On the two year anniversary of the enacting of federal legislation on Medical Assistance in Dying (M.A.I.D), Health Canada published its third interim report(1). This report provides insight into how many medically-assisted deaths have taken place, the settings in which they occurred, the individual’s age and gender, as well as the most common underlying medical conditions of those who have received an assisted death. The report states that a total 3,714 Canadians have undergone a medically-assisted death since both Quebec and federal legislation came into force. This means that M.A.I.D only accounted for just over 1% of the total deaths in Canada during this reporting period, which is consistent with that of other countries that permit medically-assisted deaths.

The report indicates that in 2017, the majority of individuals undergoing an assisted-death were over the age of 56 (average age – 73 years old) and with a reasonably even distribution between males and females. By far the most common underlying medical conditions were cancer-related; followed by neurodegenerative disorders and circulatory/respiratory system disorder. During 2017, almost all medically-assisted deaths were administered by a physician; with only a small number being administered by a nurse practitioner and almost none being self-administered. Interestingly, there appears to be nearly the exact same number of medically-assisted deaths taking place in a hospital setting as there are in the patient’s home, and relatively few occurring in long-term care homes or hospices.

Loss of competency and death not being “reasonably foreseeable” appear to be the most frequent reasons why requests for M.A.I.D have been declined over the past two years. Bill C-14 currently states that only people who are facing foreseeable death can receive aid to die, and this provision has sparked a number of legal challenges that claim that this criteria is counter to individual Charter rights. In addition, near the end of 2018 the Liberal government received three expert panel reports examining the possibility of extending M.A.I.D to “mature minors” (defined as those individuals under the age of 18 who are considered to be capable of directing their own care), as well as to people with psychiatric conditions and those making requests in advance(2).

Medically-assisted death may now be legal in Canada, but the debate on who should be eligible to receive, as well as other criteria, is far from over. As the framework around M.A.I.D continues to expand and evolve, it is important for RTs to remain knowledgeable. Up-to-date information on M.A.I.D is provided by Health Canada at https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html/ . In addition, specific information on the RT role in M.A.I.D can be found on the CRTO website at http://www.crto.on.ca/members/professional-practice/physician-assisted-death-pad.

(1) Health Canada. (2018, June). Third Interim Report on Medical Assistance in Dying in Canada. Retrieved from https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-june-2018/medical-assistance-dying-interim-report-june-2018-eng.pdf

(2) CBC. (2019, Jan. 3). The next frontier in the ‘right to die’: advance requests, minors and the mentally ill. Retrieved from https://www.cbc.ca/news/politics/maid-assisted-death-minors-mental-illness-1.4956388

Academic integrity – or lack thereof – appears to have become a very serious issue for colleges and universities throughout North America. In 2015, Dartmouth College (a private Ivy League in New Hampshire) suspended 64 students for cheating – in an ethics class!(1) (I have included a reference here for fear of being accused of plagiarism). Studies conducted in the U.S. reveal that more than 70 percent of students admit to cheating at some point in time in a college or university course.(2) Canada is not far behind. An investigation by the CBC into academic misconduct at 54 Canadian universities found that more than half of students admitted to having cheated on a test in the past year, with more than a third acknowledging that they did so more than twice.(3) It seems that many students simply feel that they need to cheat in order to get ahead.

We can certainly try to point the blame at our “winning at all costs” society. Politicians and celebrities tell blatant lies – athletes use performance enhancing drugs. Custom-written essays can be purchased online, and apps can print formulas on the inside of water bottle labels. Of course, there is also the proliferation of technology that takes cheating into a whole new realm beyond writing formulas on one’s palm. There are programmable calculators, smart watches, Google Glasses™ and even smart contact lenses (and I recently learning there is such a thing as a “smart ring”). All these devices have the potential to assist students in cheating on exams with minimal risk of detection.

What concerns me about this is not so much the “how,” but the “why”. Research into academic misconduct at Canadian post-secondary institutions indicates that the students who are caught cheating are often not those desperately trying to simply pass the course. They are frequently high achievers with good grades driven by an extrinsically motivated need for external validation.(4)  And yet healthcare is essentially an altruistic profession that requires intrinsically motivated individuals driven to be sufficiently competent to provide the best possible care to others.

I certainly don’t in any way have the answers to this problem. Smaller class sizes and more individualized instructions have been shown to reduce the incidence of academic misconduct. I simply think it is something we should all be aware of and concerned about. Students in RT programs who cheat on exams and assignments may not graduate possessing all the requisite knowledge to become competent practitioners in a profession that demands a high degree of knowledge and skill. If that happens, I think it is fairly obvious who is being cheated.

