CVAA Vascular Access - Volume 11, Issue 1, Spring 2017

Volume 11, Issue 1 • Spring 2017

In this issue: Peripheral Intravenous Catheters: Improving Outcomes Through Change in Products, Clinical Practice and Education Cathétérisme intraveineux périphérique : amélioration des résultats par le biais de changements touchant les produits, la pratique clinique et la formation Overview of Medical Assistance in Dying: Considerations for the Vascular Access Specialist Aperçu de l’aide médicale à mourir : considérations pour le spécialiste de l’accès vasculaire

AND A SOLUTION FOR HIGH IV FAILURE RATES. IV therapy is one of the most common, invasive procedures conducted today.

Yet complications cause up to 50% of all IVs to be replaced before therapy is completed.1 That can result in delayed treatment, unnecessary restarts, pain and discomfort for your patients and stress for you. Enter BD Vascular Access Management—a new, integrated solution for reducing peripheral IV complications. It’s an approach that can help you achieve improved outcomes for your patients by combining evidence-based clinical training and education with a comprehensive portfolio of products—all working together to raise the quality of vascular access care. Discover the difference one company can make. Discover the new BD.

Visit the BD booth at CVAA Conference 2017 or bd.com/CVAA-2017 to learn more about the Difference of One. 1 Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure.

J Infus Nurs. 2015;38(3):189–203. © 2017 BD. BD and the BD Logo are trademarks of Becton, Dickinson and Company. BD-2003 MC7517 (0217)

Canadian Vascular Access Association Association Canadienne d’Accès Vasculaire

Publications Agreement Number 40025049 ISSN 1913-6692 PUBLICATIONS COMMITTEE CHAIR France Paquet EDITOR-IN-CHIEF Linda M. Verde EDITORIAL BOARD Sheryl McDiarmid Andrea Raynak

Volume 11, Issue 1 • Spring 2017

Contents Intravenous Catheters: Improving Outcomes 7 Peripheral Through Change in Products, Clinical Practice and Education Cathétérisme intraveineux périphérique : amélioration des résultats par le biais de changements touchant les produits, la pratique clinique et la formation

Adele deRosenroll, RN, BN

CVAA EXECUTIVE DIRECTOR Melissa McQueen

of Medical Assistance in Dying: Considerations for 14 Overview the Vascular Access Specialist

MANAGING EDITOR Heather Coughlin

Aperçu de l’aide médicale à mourir : considérations pour le spécialiste de l’accès vasculaire

ART DIRECTOR Sherri Keller

Daphne Broadhurst, RN, BScN, CVAA(c), Kelly Crotty, RPh, BPharm, and Adele deRosenroll, RN, BN

______________

Vascular Access is published three times per year.

We welcome editorial submissions but cannot assume responsibility or commitment for unsolicited material.

Any editorial material, including photographs that are accepted from an unsolicited contributor, will become the property of The Canadian Vascular Access Association.

The Canadian Vascular Access Association shall not be liable for any of the views expressed by the authors published in Vascular Access, nor shall these opinions necessarily reflect those of the publisher.

Authors are responsible for ensuring the originality of their articles.

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Vascular Access Peer Reviewers Astride Bazile, RN, MSc Angele Caporicci, RN, CVAA(c), DipAdEd Carmen Cernusca, RN, BSc(N), MSc(N), CPN(c), CVAA(c) Annie Chaput, RN, BSc(N), CVAA(c) Jane Chamber Evans, BNSc, MSc(A), MSc(Bioethics), (retired) Tiffany Crisp, RN, BSc(N), CVAA(c) Nicole Daniel, RN, BScN Jane DeBoer, RN, MSc Celine Dupont, BPharm, MSc Brenda Gray, PharmD, BCNSP, CNSC, CVAA(c) Karen Laforet, RN, MClSc, IIWCC, VA-BC™, CVAA(c) Luisa Luciani Castiglia, RN, MSc(A) Caroline Marchionni, RN, MSc(A), MSc(Admin) Kim Newcombe, RN, BSc(N), CRNI, CVAA(c) Diana Pearson, RN, MSN, BSc(N), CVAA(c) Janny Proba, RN, BSc(N), CON(c), CHPCN(c) Michel Sergerie, RN, MSc Lucie Tardif, RN, MSc

Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 3

Publications Committee Chair Report A new beginning!

