Association Between Immigrant Status and End-of-Life Care in Ontario, Canada: https://jamanetwork.com/journals/jama/fullarticle/2656223 Brain death case: https://blg.com/en/News-And-Publications/Publication_5338 Resource Optimization Network website: https://www.resourceoptimizationnetwork.com/ Follow us on twitter: @Kwadcast Please send your comments/feedback to kwadcast99@gmail.com Episode transcript: Kwadwo: 00:01 Welcome to solving healthcare. I'm Kwadwo Kyeremanteng. I'm an ICU and palliative care physician here in Ottawa and the founder of resource optimization network. We are on a mission to transform healthcare in Canada. I'm going to talk with physicians, nurses, administrators, patients and their families because inefficiencies, overwork and overcrowding affects us all. I believe it's time for a better healthcare system, best more cost effective, dignified and just for everyone involved. Kwadwo: 00:37 Thanks everybody for joining us on solving healthcare. It's your host Kwadwo Kyeremanteng. Before joining our second part of the conversation I had with Dr. Gianni D'Egidio, I just wanted to talk about a couple of things. Number one, I have been extremely overwhelmed and grateful for the feedback I've received about part one. It's been mostly from nurses within critical care and, and what they've fed back to us is how meaningful it's been that somebody has been advocating for their concerns. And I gotta tell ya, you know, it really does come from the heart when you see how hard these these guys work to try and improve Karen and get their patients better and functional. And I had this moment a couple days ago. Uh, working in the ICU is like three in the morning and brought down a fairly sick patient and watching everybody moved together and working together to get that patient comfortable, to get that patient set up, to provide speedy, efficient and honestly love and care it, it is truly was magical and sometimes you take for granted what people do. Kwadwo: 02:17 And I, I just wanna I wanted to mention again, these guys are my mini heroes, how hard they work, how excellent they are at their job and it can't be, can't be overstated. Um, so I just wanted to mention that real quick. The other thing, uh, was going to mention in terms of any feedback, you could send an email@quadcastninenineatgmail.com and you could follow us @Kwadcast on Twitter. Okay. So part two of our conversation with Gianni D'Egidio it's a good one. I won't lie to you. We talk about how culture can impact the level of care that is requested. We talk about Gianni's ability to discharge patients efficiently. We talk about the dangers of dr Google. We all know dr Google seems to know everything, but does he or she, we talk about the perception the media gives on medical care and the villainized nation of physicians. And then we talk about these recent brain death cases. So, so just to clarify, these are cases where patients are declared dead cause they're brain dead and the family has questioned that diagnosis and and have appealed to the courts for judgment. So without further ado, dr Gianni D'Egidio Gianni: 03:59 I'll answer it again. The drive to address these issues to confront families I the dry, where's it coming from? It is an absolute, I'm absolutely infuriated with the, I guess absurdity of these cases when if you, a rational objective individual would look at this and say this does not make sense. And this brings us into the topic of what is driving this from the substitute decision maker side of things. And these are my comments and some of it supported by evidence. Some of it supported by just my anecdote. The of these 12 individuals in my study, only one was born in Canada. The vast majority of individuals, 11 out of the 12 were not born in Canada. And there was always a religious argument to their, um, request for therapy. And this is similar, not exactly the same, but to a Dr. Fowler study from Toronto looking at individuals who are recent immigrants to Canada. Gianni: 05:06 We'll re, we'll demand, well not demand, but will undergo sociology. Yeah. It's associated with more aggressive care towards end of life. Right? So there's a religious cultural factor to it and I'm not being demeaning about that or whatever else, but this brings us into a bigger societal issue of the inability of, of religion to appropriately deal with death. I find, um, if we're going to, uh, say that physicians are not properly educated and cannot deal with death, I would have to make the exact same argument for religion. Um, there is this consistent argument that life at all costs and despite every single religion saying, Hey, when you die, you're actually going to go to whatever it may be, let's say heaven and better place, whatever else. Um, and there's this consistent argument, which again, if you speak to religious leaders from every associated faith, there'll be a disagreement about how aggressive to be towards end of life. And I've had that because we're fortunate that at our institution has spiritual care services and some very well respected members of the religious community of all different types of faith who will, who I've had the opportunity to discuss this with. And they agree that yes, we don't need to be this aggressive towards end of life. So that brings up a whole other, like you could do a whole other podcast on, on that. And I'm not gonna get into the sides that Kwadwo: 06:28 that is a, a monster topic. Um, so one thing we haven't touched on is like how exactly are we going to fix these issues? So we've identified that, you know, culturally we, it's hard to accept death. Uh, we, we see that we could be better communicators, better, better at dealing with advanced care planning, goals of care discussions and so forth. We talked about how conflict manage, like we're not taught how to manage conflict in medical school and in residency. And fellowship or as even staff really. So where do, where's the biggest bang for your buck? Where should we, how do we fix this business? Gianni: 07:17 Um, I guess I'll, I'll go back to the points I made earlier about, um, lack of education and then the fear component. Uh, tying it back to those two things in terms of education, we need to be educated on how to confidently propose a treatment plan. And you can't teach confidence, but you have to be able to reassure individuals. And I try to tell my med students and residents this, that yes, getting sued or getting a complaint absolutely sucks. If you follow the ethical, legal and medical framework of proposing an appropriate treatment plan, you will be absolutely fine. Yes, it's gonna suck. You'll get a college complaint, you might get sued, that's gonna take years of potentially of your life. But there are methods to deal with that. And the vast majority of the time, I think, at least from what I know, you're going to be absolutely fine in the end, but you have to deal with that. Gianni: 08:12 Um, and I'm not trying to minimize these issues, but you, you're going to have to deal with that. And that gets into a system or of a system type of, of issue is why is it as physicians, when we try to do the right thing in these certain cases that we are absolutely going to get punished for it. There has got to be some either new legislation and new policy that will allow us to constrain the treatment options available to an individual and at the same time guarantee that this not, this does not get dragged through the courts or result in complaints or whatever else it may be. Now these are for the extreme cases. Um, but there has to be some sort of change in legislation. And this brings us back to the study that the, about the ethical failings of, of the CPS policy and the health care consent act, those, those two things need to change and they need to be more supportive of other ethical principles. And I'll be Frank, need to be more supportive of the healthcare teams that are involved because with changing technology and changing, um, demands from the public, this is only gonna get worse unless those two pieces of policy and legislation change. Kwadwo: 09:18 Yeah. I mean like you look at it, you're going to have more, less engagement by a care teams and less people are gonna want to do this for a living. The longevity of our nurses, allied health decreasing, you're seeing more physician burnout, you're seeing more and more physician issues in terms of mental health, wellness and so forth. And then, I don't want to keep harboring this, but like the financial impact, when you look at the decreasing labor force, when you look at providing care, like it really is defensive medicine. You're providing care because you're afraid of the consequences of, of the complaint of you ha or you're afraid of the consequences of, of being sued. Like it's a lot, you know, and like, and then in our current environment we end up cutting services that are often most beneficial like social work, physio-therapy spiritual care, like all that stuff is being cut. Kwadwo:
