E87 Chip Doig on the Ethics of Donation after Cardiac Death, Conflicts in the ICU, and Staying Fresh

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Chad Ball  00:12

Welcome to the Cold Steel Surgical podcast, with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian, as well as international, guests over the past year. While the topics have been broad in range, whether clinical, social or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

Dr. Chip Doig is an intensivist at the Foothills Medical Center in Calgary. In this episode, we focused on a number of ethical issues in the ICU. From donation after cardiac death, to the idea of futility, and how to discuss that with patients and their families. Finally, we try to understand how Dr. Doig remains so fresh after all these years as an intensivist. Dr. Doig, it’s an absolute pleasure to have you on the podcast. You’re truly a mentor for myself, for sure. And I’m sure Dr. Ball as well.

Chip Doig  01:48

Is this where I call Chad grasshopper?

Ameer Farooq  01:51

Yes. This is exactly the right time!

Chad Ball  01:57

Still waxing on and waxing off, but I can’t figure out how to stop.

Ameer Farooq  02:02

Or Padawan, Padawan also works well in this scenario. For the listeners who may not know you, can you tell us a little bit about where you grew up and where you did your training?

Chip Doig  02:12

Absolutely. So, I am a first generation Canadian. My parents came to Canada from England in the 1950s and settled in a small town called Hawarden, Saskatchewan. So, if anybody’s interested, drop an hour south of Saskatoon, go a little bit west, and it’s close to a town called Outlook. From there, they moved into Saskatoon. So, I mainly grew up in Saskatoon, but then went to University in Saskatchewan and med school at the U of S, in Saskatoon. I have to say, it was a fantastic place to grow up, fantastic place to do med school and I still have a lot of family that are still in Saskatchewan. Even though now I’ve lived more years in Alberta than I did in Saskatchewan. Still bleed green, though, and still cheer for the Roughriders.

Chad Ball  03:14

As you should, there’s no doubt. I’m curious, in terms of your training pathway, where did you go to medical school, and residency, and fellowship and so on.

Chip Doig  03:25

So med school was at the University of Saskatchewan, at that time the U of S had an older curriculum, so it was a 5 year curriculum. And it was the only school in Canada that had a 5-year curriculum. Maybe that was the school for slow learners. But the history behind it was the fifth year was a full clinical year. And when they converted to a fifth-year program, they were trying to get rid of the internship here. And that actually wasn’t successful, so all that ended up is that the teaching hospitals had a year of free labor from the med students. But in that way, it was also excellent because we got a lot of clinical experience. I went from there to St. Paul’s Hospital in Vancouver. And so, it was a growing up in Saskatchewan and going to that school there was fantastic. St. Paul’s hospital was also fantastic. So that was in the late 1980s. In fact, it was the, I don’t want to say the height, but certainly the start of the vast number of patients we saw with HIV, without much in the way of effective therapies. St Paul’s High School was this little bastion of hope, not only for individuals in the West End that were suffering from HIV but also individuals who, for other reasons, were at high risk of HIV or individuals who were in the, you know, were living rough or socioeconomically disadvantaged. Sort of the, quote unquote, Eastside areas of Vancouver. It was an amazing place to learn how to care for patients as a rotating intern. And maybe some of your audience will need to have that explained to them. And then, my wife, we started dating in med school. And when I was in med school, she’s an accountant. So she had actually gotten the job in Calgary, I was in Vancouver. I am one of the few people who did some of my training in Vancouver and decided to leave. But there was 2 reasons for it. One was, yes, I went out to my wife. And the second is, the only downside about Vancouver, even though it’s lovely. You know, growing up in the winters in Saskatchewan, I didn’t mind -30, -40 below. Because the sky was always bright and blue. The winters in Vancouver are a little bit gray and a little bit wet. And I think I suffered a bit of seasonal affective disorder there. So, did my training in internal medicine and then critical care in Calgary. Did training in clinical epidemiology, did training in bioethics at the University of Washington. Currently, I’m doing 2 different masters, the Masters of Public Policy at the University of Chicago, or School of Public Policy, and a Masters of Health Economics at London School of Economics.

Ameer Farooq  06:43

Clearly, you don’t have enough degrees in your life. So makes sense that you currently pursue 2 masters. And I’m going to do a little psychoanalysis here. So, my parents are immigrants as well. How much do you think having immigrant parents, growing up in somewhat rural Saskatchewan, how important was that to you, in terms of the person that you are today and your career path overall?

Chip Doig  07:12

So there’s a lovely thing about, I don’t know if it’s unique to Saskatchewan, I’ll say Western Canada, because I do feel like I’m a Western Canadian boy. So, there was an adage, which was not a handout, but a hand up. And I was always impressed with how individuals would always help each other in Saskatchewan. I think that’s extremely important. And maybe it’s something that we tend to lose at times, even in the medical profession, right? Sometimes, when you get a consult in the middle of the night, and somebody is asking you for your opinion. We perceive it as a burden, not as a “how can I help?” And “how can I help?” or a hand up is something that I’ve tried to take away with me from growing up. Certainly, the other nice thing about my parents is, my mum grew up quite poor as a young woman, was the first person in her family to ever go to university. Scholarship and education were extremely important to her. My dad’s family was a little bit better off than my mom’s family. So, education wasn’t something new in my dad’s family, but it was also something that was stressed and strived for. So, it was also nice to have those role models. And my mum was an amazing person, she was an example to me of continuous professional education and development. So, I saw her do that all of her life. And my dad as well.

Chad Ball  09:19

I want to take us right into the fire out of the gate here and talk about, and particularly, the ethics that surround transplantation. You were well known for some of your concerns surrounding DCD or donation after cardiac death specifically, and I was wondering if you could take us through your, sort of, 30,000-foot framework of organ transplantation in general and then maybe work us into the weeds of DCD in particular?