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t the start of every year, the Board meets to discuss what will be the next priorities of the association. On the same occasion, we discuss who will be chairing and taking part in each committee. A lot has happened in the Publications Committee recently! In the past year, we have completely revamped the publication process, contracted a new publisher (Pappin), and welcomed a new Editor-inChief (Linda M. Verde) and a new member of the Board (Andrea Raynak)!

Andrea and I will continue to oversee the clinical content and ensure its relevance for our reader. Lastly, as we welcome Linda and her expertise in editing, publishing and writing, you can expect a much-improved quality of writing and access to someone who can really help you construct and improve your manuscript. Do not hesitate to reach out— you do not want to miss out on this opportunity.

France Paquet, BSc, MSc, CVAA(c), VA-BC™ Publications Committee Chair

What can you expect from these changes? First, a brand-new look for Vascular Access and second, a continuous search for potential authors and subjects that interest you. Therefore,

Rapport de la Présidente comité des publications Un nouveau départ!

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haque année, le conseil exécutif de l’ACAV se rencontre pour déterminer quels seront les priorités de l’association. Par la même occasion, nous discutons des différents comités et décidons qui prendra part à chacun d’eux. Plusieurs changements sont survenus au cours de la dernière année au comité des publications. Nous avons complètement revisité le processus de publication, signé un contrat avec un nouvel éditeur (Pappin), accueilli une nouvelle éditrice en chef (Linda M. Verde) et un nouveau membre du conseil exécutif (Andrea Raynack)!

Que pourrez-vous constater comme suite à ces changements? En premier lieu, un tout nouveau look pour Vascular Access, deuxièmement, la recherche continue

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d’articles et d’auteurs qui vous intéressent. C’est pourquoi Andrea et moi continueront de superviser le contenu clinique de la revue afin de s’assurer de leur pertinence pour notre lectorat. Finalement, avec l’ajout de Linda et de son expertise comme auteure et éditrice, vous pouvez vous attendre à un niveau relevé d’écriture et l’accès à une personne qui pourra vous aider à construire et améliorer votre manuscrit. N’hésitez pas à la contacter, vous ne voulez pas manquer une telle opportunité.

France Paquet, inf./RN, M.Sc.inf./MSc(N), VA-BC, CVAA(c), Présidente comité des publications

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Message from the Editor-in-Chief

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ello! My name is Linda Verde. I am very excited to be the new Editor-in-Chief of Vascular Access, and am already impressed with the people, the process and the quality of your journal.

Sharing your expertise as vascular access specialists by writing relevant articles is what makes this publication so valuable. My part will be to make sure the language flows and the information is presented in a way that is clear, accurate and, I hope, captivating. You can be sure that I will do all that I can to maintain the journal’s high standards because excellence is important to me.

delicate topic. Daphne Broadhurst, Kelly Crotty and Adele deRosenroll provide special considerations for vascular access professionals and encourage you to think about the role you are willing or not willing to play. This is something you need to know before you engage in the process.

I thank CVAA for the opportunity to work with you as authors, reviewers and readers, and look forward to many great issues ahead.

Linda M. Verde Editor-in-Chief

Because I am new to your association, you might like to know a little about me. For the past 20 years, I have been a freelance editor and writer. Some of my clients include College of Nurses, IDEAL Way, CIBC Wood Gundy, Rise Asset Development, 3M Canada and Your Holistic Earth. My background experience covers a variety of fields and my interests are diverse. I love reading, writing, cooking, good wine, theatre, films, painting and music. My guilty pleasure is W IN NO reading or watching spy stories. Personally, ABLE AVAIL DA I am a mother of three and grandmother CANA of five.

The Site~Rite® 8 Ultrasound For more than 20 years, I worked at Ivey System with integrated Sherlock 3CG™ Diamond Tip Confirmation Business School, preparing their content System is designed to simplify (cases, textbooks, articles, course work, the placement of vascular etc.) for publication. I joined the editorial access devices team of their prestigious management • Vein measurement tools magazine and quickly rose to managing • PICC Tip Tracking editor and eventually took the reins as • Tip confirmation publisher and editor. This is where I learned to love editing.

Working with your publications team on this first issue has been a great learning experience. In the first article, Adele deRosenroll gives evidence that a change in products, when accompanied by focused training and use, has improved outcomes for peripheral IVs. The article on medical assistance in dying (MAiD) is the first that has been done by CVAA on this cvaa.info

Site~Rite® 8 Ultrasound System Indications For Use: The Site~Rite® 8 Ultrasound System is intended for diagnostic ultrasound imaging of the human body. Specific clinical applications include: • Pediatric • Peripheral Vessel • Cardiac (adult and pediatric)

• Small Organ (breast, thyroid, parathyroid, testicles) • Musculo-skeletal (conventional and superficial)

Imaging Applications Exam Type (Adult and Pediatric) Vascular Bard Canada Inc. 2715 Bristol Circle, Unit 1 Oakville, Ontario, L6H 6X5 Tel: 1-289-291-8000 Customer Service: Western Canada: 1.800.268.2862 Eastern Canada: 1.800.387.7851 Ontario: 1.800.387.9473 Fax: 1.800.632.2109

Assessment of vessels in the extremities and neck (e.g., jugular, carotid) leading to or coming from the heart, superficial veins in the arms and legs (e.g., basilic, cephalic, brachial, femoral, radial, saphenous), and vessel mapping.

Assessment of superficial thoracic vessels (e.g., axillary, innominate, subclavian) Imaging Applications Exam Type (Adult and Pediatric) Vascular Access

Guidance for PICC, CVC, dialysis catheter, port, PIV, midline, arterial line placement, access to fistula and grafts, and general vein and artery access

Interventional

Guidance for biopsy and drainage

Superficial

Assessment of breast, thyroid, parathyroid, testicle, lymph nodes, hernias, musculoskeletal procedures (e.g., joints, ligaments, tendons), soft tissue structures, and surrounding anatomical structures

Sherlock 3cG™ Tip Confirmation System (TCS) Indications For Use: The Sherlock 3CG™ Tip Confirmation System (TCS) is indicated for guidance and positioning of Peripherally Inserted Central Catheters (PICCs). The Sherlock 3CG™ TCS provides real-time PICC tip location information by using passive magnet tracking and the patient’s cardiac electrical activity (ECG). When relying on the patient’s ECG signal, the Sherlock 3CG™ TCS is indicated for use as an alternative method to chest X-ray and fluoroscopy for PICC tip placement confirmation in adult patients.

Limiting but not contraindicated situations for this technique are in patients where alterations of cardiac rhythm change the presentation of the P-wave as in atrial fibrillation, atrial flutter, severe tachycardia, and pacemaker driven rhythm. In such patients, who are easily identifiable prior to catheter insertion, the use of an additional method is required to confirm PICC tip location.

Please consult product labels and inserts for any indications, contraindications, hazards, warnings, precautions and directions for use.

Bard, Advancing Lives And The Delivery Of Health Care, Sherlock 3CG and Site~Rite are trademarks and/or registered trademarks of C. R. Bard, Inc. © 2016 C. R. Bard, Inc. All rights reserved. BAS/SRT8/0916/0027

Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 5

Message de l’éditrice en chef

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onjour! Je suis Linda Verde. Je suis enchantée d’être la nouvelle éditrice en chef pour la revue Vascular Access, et suis déjà impressionnée par les gens, le processus et la qualité de votre revue.

Le partage de votre expertise en tant qu’expert en accès vasculaire par le biais de l’écriture d’articles pertinents à votre pratique est un élément clé de cette publication.

Mon rôle sera de m’assurer à ce que l’écriture et le flot du manuscrit permettent que l’information présentée soit claire, précise et, je l’espère, captivante. Vous pouvez être certains que je ferai tout ce qui est en mon pouvoir pour maintenir les standards d’excellence du journal parce que l’excellence est très importante pour moi.

Puisque je suis nouvelle venue dans votre association, vous apprécierez peut-être en apprendre un peu sur moi. Au cours des 20 dernières années, j’ai été éditrice indépendante et auteure. Quelques un de mes clients inclus: College of Nurses, IDEAL Way, CIBC Wood Gundy, Rise Asset Development, 3M Canada et Your Holistic Earth. Mon expérience antécédente est variée et englobe une multitude de champs d’intérêts.

J’aime la lecture, l’écriture, la cuisine, le bon vin, le théâtre, le cinéma, la peinture et la musique. Mon plaisir coupable est les histoires d’espionnage. D’un point de vue personnel, je suis mère de 3 enfants et grand-maman de 5.

livres de références, articles, plans de cours, etc.). J’ai joint l’équipe éditoriale de leur prestigieux magazine de gestion et rapidement suis devenue directrice de la rédaction et éventuellement directrice de la publication et éditrice. C’est à ce moment que la passion de l’édition s’est révélée.

Le travail avec votre équipe des publications sur ce premier numéro a été une formidable expérience d’apprentissage.

Dans le premier article, deRosenroll démontre comment un changement de produit accompagné de formation spécifique peut améliorer les résultats pour les cathéters intraveineux périphériques. L’article sur l’aide médicale à mourir (MAiD) est le premier publié dans Vascular Access sur ce sujet délicat.

Daphne Broadhurst, Kelly Crotty et Adele deRosenroll offrent des considérations spéciales pour les professionnels en accès vasculaire et vous encourage à réfléchir sur votre rôle. C’est un élément important auquel vous devez réfléchir avant de vous engager dans ce processus.

Je remercie l’ACAV pour cette opportunité de travailler avec vous en tant qu’auteur, réviseur ou lecteur et j’attends avec plaisir les prochains numéros.

Linda M. Verde Éditrice en chef

Pour plus de 20 ans, j’ai travaillé à l’Ivey Business School, à la préparation du contenu des publications (étude de cas,

Page 6 • Vascular Access • Volume 11, Issue 1, Spring 2017

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Peripheral Intravenous Catheters: Improving Outcomes Through Change in Products, Clinical Practice and Education Cathétérisme intraveineux périphérique : amélioration des résultats par le biais de changements touchant les produits, la pratique clinique et la formation Adele deRosenroll, RN, BN

Abstract

Résumé

The rate of peripheral intravenous catheter (PIV) failure is reported today to be 35–50%. These failures contribute to material costs, increased nursing time, delays in treatment, treatment of complications and patient dissatisfaction. We reported observational data from two in-patient hospital sites that evaluated the effect of a change in PIV products and procedures developed to align with the then published 2011 Infusion Nurses Society (INS) Standards of Practice. The primary purpose was to evaluate the effect of these changes on the rate of peripheral IV restarts, and track practice and compliance with a closed-system PIV (BD Nexiva™ Closed IV catheter) and securement dressing (3M™ Tegaderm™ IV Advanced Securement Dressing 9525HP). The secondary purpose was to determine the impact, if any, on the incidence of catheter complications, compliance with policies, and consistency of practice. Data from baseline to 24 months showed a substantial increase in positive patient outcomes by decreasing the number of PIV complications for all of the following: 45% reduction in accidental or dislodged PIVs; 67% reduction in positional PIVs; 36% decrease in leaking at the site; and 42% decrease in kinked tubing. The 18-month assessment indicated a reduction of 21% in the rate of phlebitis. Continuing accessible staff education made a significant contribution to the substantial improvements in patient outcomes, clinical practice, and compliance.

Le taux d’échec du cathétérisme intraveineux périphérique (CIP) est aujourd’hui de 35 à 50 %. Les échecs en matière de CIP contribuent aux dépenses en matériel, à l’augmentation du temps consacré aux soins infirmiers, aux retards de traitement, aux complications devant être traitées et à l’insatisfaction des patients.

Nous avons rapporté les données d’observation provenant de deux établissements hospitaliers qui ont évalué l’effet de changements touchant les produits et les procédures de CIP effectués pour se conformer aux normes de pratique de 2011 publiées par l’Infusion Nurses Society (INS). L’objectif principal était d’évaluer l’effet de ces changements sur le taux de reprise des CIP et de suivre la mise en pratique et le respect des normes visant le CIP en circuit fermé (cathéter BD NexivaMC Closed IV) et la mise en place d’un pansement d’immobilisation (3MMC TegadermMC IV Advanced Securement Dressing 9525HP). L’objectif secondaire consistait à déterminer l’effet de ces changements, le cas échéant, sur l’incidence des complications du cathétérisme, le respect des politiques et l’uniformité de la pratique. Les données recueillies sur 24 mois ont révélé une augmentation considérable des résultats cliniques favorables par suite de la diminution du nombre de complications liées au CIP, à savoir : réduction de 45 % des retraits accidentels ou non du cathéter; réduction de 67 % des cas de cathéter positionnel; réduction de 36 % des fuites au point d’insertion; et réduction de 42 % des pincements de tubulures.

L’évaluation à 18 mois a fait ressortir une réduction de 21 % du taux de phlébite. L’accès du personnel à une formation continue a contribué de façon significative aux améliorations considérables notées en matière de résultats cliniques, de pratique clinique et de respect des normes.

