With a goal of improving the life of healthcare providers as individuals and as clinicians.
Farzad 'Raffi' Refahi
Respiratory Blog, associated with Respiratory Therapy by Farzad, began with a goal of improving the lives of healthcare providers as individuals and as clinicians. There is a focus on cardio-respiratory concepts from the perspective of a Respiratory Therapist.
Cropped screenshot of the first page of the article
Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.
This month I found a great piece to share with you. This one falls under Asthma and Original Research. The objective of this paper is to “examine the proportion of participants with negative BDR testing who had a positive MCT (and its predictors) result and characteristics of MCT, including effects of controller medication tapering and temporal variability (and predictors of MCT result change), and concordance between MCT and pulmonologist asthma diagnosis.” (1st page of the article, p.479)
Performance Characteristics of Spirometry With Negative Bronchodilator Response and Methacholine Challenge Testing and Implications for Asthma Diagnosis
By: Janannii Selvanathan BSc, Shawn D. Aaron MD, Jenna R. Sykes, MMath, Katherine L. Vandemheen MScN, J. Mark FitzGerald MD, Martha Ainslie MD, Catherine Lemière MD, Stephen K. Field MD, R. Andrew McIvor MD, Paul Hernandez MD, Irvin Mayers MD, Sunita Mulpuru MD, Gonzalo G. Alvarez MD, Smita Pakhale MD, Ranjeeta Mallick PhD, Louis-Philippe Boulet MD, Samir Gupta MD
Common abbreviations used in this study and blog post include PFT= pulmonary function testing, BDR= bronchodilator response and MCT= methacholine challenge testing (p.479).
Reasons you may find this article interesting:
It is on asthma which impacts many individuals in the population (“the third most common chronic disease in adults” p.480).
This article involves many recognisable and respectable experts. The authors of this study have also taken part in many other research projects as well. For my Canadian followers, many of these authors work in Canada! I have been lucky enough to attend and enjoy talks, in person and virtually, by Dr. Shawn Aaron, Dr. Gonzalo G. Alvarez and Dr. Samir Gupta.
There were follow up testings to assess the accuracy and consistency of the findings.
This article is an excellent reminder for clinicians who order these tests to properly instructs patients to prepare for PFT and MCT. Variability in MCT results based on seasons, environmental allergies, and impacts of other medications are important considerations.
This is a well-written article. There is a nice flow that guides the reader through the method and the reasoning behind those decisions. The results, conclusions and reflections are also nicely done.
My reflections and thoughts after reading this article
If you have almost no time to read the full article: Firstly, make time as this is a great article. Secondly, if you still don’t have time then check out the ‘Take-home Point’ on the second page of the article where authors have included a quick summary and conclusions from this article (p.480).
I am worried that many patients may go undiagnosed or misdiagnosed. Asthma can be properly managed; Prolonged uncontrolled asthma can lead to more frequent exacerbations but also permanent changes to the lungs.
As respiratory health community and excerpts, we need to educate clinicians and patients so they get tested. Also, we need to raise the minimum standard so testing gets performed by trained individuals who have access to proper, accurate and well-maintained equipment. In addition, we have to make sure these clinicians know how to interpret and follow up with patients correctly. For example, not to just rely on a pre-spirometry. In case post-spirometry was done, we need to have knowledgeable clinicians who don’t automatically exclude asthma when no significant improvement was evident. We need clinicians who know the importance of MCT, and organizations to support the costs related to the testing. Besides, we want clinicians to understand that there are factors that could impact the MCT outcomes. 6.9% of participants who initially had a negative MCT end up having a positive reaction in the follow-up testing and 55.6% of those who initially had a positive MCT end up having a negative one in the follow-up testing ( Figure 2B, p.484). On the bigger image, it is essential to understand that PFT and MCT are not the ultimate answers and they are just assessment tools that need to be tied with other clinical assessments and evidence.
Over the past few weeks, I have spoken to a number of teachers as they prepare for the upcoming school year. Due to legal reasons, I need to clarify that this blog post is based on my personal thoughts and you should follow the recommendations and guidelines provided by your employer, ministry of labour, and the local and/or national health regulatory bodies. I have no comments about how to safely plan, organize and operate a classroom. However, my experiences as a clinician working in the hospital, and the use of PPE, may be helpful for teachers. As a respiratory therapist at a Pulmonary Function lab, I coach patients as they perform breathing tests. Due to the nature of this diagnostic testing, I need to take the appropriate precautions so I not only protect myself, but also the people who are coming for testing. I am going to focus on what I wear to protect myself. A surgical mask, a face shield, a gown, and a pair of gloves. I am guessing that teachers are asked to wear cotton masks, or surgical masks if available. If you have access to a face shield, it would be a great idea. Make sure it curves around to cover your face from different angles. Also, it would be helpful if the shield covers not only the eyes but extends to cover over the mask. Have a bottle of hand sanitizer nearby to clean your hands as needed, especially before and after touching your mask or face shield. While I have access to scrubs and gowns, you may be more limited. One idea is to bring a change of clothes to work so you can change at school. The clothes that you have worn during the day can be placed inside a plastic bag and transported directly into the laundry machine or basket (depending on whatever system you have in place). Since I do not have access to a classroom or teaching experience, these recommendations are based on my conversations with a few teachers. It is not a perfect system. You need to look at things case by case. As always, follow the best practices put in place by your employer and local/national health regulatory organizations to protect yourself.
If you found this helpful, please consider sharing it with others.
Kelly Hassall RRT FCSRT MEd khassall@stjosham.on.ca
Experiencing asthma and a family history of Berylliosis exposed Kelly Hassall to the importance of respiratory health and set her on a path to become a quality respiratory therapist. Through this journey, Kelly has tried various roles including clinician, educator, manager, and leader. I had seen Kelly as a presenter at conferences, however, it was not until my volunteering at RTSO where I officially met her. She is driven and knowledgeable and has the ability to look at things with a wide lens. Kelly is well known to the RT community so I reached out to Gino De Pinto to hear his thoughts on our interviewee. The following introduction is byGino De Pinto:
I have had the pleasure of knowing Kelly for the past 14 years. We have worked together to educate students through the early days of clinical immersive simulation, help navigate student placements and most recently on various projects with the RTSO. Kelly has always been solution orientated, innovative and a true respiratory therapy leader. Over the past few months this quote from Rosalene Glickman sums up Kelly’s work as a leader in our profession.
“Every situation – even a disaster – is an opportunity to be your best.”
Rosalene Glickman, Ph.D.,
Our profession was lucky to have Kelly at her best advocating for pandemic pay, organizing timely relevant webinars and providing pertinent resources during the first wave peak of the COVID 19 Pandemic. I’m happy to call Kelly a mentor and a friend. The RT world would definitely benefit for having more Kellys pushing the profession forward.
Thank you Gino for this lovely introduction. Now please join me in the interview with Kelly.
Let’s start with one of my favourite questions to ask. I am curious to find out how people find out about our profession and why they decided to study respiratory therapy. How was the journey for you?
Having spent a large majority of my childhood learning to control my asthma while watching my father struggle with Berylliosis, I had great respect for the number of health care providers who dedicated their careers to helping those with respiratory ailments have a better quality of life. I wanted to give back to a community that had given so much to me and my family. From a young age I knew I was going to work in healthcare specializing in respiratory care and management in some way shape or form. I had the great fortune of graduating high school the year that Queen’s University and the Michener Institute for Applied Health Sciences started offering a combined Bachelor of Sciences in Life Science and Diploma in Respiratory Therapy program. I was looking into the Queen’s Life Sciences program as a “stepping stone” to medical school. This collaborative program seemed like a great fit as an introduction into the management of respiratory health. Initially, I viewed the profession of Respiratory Therapy as a gateway into the healthcare world, as I learned more about the profession and completed my clinical year, I was inspired to begin working clinically as an RT and decided this was the profession for me.
Once you decided on respiratory therapy as the profession for you, where did that journey take you?
I’ve been extremely fortunate throughout my career to date to work with an amazing assortment of clinicians in a variety of settings. I completed my clinical year in Hamilton and Toronto and learned a lot from my fantastic clinical instructors, preceptors and clinical experiences. Immediately after graduation, I began my RT career in the NICU at Mount Sinai Hospital in Toronto. I worked there in a variety of roles for over 14 years. In addition to my time at Mount Sinai, I worked at Toronto Western Hospital as a casual for a short period and then shifted my focus to interprofessional education and training. I began working in the Simulation Center at Mount Sinai Hospital and then joined the faculty at Conestoga College for the first few years of the RT program. Upon returning to clinical full-time, I decided to enroll in a Master’s of Education program and focus on clinical education while exploring the realm of research. I’ve lectured for residents and fellows in the McMaster and University of Toronto medical programs as well as a variety of interprofessional colleagues. Somewhere in all there I did work for a brief period of time as a clinical per diem for Masimo. That role was interesting as I had an opportunity to learn about the American medical system and help out at a few installs across the border. I also became an NRP, BLS and First Aid instructor which gives me a chance to teach the public as well as a variety of clinicians. In 2017, I moved to St Joseph’s Healthcare in Hamilton where I currently hold the title of Clinical Resource Leader of Respiratory Therapy and work with an outstanding team. Throughout this time I’ve also had various opportunities to work with the CRTO, the RTSO and the CSRT in various capacities to promote the profession, assess peers and assist with professional development.
In terms of memorable moments…what happens on shift stays on shift…that being said I am most grateful for the many inspiring leaders and clinicians that I have had the opportunity to work with and learn from. I’m also extremely grateful for the various opportunities I’ve had to attend conferences and workshops…the most memorable of which would be a tie between an European Conference I attended in Portugal in 2013 (my colleague and I met Jane Pillow and she offered us a chance to work with the sheep in her lab) and the AARC in Las Vegas in 2018 (the keynote was ZDogg…amazing!). I would also be at a loss if I were not to point out the pride in seeing some former students step up to the plate over the past few months to not only show up to work but go above and beyond with clinical practice suggestions, food drive fundraisers and support of their profession.
Learning about your wonderful journey gave me the same reaction of awe and admiration, which is similar to when I get to meet and listen to inspiring presenters in conferences. Not surprisingly, you are a frequent speaker at various conferences.
As you mentioned, you have worked in various roles. What can you tell me about your clinical roles?
To me, one of the most amazing things about Respiratory Therapy is how diverse our profession is. There isn’t a day that goes by that I don’t learn something new. For years I specialized in Women’s and Infants’ Health. The first day I stepped into the NICU I was petrified…the patients were so small and it seemed as though I had so much to learn. Over the years this area of care along with Labour and Delivery became my second home. The challenge of arriving at a delivery never fully knowing what to expect and the many valuable opportunities to work with and learn from the rest of the interprofessional team made the clinical environment engaging and extremely rewarding. For the most part, the successes would outweigh the challenges. When I moved to Hamilton I began to spend more time in the adult world and I’ve spent the past three years learning so much from my colleagues. The day that I observed the ICU team stop rounds to go in and sing “Happy Birthday” to a patient was the day that I realized that it’s not the clinical area or patient population that matters to me, it’s the clinicians working together to provide the optimal care for each person and the environment of respect and trust that this creates that makes the time I spend away from my family worthwhile.
In your opinion what makes a person a quality RT?
When I reflect on the RTs that have inspired me the most, the traits that come to mind are respect, critical thinking, trust and resilience. No matter where you are in your journey as an RT, whether it’s a student entering clinical or a 30+ year veteran gearing up for retirement, there’s always an opportunity to learn, to reflect and to adjust your practice. The clinicians who have inspired me the most are not afraid to admit when they are being faced with a challenge beyond their experience and are quick to seek resources or help. Instead of backing away from a challenge they often step up and look for ways to find a solution. They stand up for what they believe in and never throw anyone “under the bus”. They also take the time to say thank you and to acknowledge the efforts of others.
How did you get involved with the leadership role? What are some elements about your role that you enjoy the most?
I have crossed paths with the realm of leadership in various capacities over the years. When I was alerted that there was a posting in Hamilton for a full-time RT leadership position it seemed like the right time to try something new. Fortunately the team at St. Joseph’s Healthcare Hamilton felt that I was the right fit for their needs and here I am. I enjoy the challenge of getting to know all the various care areas and working with various members of the interprofessional team to ensure that they are supported. I work with an amazing group of RTs, AAs and Pulmonary Techs. I rely on them heavily to help me understand the clinical challenges that are being faced in each area and what I can do to support their needs and enhance patient care. Since joining the team at St. Joseph’s Healthcare Hamilton, we’ve implemented an electronic charting system, moved to Bubble CPAP in our Special Care Nursery, started weekly interprofessional simulation events in our ED, evaluated ventilators and now we’re in a pandemic. It has certainly been an interesting few years.
I also am extremely grateful to have a fantastic manager who is extremely supportive in assisting me navigate the many considerations that need to be made when trying to optimize support for the RTs while working interprofessionally and collaboratively throughout an organization. I would be at a loss if I didn’t mention the RT students. A significant part of my role is to support RT students during their clinical year. I wouldn’t be where I am today without the support of the clinical instructors who supported me through my clinical year thus it’s nice to have a chance to give back to the profession by supporting the students entering our profession as well.