Chip Doig  09:45

Sure. So first off, wow, transplantation is amazing. So, you think back to either the first allogeneic transplant, maybe technically autologous between genetically identical twins, Thomas Starzl’s work with livers in Pittsburgh, all the work that has come since then. And I’m going to just skip over heart transplant because sometimes the first heart transplant and the surgeon, he gets all the credit. Whereas I think, where he trained and where he worked maybe doesn’t get as much credit. And all the work since then, whether it’s specific surgical techniques or immunosuppressive therapy regimens, figuring out potential recipients. Even the way that organs are recovered and maintained now, post donation, are just, it’s an amazing science. So, I have nothing but utmost respect for transplant surgeons. I guess I have a slightly different perspective, though, than some individuals. So, it’s easy to depersonalize when we talk about donation and transplantation. Or to focus solely on the potential recipient. And I think that’s where a lot of, not public education, but bluntly, social marketing to both the profession and the public has occurred. So, most of the focus is on the potential to save a life and save life recipient. And it does tend to minimize and discount the donor. Second is, again, this is part of not public education, but the social marketing, where we celebrate the donor. So, again, I understand this from an emotive perspective. So, the family where an individual has donated a number of organs, they received substantial media coverage, and they’re praised. But we don’t hear about the family where individuals have chosen to donate but are unsuccessful. For some reason, organs can’t be recovered or tissues can’t be recovered or used. And there’s very little discussion about the individuals who, for many reasons, choose not to donate. I’ll highlight an example of that in a second. And then the third is just to remind everybody that donation after cardiac death is nothing new. I’m not talking about organ recovery that occurred prior to the original definition of brain death or a neurological determination of death. But we tend to focus on organs as if they’re the only thing that counts. And we discount, when we do that, the importance of tissue recovery, the importance of tissue donation, and the gifts that donors that are tissue donors provide. Just to remind everybody, again, the donation of skin results in life saving burn coverage. The donation of heart valves can preclude somebody having worsening heart failure in requiring transplantation. Of course, corneal transplants dramatically improve the quality of life of individuals, much like any other transplant can. So, it’s not that I’m opposed to DCD. But there are some things to think about. So, I’m going to focus for a minute on donors and donors in 2 ways. So, the first, I just mentioned that we don’t talk about individuals who choose not to donate. So, I’ll just, I hope, appropriately anonymize the story. But a person who suffered terrible difficulties through their life. So, here are some of the difficulties. Raised in a family where their parents were taken from their families and placed in residential schools. So, this is an individual from an Indigenous or First Nations background. Within the family growing up, not only having parents that had been dislocated and therefore, personally suffered significant trauma, the intergenerational trauma then of not being, potentially effective parents. Then this individual also suffered psychological, physical and sexual abuse as a child. Left home at the age of, if I remember correctly, around 15 or 16. Lived rough, or without secure housing, in a city. Entered into sex trade as a way to raise money. Became addicted to substances. And of course, immediately there’s a mode of response in most of our society to look disparagingly on that person. So, a number of multiple whammies, you know, just direct discrimination that occurs from our community against Indigenous persons, against somebody who might be a sex trade worker, and against somebody who has a substance use disorder. So, this individual suffered a cardiac arrest from an overdose, and was in hospital. Unfortunately, had a severe hypoxic ischemic brain injury and criteria for death. So, I sat down and talked with the family, and this wasn’t the first time talking with the family. But it was the decedent’s partner and the decedent’s brother. So, the descendent essentially no longer had a relationship with the rest of the family. There were other friends that had come to visit this person. So, this person had a, in some ways, a vibrant social support network. You know, social circle. But I spoke with the brother and the partner. So, I did as we do in the ICU. Talked about what it means, what the injury meant, the determination of death. We had a pause, we then discussed what next steps would be. Either removal of the life sustaining machines, in this case, not life sustaining, but I use the term physiological support devices and/or the option of organ donation. And the decedent’s brother used some very direct, angry, physically appeared angry at me, swore at me. And the essence of that comment was, what has society ever done for my sibling, that you would have the nerve to ask that my sibling help out others? That’s very dramatic and very telling. And yet, we don’t tell the stories of why people might say no. I’ll add a second part of the story, though. And the second part is that the decedent’s partner, and I’ve used the term descendent, because I’m trying to make certain that this is de-identified or anonymized. So, the decedent’s partner quietly said to the brother, “but you know, that’s not how they felt. They always tried to help. Help you, help their friends, help me. So, I think we should focus on that”. So, I’m not going to tell you the outcome of whether a final decision was to donate or not to donate. But clearly, again, on one hand, we celebrate only those individuals who ultimately become a donor. And by celebrate, I mean public adulation or public story. And on the other hand, we don’t tell the stories of the other individuals that died. I think that’s a significant shortcoming in the entire donation and transplantation discourse that we should be having as a profession. I also use the term social marketing and I use that very specifically, that is the language that was used in the 1999 National Committee around improving organ and tissue donation, that it shouldn’t be public education, it should be social marketing. There’s a huge amount of public health information, articles on social marketing versus public education. But the essential is public education is, we provide you facts, social marketing is, we try to change your opinion and make you do something that we think that you should do. Now, I’m not sure what’s right there, what isn’t right there. So that’s the first part about the potential donor. Second part. And okay, it’s obvious now that I’m not a surgeon, or a man, of few words. So, the second part is that, oh, I was just blanking what I was going to say about the second part because I had to go into that little segue. So, it’s the variability in practices around end of life. At least with donation after neurological death, we have fairly clear standardized, directed approaches about who is a potential donor and the potential donors after somebody has died. The difference with donation after cardiac death is, we still don’t have that across the country. So we have criteria that’s standardized when we recover the organ out, now that somebody’s dead and when we recover the organ. But there isn’t discussions about variability in practices around withdrawing or withholding life sustaining interventions, or life sustaining treatment, and how we make those decisions. Particularly in individuals with brain injuries. So locally, I’m quite comfortable that we have fairly consistent practices. We embedded in our protocol, very specific ways that we make decisions on who is or who is not. Or how we decide when we consider somebody a candidate for withdrawal of life sustaining therapy, and then approach the families. But there is data that that is quite variable across jurisdictions. And I think it’s a mistake that, as a critical care community, we haven’t resolved that. So, I think we can resolve it in each of our own local centers. And that’s the way have been able to approach it within my own frame of reference. But I still admit that I have worries that we haven’t done this nationally, across multi jurisdictions, like across North America, let alone internationally.

Ameer Farooq  22:35

So I wanted to drill down a little bit on the definition, because you’re one of the coauthors on a New England journal paper that actually looked at the resumption of cardiac activity after withdrawal of life sustaining measures. And I think fundamentally, one of the challenges around DCD is, as you say, making sure that we have a consistent definition. So, can you talk a little bit about how you locally have defined DCD and what are the variations across the country and how does that play out?

Chip Doig  23:12

Yeah, excellent. So first off, huge amount of credit to 3 people in particular. And you know, there’s always a risk when you identify a few people. There’s a huge number of people who deserve credit for the study in the New England Journal. But first off, the lead author is Sonny Dhanani, Sonny is out of CHEO, in Ottawa. Huge, heavy lifting, and an example about how important research is as much about the person leading it, as the quality of the work. So, Laura Hornby is somebody who has worked with Sonny, worked in the area of organ donation. I think Laura was extremely important. Nathan Scales was extremely important developing a lot of the software, so that we could capture the physiological data and doing hard analysis. And Sam Shemie. Sam was integral to the work being done. So, all credit to those 4. Me, I was just an investigator on the steering and writing committee and trying to do my best. So, that work was extremely important. And identifying particular the issue around resumption of the hemodynamic and/or the electrical activity in the heart, after the withdrawal of life sustaining intervention is extremely important. So, that’s what that study was all about. And there are individuals, there’s different terms used. So, you’d think I should be a surgeon because I love the eponyms. So, there’s something called the Lazarus sign and the Lazarus phenomenon. Lazarus sign is muscular contractions that occur in individuals after the undetermined death by neurological criteria. Lazarus phenomenon is the resumption of cardiopulmonary activity, when you thought that cardiopulmonary activity has ceased. And there was data that suggested that that didn’t happen. So, there’s a literature review that said, boy this is extremely rare, that preceded the DEPART and DEPICT study, which was the usability study leading into DEPART. But that was incongruent with the clinical experience, many individuals such as myself, who had seen Lazarus phenomenon. So, spending nights in the ICU, the death of an individual was an extremely personal event. And what I try to tell individuals working in the ICU is, now in my life, there have been 2 extremely powerful moments. It’s been the birth of my children, it’s been the death of loved ones. And so, by virtue of our position, we have the privilege to be either intervenors or observers. These 2 intensely powerful moments in a person and a family’s life. So, treat that with a great deal of respect and responsibility. And that includes, if we’re in the ICU, we don’t leave an order that just says, “disconnect devices, withdraw physiologic support”. And we walk away and the family never sees hide nor hair of us. But that actually, we’re present with the nurses and with the family. So, I’ve sat at bedside, either with the nurses outside the room, sometimes family asking me to be with them in the room. And I’ve seen activity start and stop. So, this trial is extremely important, because it defines that. And I guess the important thing about this is, there was variability in how we said that somebody met cardiac criteria for death. So, there was variability across Canada, there was variability in Alberta. Edmonton and Calgary had slightly different definitions for when we said that somebody was dead, based on cardiac criteria. What this study provides is some outstanding evidence that if you wait 5 minutes with the absence of any hemodynamic forward flow, so any pump activity, then you’re not going to have any pump activity return. And so, this work is extremely important for helping inform DCD practices. For example, what we’ve done in Calgary with our definition of cardiac death is with now harmonized with the data from the DEPART.

Ameer Farooq  28:27

I’ll just reflect on my own experience being on the renal transplant team in Calgary, which is a great group of individuals that I got to work with. But I have to say, one of the jarring experiences about being on that rotation, and participating in DCDs is, you’re sitting in the operating room and you have a monitor that’s connected to the monitor down in the ICU, and you’re looking at the patient’s vital signs. And after the life support measures, or physiologic support, as you say, have been withdrawn, and you’re looking for parameters that that patient has to fall into, as you’ve outlined, in order for them to be a candidate. And then suddenly there’s a mad rush as that patient comes up directly from the ICU, in Calgary, which is in the same building, up to the OR where everyone is standing, dressed, scrubbed, ready to go ahead and retrieve those organs. And so emotionally, it is a strange kind of feeling that you have where you’re essentially hoping that this person dies in the period that you need for them to be able to retrieve their organs. I don’t know, do you think emotionally this that somehow feels different to you? And that perhaps plays a little bit into the ethical decision making around this, especially when you’re there with the family, and having spent a lot of time taking care of these patients and talking to their families. Does the emotional side of that play into the ethical decision making when you’re thinking about something like DCD?

Chip Doig  30:05

So it is a bit macabre, isn’t it? I don’t think we should understate this. And I don’t think we should understate, even though I provide an ICU perspective, I think your experience is not different than what I’ve heard from other individuals. And we should find it a bit macabre. Because if we don’t, in some ways, we’re depersonalizing the importance of the donation and recovery from that individual or from that family. So, it’s extremely important. I think it may even be worse in some centers. So many of the centers that I know, in Canada, practice the withdrawal of the life sustaining interventions or treatments. So, if people are extubated and removed from ventilators, if the vasoactive medications are stopped, those are done outside of the operating room. I’m not sure that that’s true in all Canadian centers, but I think it happens in most Canadian centers. But in many other centers, that I’m aware of through personal communication with other physicians or reports, it happens in the operating room. So can you imagine, so you’re scrubbed in and waiting in the operating room, as you’ve described it now, looking at a monitor. And instead, you’re scrubbed in waiting, and the person is immediately in front of you. I think it’s probably beneficial to the recovery team, though I haven’t seen any data on this, that there is a little bit of distancing and separation in time when the withdrawal occurs in another setting. Because that watch, and then suddenly having the body arrive in the operating room, I think that distance allows probably a bit of an emotional or psychological reset. Whereas, you know, if you’re pondering and waiting with that person in front of you, and as soon as the second ticks over the time limit, you start the surgical procedures for recovery, I could imagine that would be more psychologically distressing.

Chad Ball  32:35

Yeah, I agree with you guys. Both of you very much. And it’s always interesting to think back to being a fellow and getting on planes and showing up in hospitals you’ve never been in. Even outside of DCD, with standard donation, the variability in the underlying vibe and structure and process. It’s interesting, for sure. Dr. Doig, I was hoping to touch on a few other issues with you today, that Ameer and I had talked about. I was wondering if we could take it outside of donation and just talk about some general ICU ethical issues that someone of your experience has experienced and continues to experience. I wonder, in particular, if we could start with the scenario where the critical care team’s goals and the patient family goals don’t necessarily align. I’m curious how you address that. And in particular, how you manage that scenario when you would define the scenario or the situation as potentially medically futile, although I recognize that definition is laced with landmines.

Chip Doig  33:54

So, Nancy Jecker is responsible with Lauren Schneiderman and Al Johnson for the seminal paper on futility, in the Annals of Internal Medicine. Boy, showing either my age or just that I read too many papers. Around 1996-2001, in that age, that time interval. Fantastic paper in the Annals of Internal Medicine. She then, I believe with the same coauthors, wrote a book called Wrong Medicine and also extremely powerful. Trying to focus on how we define futility and then exercise it in a practical way. Of course, many people took exception to that term. Even trying to determine how to define futility. So arguments about outcome futility, physiologic futility, the accuracy of making those decisions. So, it certainly has been an area that, I think, anybody practicing in an intensive care unit, physician, nurse, respiratory therapist, social worker, has experienced. It’s also extremely fraught with difficulty. So sometimes I get why families have difficulty understanding where their care team might suggest withdrawal or withholding of life sustaining interventions, and they see it otherwise. I think a lot of it actually does come back to us. And I don’t mean us as individual practitioners in the ICU, but I’ll just give a few examples of where we may not do as good a job as we should. And one of the end results is conflict or dispute that occurs within the ICU at the end of life. I think that’s tragic because, again, this is one of the most intimate times for a family. And we surrounded, or proceeded immediately, by dispute and conflict. And that’s horribly unfortunate. But first off, you can imagine that if somebody is from a community that society does not treat equitably, how it creates a significant amount of difficulty. So, I’m not going to pull out a particular group within our broader community. But I think there’s lots of data to suggest that there remain behaviors within our medical profession, that are discriminatory towards different parts of our community. And so, we shouldn’t be surprised when there might be mistrust or an unwillingness to accept advice from members of the ICU care team. Because we could be, in the eyes of those families, just representative of a broader problem within the health profession, and actually within society as a whole. Second is, unfortunately, some patients who are in the ICU end up there because of misadventure. So, patient safety and quality of care are sometimes problematic. Not to say they aren’t problematic in the ICU too. But you can understand why a family may not be trusting if somebody has suffered a patient safety related event, that has either resulted in them ending up in the ICU or it has occured in the ICU, preceded at some point, a decision about withdrawing or withholding life sustaining intervention. So those are 2 extremely important things. And the third is communication and professionalism. Do we actually spend time communicating and caring for patients and their families so that we build a sense of trust. So, boy, healthcare has changed a lot over the last few years. We’ve gone to models of care where teams were, you know, I think both surgical services. You might be operated on by one surgeon and a second surgeon is on call at night and takes over care. So, sometimes identifying and understanding who the most responsible person is, and communication that occurs between different team members with families, can sometimes be confusing. I don’t want to say it’s different, but we all present information differently. So, families can become confused, concerned. So, I think sometimes a dispute might have been preceded by difficulties in communication and how we express ourselves professionally towards families, both in demonstrating competence, but also empathy and compassion. And then there are just some decisions that are difficult. Where, for many reasons, families might disagree with us. I have to say that it’s funny though, how ICU is, in some ways, treated differently than other areas. So since you’re surgeons, if a surgeon says, “I’m not going to do an operation that isn’t going to help. We’re not going to proceed.” Then “I’d like a second opinion.” Okay, second surgeon comes in says, “I’m not going to do an operation, it’s not going to help. We’re not going to proceed.” Essentially, the opportunities for surgical procedures are essentially exhausted, because there’s no surgeon willing to take a patient to the operating room. Yet resuscitation and admission to the ICU is viewed differently. And I must admit, I don’t understand either the regulatory perspective on that. So where professional associations or professional licensing bodies, regulatory bodies, have said, “we’re going to treat this differently.” I don’t think the courts have come down on a final say on this. I think the courts treat each case, as we do, individually. And I’m not certain there will ever be a clear answer from the courts that can be used. But I must admit, I struggle. So, in the ethics literature, we sometimes treat withholding and withdrawal as ethically equivalent. Pragmatically, they are quite different. Because, for some families, it’s far harder to withhold than withdraw. And for some health care practitioners, we don’t want to start because we’re concerned, we’ll never end. And so, meaning that, if we start resuscitative interventions, attached physiologic support, once the patient enters into the ICU, we’ll enter into conflict about the appropriateness then, a trial of interventions haven’t worked. Let’s withdraw. So, the way I approach these is, sincerely, with a lot of humility and modesty with the families. It often takes an immense amount of discussion, timespan, clarity, so that families get consistent information. And even then, there’s dispute. So, for some patients, disputes are a little bit more, there’s a process we use, a consensual dispute resolution process. That’s actually been published, similar processes have been published in the literature that’s actually in guidelines now, through the American societies and Canadian societies around critical care, that we follow these types of consensual processes. But it doesn’t mean that it’s easy. And in fact, there have been studies of psychological distress in other providers, and particularly our ICU nurses. And the problems with providing treatment, which is not considered to have therapeutic effect, where the family are in disagreement with the provider team, has actually been identified as a major area of psychological distress, particularly for bedside nurses. And a major reason why individuals leave the ICU. And that’s unfortunate. So, it’s one of those areas we still struggle with, in the ICU.

Chad Ball  43:53

On the surgical side, it is interesting. There’s requests that come our way, as you know, that are just technically not possible to achieve. And I think those are the easy ones that probably all of us would agree upon, where the gray comes, quite frankly, me, be yes versus no, due to an individual surgeon’s technical ability or comfort level from there, you know, day practice. I think that’s where inviting your friends and being collaborative is clearly always gonna result in hopefully a more settled, maybe a collective response. The other thing I wanted to ask you in particular, though, is, we wrote a paper probably 10 years ago and published it in the Journal of Trauma that was almost 400. It was many, many critical care physicians, some of which were surgeons and some of which weren’t, that looked at end of life care and outlook into that broad topic, based on country of origin or country of practice, I should say. And culture and religion. And it was, my impression from doing that work with a relatively small group that, there was unbelievable variability across regions. And what prompted us to do that was really my movement from a residency in Calgary to spending almost 4 years in the US, initially doing surgical critical care. And just seeing the lengths with which the inability to recognize medical futility, relative to what I had seen in Canada and in a few different places outside of Calgary. The difference was tremendous. And remarkable. I’m curious what your thoughts are on regional variability in, sort of, a prism or the framing of end-of-life care. Whether that’s geography or reimbursement or religion, or really anything?

Chip Doig  46:14

Yeah, I think that’s important. So first, reimbursement. So, in some centers, in the United States versus Canada, of course, if an individual does have insurance, ICU can be a revenue generating center for hospitals. So, one way, disputes that arise over if treatment should be withheld, or treatment should be withdrawn. There might be a different perspective from senior administration and as practicing clinicians, we’re dependent on support from administration if we do enter into difficult discussions with family. I think there is examples of communities that are systemically disadvantaged. And again, we just think as healthcare professionals, that as individuals, we are good, we honest, we have integrity. But I think, and even if we’re proud of our profession, or hospital and think that way collectively about ourselves as individuals within that larger group, that may not be the experience for the individuals who are receiving care from that system. So, it’s important to remember about being the individuals who have been disadvantaged systemically by our systems. So, the third is, there is data, though, that there are differences collectively in practices. So, there’s differences, for example, some literature, Southern Europe versus Western Europe, in terms of how life sustaining interventions are perceived by the community, and therefore offered by the health system. Likewise, the language we use around decisions, treatment decisions, there’s data from countries in Southeast Asia or the Asian rim, where the language used can be different between regions, and probably within our own hospitals or own units in between their teams, certainly between individuals. But we probably have language that we collectively tend to use consistently. But the way we do that, in Calgary might be different languages, might be different in Edmonton. And that might be good because our communities are different. But I don’t think we understand how to necessarily approach these discussions where there is conflict. So, there’s been some fantastic work around end-of-life care. So, Daren Heyland, Critical Care Physician from Queen’s University, Kingston, did a fantastic amount of this work with the Canadian Critical Care Trials Group. So, credit to Daren for a lot of this. So, some of the things that we should do, how we discuss things with family are understood, but there are some things that probably, when there is dispute and conflict, we haven’t investigated the language you use as well, under those circumstances.

Ameer Farooq  50:02

COVID and the last year has been such a different time in all of our lives. And it’s really brought to the forefront a lot of the issues around ICU care and essentially the resource limitations, and sometimes the decision making that goes around that, related to COVID-19. And I’m curious if A) this whole experience has perhaps changed the way you think about the role that you have in the ICU, in the broader medical context, and B) if things have changed, perhaps subtly, in terms of how patients and their families view the ICU, and perhaps, approach that end-of-life discussion.

Chip Doig  50:47

I guess I’ve lived through a few different times in our society where the general public and the healthcare system have been, bluntly, have been scared. So, I remember back in the late 80s, as the spread of HIV became significant to our communities. First, some quite offensive language that was used. So, for example, in some circles, it was called the gay plague. And that wasn’t different than how some people use the term, the “Kung Flu” now and the discrimination that Asian Canadians now face from the type of language used. And I remember in St. Paul’s, actually a little bit of a funny anecdote. We would admit 12 to 15 patients on the medicine team each night, and we had patients that were hoteled or stayed in the emergency department. And our goal was always to have our patients out of the emergency department, on the floor, before the start of our next night on call. And when I came to Calgary, one of my first nights on-call, I sent the clinical clerk down to do the admission. And I got paged by the emerge doc, quite livid and upset, about an hour and a half later. And I’m like, “like, what’s the issue?” And he’s like, “well, you guys decided to admit this patient and we have a 2-hour limit, that once the patient then decides to be admitted, they have to leave the emergency department within 2 hours.” And I’m like, wow, that’s totally different than in Vancouver. So, the other thing that I’ve experienced is SARS, and though we didn’t have cases of SARS in Calgary in the early 2000s, we prepared for accepting patients. H1N1 in 2009 or 2010. And then, of course, with the concern about hemorrhagic fevers, quote unquote, Ebola, we had to be prepared for hemorrhagic fevers in 2016. But if I go back to HIV, there was talk about the healthcare system collapsing under the weight of patients who had HIV. There was fear about spread within the hospitals from it. And the lived reality, after a while, was quite different than what was communicated in the lay media and how it was sometimes portrayed. So, I credit the St. Paul’s, as a hospital, for teaching me. So, I remember our senior sister, who was the senior hospital administrator, coming around at night when I was on-call. Asking me how I was doing, were we coping? More or less saying, don’t worry, we’ve got this. And that’s how I was initially trained. Yet, if I went home and I read the newspaper, the system was collapsing. And I don’t think the experience at St. Paul’s was different than, for example, at St. Mike’s, in Toronto. So now I look at our experience with COVID. So COVID has been terrible in many ways. So first off, it has certainly affected the vulnerable part of our community, our seniors, and I don’t think our general public health measures were actually well focused on specific protection of our most vulnerable in our community. So, we saw widespread masking, social distancing those interventions. I’m not certain that they were particularly well targeted and well directed to preventing spread of infections within our long-term care facilities and those particularly over age 75 who were initially infected and died. Certainly, as it spread through younger individuals, and I will point out with those individuals, for a lot of them, we provided care in situ. So, they actually, they might have come to hospital or if they came to hospital, they were they were cared for outside the intensive care unit. So, near the faces of the spread of the infection in Canada, I don’t think the ICUs were particularly hard hit. But there was a lot of fear. For sure, there’s a lot of fear about total number of patients we might have to manage. But there’s also fear about spread and spread to providers. And I think some of the information that we heard from other jurisdictions, for example, from Italy, probably did us a bit of disservice in caring for the community, and also how we responded, in general, within the community. Sort of from November through December-January, we’ve seen a lot of individuals who have been primarily in the age range of 50 to 70. Most of them have some chronic health conditions, the 2 most common being hypertension, or diabetes, and obesity, or an increased BMI. How we characterize that, so is that a chronic health condition, or not. That’s also the other major risk factor. So those individuals in the ICU, in one way, were no different than other patients that we typically see in the ICU. So acute lung injury, fairly, what our expertise is, managing physiologic support devices, supporting abnormal physiology, while all things improve. I actually think that was relatively straightforward. Was our capacity increased? Yes, but we manage that as a system. So, my perspective is a little bit different than some other ICU physicians who have either been quoted in the general media or in social media. I thought our systems actually do extremely well managing the surge, managing the additional patients. Not to say we weren’t busy, we were absolutely busy. But the system helped us. So, I like to think about the ICU, the role of any consultant should be, and sometimes we forget. Two in the morning, you get that consult. Whether you’re the senior resident, the junior resident, the attending physician. Two in the morning, you get that consult and it’s like, “Ah man, I got another patient I have to go see.” Rather than, “somebody is asking for my help, how can I go help? Somebody needs my help, how can I go help?” So, if the ICU is sort of, I like to think, the ethos of the ICU should be, how can I help within the hospital, within the system? How can I help? The surgeons had a difficult case? How can I help you? The anesthetist calls me from the operating room? You bet. Thanks for telling me about the case. How can I help? You want the patient can I You betcha. In this case, with the ICUs filled up, we asked for help from the rest of the hospital, the rest of the system, and it’s amazing how it responded. So, former ICU nurses who worked in recovery room, who worked in surgical oncology, who worked in outpatient clinics, came back to the ICU. I had pediatric emerge docs working beside me as our chairman says a search doc. So, an additional pair of hands in the ICU. We impacted care to other patients in the system by shutting down surgical services. I’d like to think that in some places, we really tried to keep the system working as effectively as possible. So, I’m actually quite proud of how Calgary did that. I think we had very few surgical down days, or surgical cases canceled. But I know that wasn’t the case across all of our province, let alone our country. But in some ways, it was amazing. So, working in the ICU was, in one way, just with my experience, no different than what I’ve seen in other significant health threats to our community and our system. And in other ways, I was really gratified to be working in our system to see how well it coped. I think it coped extremely well. There is one thing I worry about, though, and there’s a significant amount of data available and lots of public websites around mortality during the COVID pandemic. And so, the term “excess deaths” is used. So, these are the observed deaths over a time period, above the expected deaths. And that’s usually calculated using standardized numbers. So, per 10 000, per 100 000. And the expected deaths are the deaths that occurred, as an average over the, most sites record over the previous 5 years. So, we’re definitely seeing excess deaths in our community, those excess deaths are not fully explained by COVID. So, there are excess deaths above and beyond COVID. And that’s actually quite disconcerting for me. So, I think I personally have admitted more individuals post cardiac arrest from opioid intoxication into the ICU, during the period of the pandemic, than I’ve admitted who have had COVID. And I know of individuals who have presented to hospital, in a delayed fashion, from strokes or acute myocardial infarctions, that have not survived. I’ve even seen individuals who have presented in a delayed fashion with upper gastrointestinal bleeds from duodenal ulcers, who have had significant morbidity. Quite different than I think I would normally see, although that might be a bit more anecdotal. So, when all of this is finished, I think there will have to be some careful consideration about how we responded to COVID. Both from a public health perspective, but also in say, acute care health system perspective on whether we provided the best care possible to the entire population, the entire spectrum of illnesses. Of course, one of the difficult things is, we won’t know what would have happened if we had done something differently. But there are maybe some international comparisons that need to make, because there were differences in some jurisdictions about how they managed, and how they managed the response to the pandemic.

Chad Ball  1:03:02

That’s certainly a very hot topic. Right now, there’s no doubt, we have a manuscript coming out that looks at, just the change in the injury pattern and volume on the trauma service. To your point, it was very clear that levels of interpersonal violence, particularly gunshot wounds, went through the roof. In fact, it went up almost threefold. And that’s interesting, where you didn’t have, in a country like the US, a massive influx of handguns into the community, it still happened. And it was clear to us, looking after the patients, probably like it was to you as well, that there was a lot of social obstacles that had led to, certainly, the turmoil and the subsequent injuries as well.

Chip Doig  1:03:51

So, you’re right, Chad. I pointed out a few cases. Now, there’s epidemics of events that that we don’t see, they’re hidden in society and at times at the health profession, for example, domestic violence. And we might see physical violence, we see less of, sometimes, the psychological violence that occurs. And so, the social distancing and the requirement to stay at home. I do wonder what the morbidity will be of the, victims of, for example, domestic violence. The expenditures. So, I think 383 billion is our federal deaths. And of course, that stimulus spending was to maintain our GDP. So, boy I might have numbers wrong. But if our GDP is about 1500 billion, we spent about 20% of our GDP as a single deficit in a year and that’s huge. And so, thinking from a economics, not just a pure outcomes perspective of our health system, will we be able to say that, how we manage this. Did we manage it efficiently and effectively? So effectively, did we actually improve outcomes? And efficiently did we improve outcomes at a reasonable cost? I think that’s going to be something that’s going to be the subject of research for many years to come.

Chad Ball  1:05:46

Dr. Doig, we’ve touched on a lot of topics, and we’re mindful of your time. But we wanted to touch on just 2 more before we let you go. The first is something we could probably talk about for hours, and I think you and I probably have. But you’ve mentioned a few times, the research world with which you have come up in, that you still participate heavily in, I’m curious if you can give us your thoughts on the publish or perish traditional axiom. And maybe reflect on anecdotal observation that the drive to do research, certainly, in the surgical world, I don’t know in internal medicine and critical care world, if it’s the same, at the trainee level, seems to be much lower, both in terms of expectation, as well as just natural endogenous want to pursue those avenues. I also wonder, a little bit as a result, what the impact of health authorities that really don’t care much about anything beyond, in theory, quality patient care, leading to popular opinions surrounding health care in general, that are directed towards a government. I think we all know that, doing research, there’s more and more obstacles every week and every month. And I don’t think the health authorities, in this country anyway, really care much about the theoretic link between good quality research and patient safety and quality and so on. But maybe my view of that is jaded, I’m curious what your thoughts are?

Chip Doig  1:07:31

Well, it’s interesting, right? So, a couple of very simplistic observations. It’s amazing, the training that some individuals have, as they enter into medicine. And if they’ve already started postgraduate studies by the time they enter into medicine, or they complete postgraduate studies before or during medical school, research intensive graduate studies. And yet, somewhere during their clinical training, that drive to do that type of work disappears. I think it means there’s a fundamental problem with how we’re recruiting individuals. Not that everybody should want to or should do research, but if we’re demanding graduates, individuals, we’re not demanding that the practical reality is that many students have these now. Why set a criterion if research isn’t really part of their future career? What’s been the benefit of doing that? Likewise, during training, I can think of… Well, Chad, you’re a bit of an example. But I won’t use you as the example. I’ll use some of my neurosurgical, the individuals training in neurosurgery right now. So, I know neurosurgical trainees that are PGY-10, 11, 12. So they’re doing a difficult clinical training, they’re more or less required, at least in my center, to do a PhD. They’re then, during their residency, if they don’t already have one, but during their residency, if they do have a PhD, they’re going off and doing other research training. And then they’re doing, subspecialty training before they get hired. Wow. And what’s the benefit and what’s the output of that if research is not part of their future career? So, I think there’s something fundamentally flawed with, either the expectations of individuals or the way we’re training individuals, if research is not important. So, the second observation I’ll make is, boy, I’ve been lucky enough to be involved in a whole bunch of different projects and I like to think I was just in the right place at the right time. And I like to think that I have a bit of an inquisitive nature, and a bit of a kid in a candy store. Or maybe a cat with a laser light, you sort of point a laser light, I’ll follow that around and have fun with it, until the next laser light comes along. So, some of the projects that I’ve been involved with, and bluntly, have led, has just been that I asked a question during doing some of the work. So, I lead the clinical skills program early in my career. I just asked a question about how we were doing the OSCE exams in our clinical skills. Said to myself, “boy, probably be good to evaluate this”. Turns out, I had a publication in Academic Medicine. And that’s not a big clinical journal, but it’s actually the leading medical education journal. Now, lucky enough to work with a guy called Paul Coutts. So had 2 nature medicine papers with Paul and a couple of them were just asking simple questions. So, asking a simple question. So, the thing is that I’ve been very fortunate interacting with individuals. On a clinical side, it’s extremely gratifying to care for an individual. I mentioned earlier, the privilege of caring for somebody and the responsibility that goes with that. One of the huge impacts, though, I think we tend to forget, whether it’s a important quality improvement initiative, this improved quality of care in our local center, or it’s an important research program, or it’s even education, how we’ve improved the skills of individuals in our community, our professional community. So, when you publish, when you do that work well, and the results are valid, and you publish that work, whereas our direct care might improve a singular individual, we actually have the opportunity to improve the care for a larger percentage. So, our potential to help extends dramatically. And I think we forget that. And so, I see research as part of our professional responsibility, because if we figured out a better way to do things, isn’t it important that we communicate that and share our experience with others. Unfortunately, I think what’s happened with research, though, on the negative side is, sometimes we’re focused on research productivity, or research excellence. At the sacrifice of clinical productivity, or clinical excellence. So, I think we should be striving to be both. So, for me, it should never be about the quantity, it should be about the quality. I guess the final comment I’ll make about it is, I have changed my perspective about research a couple of ways. And one of the ways is the importance of a publication, so where we published. So, everybody wants JAMA, Jama Surgery, Lancet, Nature Medicine, so these super big journals. So, the first is, I had an individual who I consider to be, not only Canada’s, but probably the world’s leading critical care researcher, Deborah Cook. So, Deb is at McMaster, phenomenal person. Deborah once told me that the publications that she was most proud of sometimes aren’t in the top tier. They’re the genesis of the idea. They’re the original work that started off the larger program of research, and they’re in second tier journals. So, we sometimes dismiss publications from second tier journals, but I think they’re important. We sometimes dismiss publications like case reports or case series, and yet, I try to remind individuals who are heading into research, or trainees that are writing up their first paper. A case report or a case series can be extremely important. And in fact, let’s not forget that our understanding of HIV started with a case report of an unusual opportunistic infection in San Francisco. And reporting of Kaposi sarcoma in IV drug users in New York. So, case reports and case series are just as important as other types of publications. And the final thing is, sometimes focus on journal publication. So, I think there’s an importance to lay media publications too, I’m not sure I’m going to extend it all the way to all types of social media, but I’m participating on your blog. So, I might be old fashioned. And TED Talks are certainly really important. But we should be celebrating other facets of communicating as well. And this became an issue when I was a department head, because I had a faculty member who produced a number of opinion pieces in the Globe and Mail and the National Post. And around the department heads people, this person’s work was discounted. And I made the following comment. I said, “You know, I’m not certain how to weight some publications, because I don’t know how many people have read them, how many people have cited them, and therefore the impact that they have.” But I said, “I know the circulation of the Globe and Mail. And I know how many senior health, or policy, or governmental, or individuals will read the editorial page of the Globe and Mail, or the National Post. So, you’re telling me that these publications aren’t important? Explain further.” And so, I do think actually thinking outside the usual convention of our peer reviewed literature and publications, are important. As long as they have a tangible impact. So, I hope those comments make some sense.