Key words: peripheral intravenous catheter (PIV), infusion standards, catheter complications, education initiatives, vascular access team, Nexiva™, Tegaderm™, phlebitis

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Peripheral Intravenous Catheters: Improving Outcomes Through Change in Products, Clinical Practice and Education

Introduction

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odern intravenous therapy is less than a century old, but astounding advances have been made in the last 25 years (Millam, 1996). Part of that progress includes the development of new products, techniques and therapies, as well as the establishment of professional standards of practice.

Today, the use of peripheral intravenous catheters (PIV) is an integral part of the patient’s healthcare plan, particularly in the present-day hospital setting (Brady, Bruno, Marchionni & Paquet, 2016). It has been estimated that, on any given day, approximately 60% of hospital in-patients have at least one PIV in place (Helm, Klausner, Klemperer et al., 2015). In fact, PIV insertion is the most common invasive hospital procedure worldwide (Helm, Klausner, Klemperer et al., 2015).

However, it is also understood that use of PIVs carries the risk of complications, including catheter failure and infection. The rate of failure has been reported at 35–50% (Helm, Klausner, Klemperer et al., 2015). These failures can contribute greatly to material costs, nursing time, delays in treatment, treatment of complications and patient dissatisfaction.

Victoria Island Health Authority strives to provide superior healthcare through innovation, teaching and research with a strong commitment to quality and safety. In keeping with this commitment, the author endeavours to be current and follow best practices for PIV standards to provide the most up-to-date technologies and improve patient outcomes. In 2012, Island Health updated its vascular access policies, procedures and guidelines to align with the 2011 Infusion Nurses Society (INS) Standards of Practice. For continuing discussion and updates, the author has referenced the 2016 Infusion Nurses Society, Infusion Therapy Standards of Practice (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Dolellman, 2016).

In reviewing these standards, Island Health made the decision to implement new technologies in PIVs. The goal of this initiative was to ensure that the products supported the changes in policies, procedures and guidelines. These changes included: • Improved safety and decreased risk of blood exposure to healthcare providers and patients.

• Improved stabilization, preserving the integrity of the access device, minimizing catheter movement at the hub and preventing catheter dislodgement and loss of access.

Therefore, the organization made the decision to switch the majority of peripheral catheters to a closed PIV system (BD Page 8 • Vascular Access • Volume 11, Issue 1, Spring 2017

Nexiva™ Closed IV Catheter System), and a securement dressing (3M™ Tegaderm™ IV Advanced Securement Dressing 9525HP). Along with these changes, implementation of educational initiatives was undertaken and relevant data were collected in order to determine whether the new products and procedures improved patient outcomes.

Methods Purpose The primary purpose of this observational assessment was to evaluate the effect on the rate of peripheral IV complications, and to track practice and compliance to the new equipment (catheter and dressing).

The secondary purpose was to determine the impact, if any, on the incidence of catheter complications, improved compliance with policies, and consistency of practice.

Products According to the manufacturer, the closed IV system provides: • A soft, flexible built-in stabilization platform designed to minimize catheter movement.

• An integrated extension set to increase efficiency, and decrease risk of contamination and manipulation at the hub.

• A blood-containment system that can reduce healthcare workers’ exposure to blood (deRosenroll, Fleming & Swtizer, 2015).

According to the manufacturer, the adapted securement dressing offers: • Minimal catheter movement and improved securement with the reinforced border (specific to the BD Nexiva™ catheter).

• A waterproof, sterile barrier to external contaminants including liquids, bacteria and viruses (deRosenroll, Fleming & Swtizer, 2015).

Education The manufacturer of the catheter, Becton Dickinson Infusion Therapy Systems Inc., in the form of their BD Signature Solutions™ Program, provided education and consultation regarding the correct procedures and techniques in the optimal use of their catheter and the 3M securement dressing specific to the Nexiva™ Closed IV catheter. This was an integral part of the conversion process that supported the initial training process. They also provided support to the ongoing educational initiatives, which were developed by the vascular access nurse educator and the vascular access teams. Staff education initiatives included the following: cvaa.info

deRosenroll, A.

• Education sessions and demonstrations were implemented by the BD clinical specialists for all shifts for the first two weeks of the conversion.

• Additional education sessions were provided on the units by the vascular access team and the vascular access nurse educator.

