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Does Sunnybrook Care More About Quality of Death Than Quality of Life?

Should a hospital really have something called a "Quality Dying Initiative?" Apparently, Toronto's Sunnybrook Health Sciences Centre thinks so. And because it is Canada's largest teaching hospital, what it does carries considerable weight with hospitals across the country.

Should a hospital really have something called a "Quality Dying Initiative?" Apparently, Toronto's Sunnybrook Health Sciences Centre thinks so. And because it is Canada's largest teaching hospital, what it does carries considerable weight with hospitals across the country.

The program, which came to light recently as part of the Globe and Mail's series showcasing Sunnybrook, is described as "an institution-wide approach to putting patients (and their loved ones) first in the hospital's approach to end of life."

Obviously, patients and families who are facing end-of-life realities deserve to be treated with the greatest sensitivity. Then again, all patient and family interactions with a hospital should be based on the highest standards of competency, compassion and respect. It's hard to imagine how any hospital could justify circumstances under which patients and families would not be placed first in the hierarchy of care.

But it seems odd, almost Orwellian, to highlight a death initiative. Hospitals are all about care, delivering the right care in the safest manner. And hospitals everywhere already have a serious problem with the unintended and avoidable "dying" of patients. Indeed, there is an epidemic of medical errors and hospital harm so great that it has become the third-leading cause of death in Canada and the United States. If Sunnybrook has a similarly high-profile plan to deal with that, it's not saying. And the Globe isn't asking.

Elderly and other at-risk patients are especially vulnerable to the effects of medication errors and hospital-acquired infections. Sunnybrook does not make available to the public statistics on the number of medical errors, including medication errors, reported within the hospital. However, we do know that the incidence of ventilator-associated pneumonia for patients at Sunnybrook is four times higher than the provincial average. And as noted in an earlier piece, Sunnybrook, with all its resources and teaching responsibilities, ranks no better than average in hand hygiene for pre-patient contact.

Patient Protection Canada has also learned that Sunnybrook does not follow a crucial and almost universally recognized safety protocol for the administration of medication to patients who cannot swallow and must take all nutrition and medication through an enteral feeding tube. Evidence-based research shows that patients on enteral support are placed at significant risk of harm, including death, when these protocols, which are endorsed by the Institute for Safe Medication Practices, are not followed. How do these risks match up with Sunnybrook's Quality Dying Initiative?

Sunnybrook already has something of an infamous reputation in end-of-life matters, largely resulting from the decision by two of its most prominent doctors, Gordon Rubenfeld, Chief of the Program in Trauma, Critical Care and Emergency Medicine, and Brian Cuthbertson, Chief of the Department of Critical Care Medicine, to terminate the life support care of Hassan Rasouli, a brain-injured patient whose condition they felt no longer merited such resources, despite the family's strongly voiced wishes.

Rejected in that position by lower courts, Drs. Rubenfeld and Cuthbertson, and Sunnybrook, took their argument through appeals all the way to the Supreme Court of Canada and lost. The significant cost of what amounted to an exercise in legal and ethical futility, which other leading physicians have said they would never have attempted, has not been disclosed by Sunnybrook. Nor has the Globe and Mail reported on it. By contrast, the Globe was quick to note in a recent article that the cost of Mr. Rasouli's care in a Sunnybrook ICU is more than $3,000 a day, compared with the price tag -- as the newspaper indelicately put it -- of $340 a day for palliative care.

The Rasouli case has prompted many to wonder if Sunnybrook has an overly-aggressive culture when it comes to deciding who will live and who will die, and what care they are entitled to as a result. Other families have reported unsettling experiences involving the handling of end-of-life issues by Sunnybrook. Some are documented in this well-researched piece in the Toronto Star.

These episodes, which suggest something of an occasional tin ear on Sunnybrook's part to public sensitivities, are at odds with the hospital's otherwise impressive reputation for having among its ranks some of the most talented healthcare professionals in Canada. For decades, my mother served among them as a nurse. She and other members of my family have also been patients at Sunnybrook, and I have had a number of interactions with the hospital.

But boasting of a "Quality Dying Initiative" only complicates a minefield already fraught with fear and unease for too many families. When you have studied the extent of unintended hospital deaths and patient harm, talked with so many families about the injury caused to loved ones in the hospital setting, and experienced first-hand the willingness of some hospitals to lie and cover-up the wrong they have inflicted -- as I have -- it is very difficult to see how this program will be immune from other hospital failures that lead to tragedy and emotional distress.

Families should not have to worry that the over-zealous mindset exhibited by some at Sunnybrook might also migrate into this so-called quality death initiative or that patients, especially the vulnerable elderly who might otherwise have a chance at recovery with proper treatment, could be placed in that program unbeknownst to them or against the wishes of their families.

A final point about the Globe's series: At a time when all institutions are under pressure to be fully transparent in disclosing interests that might be perceived as conflicting, it would have been appropriate for the newspaper to inform readers in its series that its publisher, Phillip Crawley, is also a member of Sunnybrook's board of directors. This fact takes on all the more significance in the context of Sunnybrook's approach to end-of-life issues since it was the hospital's board that made the decision to support, with taxpayer dollars, the unsuccessful appeals to the Supreme Court of Canada in the Rasouli case.

It will be interesting to see if the Globe's public editor has anything to say on this point.


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