One of the ongoing themes in your roles is your interest, willingness and involvement in teaching and mentorship. What advice do you have for RTs and preceptors to better assist students in their growth? Then turning the table, what advice do you have for students for maximizing their learning and growth?
No one enters into this profession to do harm. Every student who comes through the doors has spent several years preparing for this clinical experience and is striving to achieve a level of competence as an entry to practice RT. Every student is also a human with past experiences and a life outside of clinical. When you are with a student, don’t assume. Ask them what their goals are for the day, let them know it’s okay to say when they don’t know something and provide them opportunities to grow in a safe environment. They will make mistakes, they will forget things and they will misunderstand…just like we all do throughout our careers. Be clear with your expectations and timely with your feedback. It’s impossible to adjust behaviour if you are not aware of the adjustments that need to be made.
Students, you are not expected to be perfect but you are expected to be engaged and play an active part in your learning. I would rather work clinically beside the RT who scored 65% on their composite exam but took the time to understand where they lost the 35% and how to do things differently the next time than the RT who scored 85% and never took the time to review the 15% they could have improved upon. Treat each day as an opportunity to learn not only what you need to know for entry to practice but also what you have an opportunity to understand as a clinician and a part of the interprofessional team. Identify your opportunities for improvement and ask your preceptors to support you in this. Be proud of your accomplishments but also realize that just because you do something perfectly once it doesn’t mean that you’ve mastered the skill. Every patient encounter, every cart check and every patient chart is an opportunity to learn and to grow as a clinician. Your clinical year is what you make of it. Choose to make the most of it as it will set the tone for how you choose to engage in your profession and practice for the rest of your career.
Your contributions to the respiratory therapy field include volunteering work. We are both volunteers at the Respiratory Therapy Society of Ontario (RTSO) and I have seen you serve in various roles. You are the current co-chair of the leadership committee and the past-president! I definitely appreciate all your hard work and have learned a lot under your leadership. How did you hear about RTSO and what made you decide to volunteer with this organization in the first place?
Why thank you for those kind words Farzad. Words cannot express how grateful I am that our paths have crossed. The RTSO is a team and we all learn from each other as we grow together. I learned about the RTSO when I was in RT school. I happened to enter into the profession during an interesting time when there was quite a bit of tension between the CRTO and the RTs. The RTSO was the collective voice of the RTs during this tension and the clinical environment and opportunities that I benefited from were in part due to the work of the RTSO. When you graduated from RT school in Ontario you joined the RTSO…it was just accepted that you supported the society that advocated for you. Then there was the membership merger piece between the CSRT and RTSO…it was a great deal as you could join your provincial and national society and get your insurance all at the same time. At some point that ended…I’m not sure exactly when…but eventually it was brought to my attention that I was not a RTSO member any more and that the society needed volunteers to keep all the great things they were doing going. Anyone who knows me knows that it takes very little to convince me to help for a cause that I believe in so when Sue Martin asked me to help out on the Leadership Committee I was more than happy to do so. Things just sort of evolved from there…at no point did I ever expect to be put into the role of President position in the midst of a pandemic…but it happened. When the expectations of the unanticipated change in roles exceeded the time and energy I had to give the rest of the executive was there to step up and help out…just as I hope many other RTs will be inspired to do in order to keep the society going.
What have you got out of your experience?
My work through the RTSO has renewed my sense of pride in our profession and opened my eyes to all the amazing things RTs are doing across the province and the country. If there is anything that truly stands out in my mind it’s our provincial response to this pandemic as RTs. We were faced with something novel and unknown and we worked together (and continue to work together) to support each other in doing what needs to be done safely and effectively. It’s also opened my eyes to the true importance of working together across the continuum of care. Due to the massive expanse and scope of our profession, it is very easy to become focused in the care area within which you work. There is so much to be gained by breaking down these silos and sharing information, resources and experiences between the various areas of care. Just as the patient experience extends from hospital to home, so should our approach to supporting the respiratory needs of our patients. Our provincial society truly is our opportunity to unite as RTs across the province to share concerns, thoughts, resources and supports. It is a mechanism through which we can unite and systematically work together to get concerns addressed at the Ministry level as well as a mechanism for addressing concerns that are central to our practice in our province. I would also be at a loss if I didn’t mention the incredible amount of collaboration and assistance that has been provided to the RTSO by the CSRT and CRTO as well. While it is important to recognize the differences between the various organizations, it is also important to acknowledge the tremendous amount of collaboration between the RTSO, CSRT, CRTO and various other organizations such as the CTS and the ORCS that enables our profession to move forwards and enhance patient care.
Why should RTs consider volunteering with RT organizations?
Your profession needs you. It’s as simple as that. You chose to enter into the profession of Respiratory Therapy out of any other allied health profession out there. Take a moment and ask yourself why. Why RT? I’m going to take a wild guess and suggest that it wasn’t so that you could miss out on long weekends, sport a variety of bodily fluids on your shoes, rock the N95 imprint on your face and score an unlimited supply of nasopharyngeal swabs. So what exactly was it? What makes you leave your house every single day, fill out your screening tool and walk into work while everyone else is barricaded in their homes?
A profession doesn’t just magically go from moving oxygen tanks around a hospital to becoming the clinical experts in respiratory care and management. It was the ambition of the RTs before us that expanded our role across the continuum of care and opened doors and opportunities for roles that our nursing colleagues or others would be glad to fill. The role that you walk into every single day is a role that has been built by the dedication, inspiration and drive of the RTs before you. It’s up to us to keep that momentum going, to use our experiences, ideas and energy to continue to provide opportunities for our profession to grow, for our voices to be heard and our clinical expertise to be acknowledged. There are over 3500 RTs in Ontario. If we all did our part just think of what we could accomplish for our profession and the respiratory health of our loved ones.
What can you tell us about your experience during COVID19, as a clinician and leader? What are some of the learnings that you can share with us?
That’s a great question….one that I’m not really sure how to answer just yet. I would say that the thing that comes to the forefront of my mind is that as crazy as this all may seem at times with all of the unknowns, I am grateful and I am proud. I’m proud of our profession for stepping up in less than ideal times to use our skills and resources to figure out how to approach the various aspects of this pandemic. I’m proud of our families for supporting us in what we need to do and sacrificing time at home with us so that we can ensure the health and safety of others. I am grateful for the generosity of the communities that have provided support in whatever way they can whether it was a painted rock, a baby monitor, ear saver, a meal or a donation to our food drives. While no one can argue that clinical skill, PPE and equipment are necessary to get us through this pandemic, I believe that kindness and understanding have helped us make it this far and play a huge role in us seeing this to the end.
COVID-Simulation with Paramedics. Kelly Hassal and Dr. Erich Hanel
How do you see our field change over the next few years? Also, what changes do you hope to see?
Another great question Farzad. From a provincial standpoint, I hope to see a restored focus from the Ministry of Health and the public on the importance of respiratory care and respiratory health. I would like to see the profession of Respiratory Therapy brought to the forefront as experts in respiratory care and management across the continuum of care. That would mean a greater presence in home and community care as well as an opportunity to engage in initiatives within long term care and retirement homes. I would like to see funding for research for initiatives such as research into PTSD among Respiratory Therapists and supports to ensure that the mental health of our colleagues is at the forefront. I would also like to see the Allied Health Fund restored to support the continuation of education and training for our colleagues. From a professional standpoint, I would like to see continued collaboration between RT leaders throughout the province and the country to share resources and experiences to address challenges and concerns. I would also hope to see increased engagement of frontline staff members in the various respiratory-related organizations and societies throughout the province and country.
When you are not contributing at work and volunteering positions, how do you enjoy your time?
Outside of work and volunteering I’m the proud mother of two amazing children and the wife of an extremely understanding non-healthcare husband. We also adopted a kitten in February of this year and we are extremely fortunate that he’s easy going as he’s constantly being picked up and cuddled. When we’re not running between activities, we love to spend time outside hiking, creeking, canoeing and riding bikes. Any other summer would be filled with BBQs, family gatherings and festivals as well. I also like to bake and quite often thank my colleagues for the great work they do with cupcakes and other treats. I also used to really enjoy travelling…I look forward to getting back to that someday.
Any final words to the readers?
Thank you. Thank you for everything you do every day to ensure that you and those around you get through this pandemic. Take care and stay safe.
It has been my pleasure sharing this interview with you all. Once again, thank you, Kelly, for taking the time to share your experiences and insights with us all!
To the readers of this piece, what are your thoughts and reflections? If you have enjoyed this interview, please share with others! Thank you for joining me on this journey of learning!
I usually write blog posts for respiratory therapists and clinicians who practise in other specialities. Occasionally, I write for the general public and this is one of them.
