consensus as to what constitutes high-quality care in MAID. OBJECTIVES: To describe MAID clinicians' perspectives on quality of care in MAID, including challenges, successes, and clinical practice suggestions. METHODS: We conducted an exploratory, multicenter, and qualitative study at four Canadian centers. Using a semistructured interview guide, we conducted interviews with 20 health care providers. Interviews were transcribed and deidentified before analysis. Adopting a qualitative descriptive approach, we used a thematic analysis to identify primary and secondary themes in the interviews and practice suggestions to improve quality of care to patients who request MAID. RESULTS: We identified three major themes. 1) Improving access and patient experience: clinicians described struggles in ensuring equitable access to MAID and supporting MAID patients and their families. 2) Supporting providers and sustainability: clinicians described managing MAID workload, remuneration, educational needs, and the emotional impact of participating in assisted dying. 3) Institutional support: descriptions of MAID communication tools and training, use of standardized care pathways, interprofessional collaboration, and human resource planning. Clinicians also described suggestions for clinical practice to improve quality of care. CONCLUSION: Canadian health care providers described unique challenges in caring for patients who request MAID, along with practices to improve the quality of care.

Double-edged MAiD death family legacy: a qualitative descriptive study.

BACKGROUND: Individuals who accompany a loved one through medical assistance in dying (MAiD) have to live with the experience and the psychological, moral and social consequences of their involvement in the process long after the death occurs. AIM: To explore the legacy of a MAiD death for individuals who accompanied a loved one through the process. DESIGN: Using a qualitative descriptive approach we conducted semi-structured interviews to collect data from family members who had accompanied a loved one through MAiD. Data were analysed using conventional content analysis. SETTING/PARTICIPANTS: 16 family members of 14 patients who received MAiD at a Canadian hospital with an interdisciplinary MAiD programme. RESULTS: The main theme in the analysis is the opposing tensions experienced by individuals who accompany a loved one through a MAiD death, which we conceptualise as a double-edge experience. This double-edge experience is illustrated through four thematic opposing tensions: (1) support for patient autonomy and ambivalence about the MAiD choice, (2) gratitude for suffering relieved for loved one and grief for lost time with loved one, (3) time as a gift and time as a burden and (4) positive legacy and challenging bereavement experience. CONCLUSION: The nature of the MAiD experience for involved families is rooted in complexity, ambiguity and ambivalence and thus resists easy categorisation. Families would benefit from structured psychosocial and spiritual supports that acknowledge this complexity, along with MAiD-specific bereavement support following the death.

Canadian emergency medicine and critical care physician perspectives on pandemic triage in COVID-19.

INTRODUCTION: Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood. We sought to investigate the perspectives of Canadian acute care physicians toward triaging scarce critical care resources in the COVID-19 pandemic. METHODS: We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes toward triaging scarce critical care resources and identify subsequent areas for improvement. Descriptive and between-group analyses along with thematic coding were used. RESULTS: The survey was completed by 261 acute care physicians. Feelings of anxiety related to the pandemic were common (65 percent), as well as fears of psychological distress if required to triage scarce resources (77 percent). Only 49 percent of respondents felt confident in making resource allocation decisions. Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources. Critical care physicians were supportive of decision making by teams not involved in patient care (3.4/5 versus 2.9/5 p = 0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 versus 4.0/5 p = 0.007). Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medicolegal protection, additional tools for therapeutic communications, and healthcare provider psychological support. CONCLUSION: There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments.

Provision of medical assistance in dying: a scoping review.

OBJECTIVES: The purpose of this study is to map the characteristics of the existing medical literature describing the medications, settings, participants and outcomes of medical assistance in dying (MAID) in order to identify knowledge gaps and areas for future research. DESIGN: Scoping review. SEARCH STRATEGY: We searched electronic databases (MEDLINE, EMBASE, PsychINFO, CINAHL and CENTRAL), clinical trial registries, conference abstracts and professional guidelines from jurisdictions where MAID is legal, up to February 2020. Eligible report types included technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies that describe MAID provision in adults who have provided informed consent for MAID. RESULTS: 163 articles published between 1989 and 2020 met eligibility criteria. 75 studies described details for MAID administered by intravenous medications and 50 studies provided data on oral medications. In intravenous protocols, MAID was most commonly administered using a barbiturate (34/163) or propofol (22/163) followed by a neuromuscular blocker. Oral protocols most often used barbiturates alone (37/163) or in conjunction with an opioid medication (7/163) and often recommended using a prokinetic agent prior to lethal drug ingestion. Complications included prolonged duration of the dying process, difficulty in obtaining intravenous access and difficulty in swallowing oral agents. Most commonly, the role of physicians was prescribing (83/163) and administering medications (75/163). Nurses' roles included administering medications (17/163) and supporting the patient (16/163) or family (13/163). The role of families involved providing support to the patient (17/163) and bringing medications from the pharmacy for self-administration (4/163). CONCLUSIONS: We identified several trends in MAID provision including common medications and doses for oral and parenteral administration, roles of healthcare professionals and families, and complications that may cause patient, family and provider distress. Future research should aim to identify the medications, dosages, and administration techniques and procedures that produce the most predictable outcomes and mitigate distress for those involved.

Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning and resource needs.

OBJECTIVE: We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments (EDs) in order to build ethics capacity and provide a foundation for the development of an ethics education programme. METHODS: This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. RESULTS: Of the 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress (16%), conflict management with patients or families (16%) and resource issues (15%). Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams (42%) was the most desired method. CONCLUSIONS: Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists.