(1) Barthel, M. (2016, April 20). How to stop cheating in college. The Atlantic. Retrieve from https://www.theatlantic.com/education/archive/2016/04/how-to-stop-cheating-in-college/479037/

(2) Gillis, A. (2007, March 12). Cheating themselves. University Affairs. Retrieved from https://www.universityaffairs.ca/features/feature-article/cheating-themselves/

(3) CBC News. Special Report. (n.d.). Campus cheaters. Retrieved from https://www.cbc.ca/manitoba/features/universities/

(4) Gillis, A. (2007, March 12). Cheating themselves. University Affairs. Retrieved from https://www.universityaffairs.ca/features/feature-article/cheating-themselves/

Elizabeth Wettlaufer, former registered nurse, is back in the news again this week with the opening of the Long-Term Care Homes Public Inquiry. Ms. Wettlaufer – in case you have forgotten – pled guilty to eight counts of 1st degree murder, four counts of attempted murder and two counts of aggravated assault back in June 2017. What makes her actions particularly heinous is that she caused this grievous harm to human life while providing healthcare services to vulnerable, elderly patients. When Wettlaufer was a practicing RN, she not only failed to provide optimal patient care – she intentionally injected her patients with enough insulin to end their lives. And, for the most part, she did this while working surrounded by other nurses, other healthcare providers and administrators.

The goal of the Long-Term Care Homes Public Inquiry is to determine how our current healthcare system allowed something like this to happen, as well as how we can prevent anything like that from occurring again. There are many parties to this investigation including the various long-term care facilities where Wettlaufer worked, regulatory bodies, professional associations, unions and government. Undoubtedly, all these various organizations will be asked in the coming weeks to account for the roles they played – or failed to play – in this latest healthcare catastrophe.

This inquiry comes at a time when we are already experiencing an erosion of public trust in the entire healthcare system – not just long-term care. Almost half of Canadians do not believe they are receiving quality health care (i). Part of this erosion in public trust comes from the perception that the healthcare system is not transparent about its flaws, and that when a problem is identified, the system is slow to take any corrective action. The Wettlaufer case is undeniably a tragedy, but it has been referred to as merely “the tip of the iceberg”(ii) .

So the question becomes, what can we as RTs do about it? The CRTO routinely receives questions from RTs regarding what to do about faults they see within their own healthcare organizations, and our advice is almost always – “raise your voices”. If you have a concern about a regulated healthcare professional’s practice, tell your supervisor/manager AND contact the individual’s regulatory body. Just because you reach out to a health professional’s College, doesn’t mean you are committed to reporting the individual. The staff at a regulatory body can talk you through the process and help guide you to the most appropriate action. And if you have concerns that certain organizational processes are putting patients at risk, report this immediately to as many departments as required – and as often as required – to ensure your message is heard.

We all have a role to play in earning back the public’s trust, and we all have a responsibility to speak up.

(i)McGill University. (2016). The Health Care in Canada Survey. Retrieved from https://www.mcgill.ca/hcic-sssc/files/hcic-sssc/hcic_2016_results_01-trends.pdf

(ii)Dubinski, K. (2017, June 26). Province calls public inquiry into long-term care homes. CBC News. Retrieved from http://www.cbc.ca/news/canada/london/public-inquiry-ontario-long-term-care-homes-wettlaufer-1.4178185

Do you know what I think is most surprising about the recent Harvey Weinstein scandal? Absolutely nothing. Same story; different day. It was Bill Cosby and Bill O’Reilly last week and its Harvey Weinstein this week. Guaranteed it will be someone else next week.  And these are just the men who are rich and powerful enough to make the news.  It doesn’t even deserve to be called news. Everyone knows that workplace sexual harassment exists in virtually every organization where a power imbalance exists – also known as practically everywhere.

The world of healthcare is full of power imbalances – physicians and other healthcare providers, managers and staff, staff and students…as well as any of the above and patients. However, I think we all recognize sexual impropriety of any form involving patients as being entirely unacceptable.  What we often fail to identify are the numerous forms of sexual harassment – some subtle, some not so much – that are inflicted every day and in every way on healthcare providers by other providers of healthcare.

Some informal research into sexual harassment in healthcare has observed that it is so commonplace now that “it might as well be in the job descriptions”.  We have become desensitized to it.  We even make excuses for it. How often have you heard, “oh, he’s just kidding “or “that’s just the way he is…he’s harmless”.  And the complex power dynamic that exists within healthcare organizations often makes it challenging to bring allegations of harassment forward and to have those assertions addressed without repercussion (or what feels like repercussion).  This is particularly true of students, who arguably have the least power in the workplace and are thus, the most at risk of being the victims of sexual harassment.