Masks are a hot topic right now. The view on masks for the public has changed over the course of the pandemic. On a personal note, I have been wearing surgical masks throughout my shift since the start of COVID19. N95 masks were used when directly caring for individuals with COVID19. While they are still uncomfortable for me, I have gotten used to the uncomfortable feeling. Off duty, I wear cotton masks when in crowded and indoor spaces.
There are some cases that exempt people from wearing masks, and this blog is not focusing on that population. For everyone else, wearing masks is recommended based on our current information and data. Some argue that forcing people to wear them is against their rights. I like to encourage those people to look at it from different perspectives. You hold the power to make a difference. I am going to give you four examples. These people come to the hospital I work at for diagnostic testing and other respiratory care. They are NOT based on any specific person or people for legal reasons, but a representation of patients who frequently come to see me for testing.
Kelly is a neonatal nurse who has severe asthma. She has fought through all the limitations caused by her uncontrolled severe asthma despite optimized respiratory care. That has not stopped her. She finished her studies and found a job. She is happy and proud that she can help kids. That’s her passion and she feels blessed. By wearing masks we limit the transfers of the virus, and we protect people like Kelly. If Kelly gets sick, it would be a much tougher fight and a longer recovery for her.
Tom is a retired firefighter. Despite best practices and equipment, he was still exposed to occupational irritants. Tom, a lifetime non-smoker who had to retire early because of a lung condition called COPD. Tom has a few newborn grandchildren. He loves them and wants to live a long life to see them grow. He wants to spend time with them and make memories. People with COPD may have a challenging time with viral infections and may require invasive and supportive respiratory care.
Mary is a single mom with fibrotic lungs. The factory she has been working at for the past 10 years didn’t have the best ventilation at the beginning. That led to permanent changes in her lungs. She is financially dependent on her job. Mary needs to manage and protect her lungs so she can provide for her family. COVID19 may lead to additional negative changes to damaged lungs.
Mike is in second grade. He has been receiving treatments to manage his cystic fibrosis for some time now. He loves visiting his grandfather and watching him fix cars. He wants to grow up and be just like him. Catching a viral respiratory disease may cause a big set back in Mike’s respiratory care.
The people I have mentioned did not choose what has happened to them, but we can choose to wear a mask and use that power to protect others. We are in this together.
Farzad Refahi August 22, 2020 https://www.respiratory.blog/masks-your-power-to-make-a-difference/ As always, this is my personal opinion and reflection. Follow the guidelines and instructions provided by your employer and the public health organizations in your province/county.
Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.
This month I found a great piece under the categories of special communication and clinical review. The objective of this paper is to “formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel” p. E1. A common abbreviation used in this article and this post is Brain Death (BD) and Death by Neurologic Criteria (DNC).
Determination of Brain Death/Death by Neurologic Criteria The World Brain Death Project
by David M. Greer, MD, MA1; Sam D. Shemie, MD2,3; Ariane Lewis, MD4; et al .
It involves many experts from various organizations. The list of these organizations can be found under Methods on page E2 (World Federation of Intensive and Critical Care, World Federation of Pediatric Intensive and Critical Care Societies, World Federation of Neurology, World Federation of Neurosurgery, and the World Federation of Critical Care Nurses).
There are notes for the adult and Pediatric/Neonatal populations.
The list of ideas and recommendations are nicely organized under their own headings:
The Concept of BD/DNC (p. E4),
Minimal Clinical Criteria for Determination of BD/DNC (p. E5),
Apnea Testing (p. E6),
Number of Examinations (p. E8),
Pediatric/Neonatal BD/DNC (p.E9),
Determination of BD/DNC in Patients Requiring Extracorporeal Membrane Oxygenation (p. E11),
Determination of BD/DNC After Treatment With Targeted Temperature Management (p. E11),
Documentation of BD/DNC (p. E12),
Qualifications for and Education on Determination of BD/DNC (p. E13),
Religion and BD/DNC: Managing Requests to Forgo a BD/DNC EValuation or Continue Somatic Support After BD/DNC (p. E15), and
BD/DNC and the Law (p. E16).
The authors address sensitive issues such as religion and law with detailed notes in the supplementary online documents 12 and 13 that are found on JAMA’s website ( or the following links: Religion and Law).
As I was reading this article, I was reminded of the practices I was taught at my main training hospital. Many of the items on the protocol, from 6 years ago, meet the list mentioned in this article. Working in the greater Toronto area, with its great diversity, reminds me of one of the complexities involved in the determination and the care of BD/DNC patients.