Ameer Farooq  1:17:23

Dr. Doig, one thing I can comment on from my own personal experience, having been on-call with you is that, it is really something to see you and have you as a staff person on-call, in the ICU. I particularly remember one night on-call, where I think there was no fellow, and you were stuck with me on-call. And I just remember walking around the hospital with you getting called to code after code, watching you drop lines and interview people like there was no tomorrow. And looking at you, as someone who’s already had a fantastic career, has taken care of people throughout their career and has had so much clinical care, it was refreshing and enjoyable to watch someone really enjoy their craft. So, what tricks do you have for staying engaged and relevant and interested, after all the years that you’ve been doing this and having been so busy? And maybe you could comment a little bit about your COVID sabbatical experience, as well. And maybe how those ties into staying fresh.

Chip Doig  1:18:28

So, a couple of things. So, first is, I’m going to give credit to a couple of my mentors. So, Dr. Ed Somerville, who is an internist in Saskatoon City Hospital. Ed was a former Canadian military physician who had left military and was in private practice. So, many of the interns were kind of scared of Dr. Somerville. And he was a family friend so maybe he treated me differently. in some ways. Or maybe I just wasn’t as frightened of him as some of the other house staff. The reason people were perhaps a little bit intimidated by him, probably a poor choice of words, is because he had high expectations with individuals. He wanted individual to always work hard and do their best. And he truly put patients at the center of things. So, some of the interns had started to make fun of Dr. Somerville because the start of his notes, often, were something like this. I remember one of them. “This X-year-old gentleman, who survived 24 missions in a helicopter over Western Europe and was shot down and spent 6 months in a prisoner-of-war camp, dot dot dot”, with the clinical details after that. And he always had the beginning sentence of his consult notes were his histories with that. And so, I went up to him like, Dr. Somerville. So some of the other house staff know, he’s always trying to one-up us, you know, show us how much he knows about things. “Dr. Somerville, why do you do this?”, and he goes, “Oh, it’s a memory cue for me. You know, as soon as I read that line, I can remember the entire patient story”. And I’m like, oh, that’s interesting. But then he also said that to remember the patient, you have to get to know the patient. And so, he taught me a very subtle lesson about hidden meanings behind things. But also, to take the time and to try and get to know the individuals that we’re caring for. And, he was actually a little bit, not that he ever showed that he was offended, but he knew some of the comments of the other house staff. Maybe he wasn’t offended, I think he was sometimes disappointed with those comments. Lots of individuals that I could point to that I had the privilege to work with, when I was at St. Paul’s. But one of them was an internist by the name of Jack Onrot, or Jake.We all called him Jake. So, he would give us Thursday afternoon teachings. And he looked forward to the interactions with the house staff. And that hour to hour and a half, to 2 hours, he would spend with us, he was completely dedicated to us. It was fantastic. And what he said was, well, yeah, I love this, because I probably learn more from you, than you do from me. It was quite the contrary, but the time he spent with house staff was important. And the same thing for me now. I learn so much from the individuals that I work with. Not just medicine, but actually how they interact with each other. I grew up in a generation where the expectation was that, you’d carry a load, you do it yourself. You’d worked hard, all those sort of things. And I’m a very social person anyways, but how I see individuals work together, as teams, isn’t something, even though I work in the ICU as a team, and I’ve played sports on a team, and I know how important teamwork is, I get so much from the house staff, team wise. Final thing I learned from Jayco was, I remember, on the medical service, I admitted this gentleman, he was living rough in socially, economically, housing disadvantaged, east side of Vancouver. Had alcohol use disorder. He was First Nations from one of the Haida communities. And so, he was admitted, unfortunately, with alcoholic hepatitis. I admitted him, he was on my medical team. The attending said, discharge him, I discharged him. We had a follow-up clinic and we booked him into the follow-up clinic, never expected him to show up. And so, the day of his follow-up clinic came, and Jake paged me and he’s like, “where are you?” And I’m like, “up on the floors”, he said, “well, your patient’s here, get down here now”. And I can tell from his tone of his voice, he was annoyed at me. It was more than just being annoyed at being late for an appointment. So I came down and the patient’s there and Jake grilled me. He was sort of like, “what was the patient’s medical problem? Did you think the patient needed to be discharged? You discharged the patient, though. What, you’re telling me you didn’t think? So, your attending said to discharge him, so you discharged him. So, you just follow, did you question your attending?” And it was sort of… So, 2 things. So, first is, he made me admit the patient back to hospital as a private patient under him, and I cared for him on top of my other duties. And then when he was discharged from hospital a couple of weeks later, I had to see him on follow-up clinic and follow with him in Jake’s follow-up clinic, as my private patient. And when I was on obstetrics, I went down to the internal medicine clinic, followed this patient. Got to know him very well. He was a gifted, gifted artist. Again, a victim of many things historically. Such as, a survivor of the residential school system, socially dislocated from his family, terribly injury during his time at school. So, anyways, I looked after him for about 6 months in the follow-up clinic and I showed up one day and he wasn’t there. I was quite worried about him and so, on the weekend, on my day off, actually, looking for him. Walked around the east part of Vancouver looking for him, I was kinda worried about him because, you know, he had made such a huge, profound impact on me. I couldn’t find him, he never came back to the clinic, never saw him again. And I was actually quite emotionally distraught by that. And Jake took me aside and he said, “listen, for 6 months, you probably provided more care for that individual than he’s had in his entire career. So, celebrate that you made a difference for a short time in that person’s life”. And so, working with younger physicians, I do try to remember the advice that individuals who helped train me, gave me along the way. I try to reciprocate that, that caring is important. One of the things I’ll often say is, one minor teaching point is, what’s the most important word in intensive care unit? And it’s, care.

Ameer Farooq  1:26:51

You you’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.