Over the past two decades the CRTO has investigated a handful of cases of sexual harassment perpetrated by staff RTs on student RTs.  And we heard the same “oh, it was just a joke” and “he didn’t mean anything by it” types of responses.  However, there is nothing particularly funny about having to stifle a full-body shudder when the person who is responsible for signing-off your competencies gives you a shoulder massage.  Or having them regale you with the details of their love life.  Students are often very reluctant to speak up in these situations because they depend on the staff RTs for good reviews and recommendations for possible future hiring.  In the past, many student RTs have remained silent, although that has fortunately started to change. 

A number of years ago U.S Homeland Security coined the phrase “if you see something, say something”.  The same thing applies here:  employer-employee; male-female; staff-students – we all need to call people out on their unacceptable behaviours. And if you are the one being harassed, the CRTO encourages you to speak up. We can’t change the fact that collectively the healthcare profession sat back and let of sexual harassment become part of the workplace culture. What matters is what happens now.

Social media was abuzz last week over the Utah burn unit nurse who was arrested for protecting the rights of her patient. The story goes that a police officer (who apparently was a part-time paramedic) wanted to take a blood sample from an unconscious patient who was injured in a deadly collision involving another driver – presumably to test for the presence of alcohol or drugs.  However, the patient was not considered to be suspect in the incident, was not under arrest and the police officer did not have a warrant.  Therefore, under hospital policy and relevant legislation, the only way the blood could be drawn was with the patient’s consent, which was not possible at that moment.  The nurse reportedly stood her ground, refusing to allow the blood sample to be taken (even as she was being handcuffed and dragged away) and is being lauded as a hero. Yet, she is the first one to say that she was only doing what anyone else would have done in the same circumstance. I hope she’s right.

It is conceivable that something similar could happen here – although perhaps not quite that dramatic. I am aware of several situations where the RT on-duty was pressured to provide patient information to police in the absence of the patient’s consent, a subpoena or a warrant. And while it may be natural to want to cooperate with the police, RTs are prohibited from disclosing personal health information to a third party unless the patient consents or the disclosure is required by law (e.g., the requirement to report suspected child abuse or neglect under the such legislation as the Child and Family Services Act). 

It is very easy in the situation such as the one faced by the Utah nurse to be intimidated by someone who aggressively asserts that they have the ultimate legal authority.  However, even in the case where a police officer has a warrant or subpoena, the RT still has defined rights and responsibilities. A subpoena compels the RT to attend a court proceeding, but it does not permit them to divulge to anyone (even the police) confidential patient information until they are ordered to do so by a judge. And in the case of a search warrant, the RT has the right to inspect the warrant and must only hand over patient information that is explicitly outlined in the warrant.

I watched the video of the nurse’s arrest, and I didn’t see too many of her colleagues rushing to her aid.  It is important to remember that you can be the only person in a room to believe something, and you can still be right. Therefore, there may be times when you are not getting any back up from those around you and that makes it all the more important for you to stand your ground and protect your patient.

It seems that facts are having a tough time of it lately. For the first time, we are hearing phrases like “fake news” and “alternative facts”. Lies repeated frequently enough (or loudly enough) are often taken to be the truth – especially if these fabrications come from celebrities (I mean, how else can Gwyneth Paltrow sell a jar of face cream called “Goop” for $140?).

Fortunately in the healthcare world we are, for the most part, being held to a higher standard. Evidence-informed practice is an expectation in (almost) every realm of healthcare and I don’t see that changing anytime soon. It simply isn’t enough to believe that a particular treatment or procedure will work – we need to be able to prove it before we can use it.

The same standard for evidence-informed decision making applies to the health regulatory world. A number of the calls/emails I receive come from RTs and others who want the CRTO to take action on a particular issue – often from the perspective that the current state presents a patient safety risk (e.g., high Vent: RT ratios, RTs not being able to perform certain controlled acts). And my response is usually – can you prove that a risk exists?

Evidence-based policy changes at the level of any organization (hospital, regulatory College and governmental) require – not surprisingly – evidence! For example, much of the information gathered on the CRTO’s renewal form is an attempt to establish an accurate picture of the current state of RT practice. This data can go a long way to providing the evidence needed to petition government or other bodies for changes to RT practice (just something to think about when you are renewing or updating your CRTO membership information).
We all need to demand that anyone trying to tell us that something is good or bad to prove it!