The provision of medical assistance in dying: protocol for a scoping review.

INTRODUCTION: Medical assistance in dying (MAID), a term encompassing both euthanasia and assisted suicide, was decriminalised in Canada in 2015. Although Bill C-14 legislated eligibility criteria under which patients could receive MAID, it did not provide guidance regarding the technical aspects of providing an assisted death. Therefore, we propose a scoping review to map the characteristics of the existing medical literature describing the medications, settings, participants and outcomes of MAID, in order to identify knowledge gaps and areas for future research. METHODS AND ANALYSIS: We will search electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL, PsycINFO), clinical trial registries, conference abstracts, and professional guidelines and recommendations from jurisdictions where MAID is legal, up to June 2017. Eligible report types will include technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies. We will include all descriptions of MAID provision (either euthanasia or assisted suicide) in adults who have provided informed consent for MAID, for any reason, including reports where patients have provided consent to MAID in advance of the development of incapacity (eg, dementia). We will exclude reports in which patients receive involuntary euthanasia (eg, capital punishment). Two independent investigators will screen and select retrieved reports using pilot-tested screening and eligibility forms, and collect data using standardised data collection forms. We will summarise extracted data in tabular format with accompanying descriptive statistics and use narrative format to describe their clinical relevance, identify knowledge gaps and suggest topics for future research. ETHICS AND DISSEMINATION: This scoping review will map the range and scope of the existing literature on the provision of MAID in jurisdictions where the practice has been decriminalised. The review will be disseminated through conference presentations and publication in a peer-reviewed journal. These results will be useful to clinicians, policy makers and researchers involved with MAID.

The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents.

Empathy is an essential attribute for medical professionals. Yet, evidence indicates that medical learners' empathy levels decline dramatically during medical school. Training in evidence-based observation and mindfulness has the potential to bolster the acquisition and demonstration of empathic behaviours for medical learners. In this prospective cohort study, we explore the impact of a course in arts-based visual literacy and mindfulness practice (Art of Seeing) on the empathic response of medical residents engaged in obstetrics and gynaecology and family medicine training. Following this multifaceted arts-based programme that integrates the facilitated viewing of art and dance, art-making, and mindfulness-based practices into a practitioner-patient context, 15 resident trainees completed the previously validated Interpersonal Reactivity Index, Compassion, and Mindfulness Scales. Fourteen participants also participated in semistructured interviews that probed their perceived impacts of the programme on their empathic clinical practice. The results indicated that programme participants improved in the Mindfulness Scale domains related to self-confidence and communication relative to a group of control participants following the arts-based programme. However, the majority of the psychometric measures did not reveal differences between groups over the duration of the programme. Importantly, thematic qualitative analysis of the interview data revealed that the programme had a positive impact on the participants' perceived empathy towards colleagues and patients and on the perception of personal and professional well-being. The study concludes that a multifaceted arts-based curriculum focusing on evidence-based observation and mindfulness is a useful tool in bolstering the empathic response, improving communication, and fostering professional well-being among medical residents.

Ethical issues experienced by healthcare workers in nursing homes: Literature review.

BACKGROUND: Ethical issues are increasingly being reported by care-providers; however, little is known about the nature of these issues within the nursing home. Ethical issues are unavoidable in healthcare and can result in opportunities for improving work and care conditions; however, they are also associated with detrimental outcomes including staff burnout and moral distress. OBJECTIVES: The purpose of this review was to identify prior research which focuses on ethical issues in the nursing home and to explore staffs' experiences of ethical issues. METHODS: Using a systematic approach based on Aveyard (2014), a literature review was conducted which focused on ethical and moral issues, nurses and nursing assistants, and the nursing home. FINDINGS: The most salient themes identified in the review included clashing ethical principles, issues related to communication, lack of resources and quality of care provision. The review also identified solutions for overcoming the ethical issues that were identified and revealed the definitional challenges that permeate this area of work. CONCLUSIONS: The review highlighted a need for improved ethics education for care-providers.

Assessing family members' satisfaction with information sharing and communication during hospital care at the end of life.

CONTEXT: Despite the fact that most deaths occur in hospital, problems remain with how patients and families experience care at the end of life when a death occurs in a hospital. OBJECTIVES: (1) assess family member satisfaction with information sharing and communication, and (2) examine how satisfaction with information sharing and communication is associated with patient factors. METHODS: Using a cross-sectional survey, data were collected from family members of adult patients who died in an acute care organization. Correlation and factor analysis were conducted, and internal consistency assessed using Cronbach's alpha. Linear regression was performed to determine the relationship among patient variables and satisfaction on the Information Sharing and Communication (ISC) scale. RESULTS: There were 529 questionnaires available for analysis. Following correlation analysis and the dropping of redundant and conceptually irrelevant items, seven items remained for factor analysis. One factor was identified, described as information sharing and communication, that explained 76.3% of the variance. The questionnaire demonstrated good content and reliability (Cronbach's alpha 0.96). Overall, family members were satisfied with information sharing and communication (mean total satisfaction score 3.9, SD 1.1). The ISC total score was significantly associated with patient gender, the number of days in hospital before death, and the hospital program where the patient died. CONCLUSIONS: The ISC scale demonstrated good content validity and reliability. The ISC scale offers acute care organizations a means to assess the quality of information sharing and communication that transpires in care at the end of life.