• Monthly classroom sessions were offered by the vascular access clinical nurse educator and were easily available for registration through Island Health’s learning management system.

• A PIV therapy website was developed by the clinical nurse educator for vascular access on Island Health’s intranet.

This provided educational materials to all staff including a self-learning guide for insertion, care, and maintenance of PIVs and videos provided by the manufacturer with stepby-step instruction on correct insertion technique of the catheter and application of the dressing.

• Printed handouts with quick tips and key information were distributed to nursing units and out-patient departments.

Data Collection Data were gathered from two separate in-patient hospital sites under the administration of the overall Health Authority. Our guiding principle for this endeavour was the Seek, Solve and Sustain model (Figure 1).

Results Restarts PIV restarts are one of the important direct patient activities collected from the vascular access team’s daily work-flow statistics. The author compared the annual restarts performed by the vascular assess teams from ‘pre-conversion’ to 24 months post-conversion. Data indicated a substantial increase in positive patient outcomes over the assessment period and a significant reduction in the causes of PIV complications.

Combined data from all sites showed 45% decrease in accidental or dislodged PIVs; 67% decrease in positional PIVs; 36% reduction in leakage at the insertion site; and a 42% reduction in restarts due to kinked tubing (Graph 1).

Phlebitis In the observational data set, the baseline rate of phlebitis (using the INS phlebitis scale) (INS, 2011) was approximately 29%. Following the education and implementation of the product changes, a decrease of approximately 10% and 21% was observed respectively at six and 18 months (Graph 2).

This improvement was in tandem with increasing compliance by staff over the assessment periods.

Data were collected in a three-phase approach: Phase 1, pre-implementation (baseline) of product change; Phase 2, post-implementation of product change (six months); and Phase 3, sustained phase (18 months). A total of 431 PIV site maintenance assessments were collected from inpatient medical and surgical units, emergency department, and surgical short stay units (at two sites) from baseline to completion of sustained phase.

The results are similar to the randomized controlled trial

by González et al. (2014), which compared complications between open-system and closed-system PIVs. Results from this study showed there was a 29% relative decrease in phlebitis rate in the closed-system versus the open system (17% versus 12% respectively) (González López, Arribi Vilela, Fernåndez Del Palacio, et al., 2014). The González trial used the hospital nurses as “field researchers” for the study, but does not mention if any educational initiatives were instituted along with the product/procedure changes.

• Each phase included two days of data collection with a vascular access nurse observing the PIV sites. (Back-toback days; no PIV sites were counted more than once.)

• Practice improvements were evaluated using statistics gathered by the vascular access teams at both sites.

Compliance Over the course of the assessment period, data indicated increasing staff compliance with the new products and procedures (Graph 3). In order to quantify compliance, we assumed a baseline of 0%, since the new procedures were

Figure 1: The BD Signature Solutions™ Seek, Solve and Sustain Model

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Peripheral Intravenous Catheters: Improving Outcomes Through Change in Products, Clinical Practice and Education

Graph 1: Rates of PIV failure from baseline to end of observation period* * combined data from both study sites

Graph 2: Rate of phlebitis from baseline to end of observation period* *combined data from both study sites not in place pre-conversion. By the end of the observation period, compliance had reached a combined rate of 77.5% from an initial rate of just over 50% six months following implementation. The continuing, accessible education initiatives described earlier made a significant contribution to this substantial increase in compliance.

In addition, improved clinician safety and efficiency were demonstrated by zero blood exposure to patients or healthcare workers. This anecdotal information was consistent in discussions with clinicians using the new products and practices. Overall, at the completion of phase 3, data indicated a number of substantial improvements in patient outcomes, clinical practice, and compliance.

Discussion The author chose to implement and evaluate an all-inone peripheral intravenous closed catheter system, with a built-in stabilization platform combined with advanced securement dressing to demonstrate improvements in patient

outcomes. In combination with educational initiatives and guidelines, converting to a new product resulted in sustainable improvements though PIV complications and phlebitis rates were reduced.

Observational assessments at each phase of data collection provided a snapshot of the current state of PIVs in-situ and tracked improvements using criteria identified in Graph 1.

However, the data collected at both sites were limited by gaps in PIV documentation and did not give sufficient evidence to comment on PIV dwell times. Variables that could have affected our data were total number of admissions, and total number of PIVs in-situ. However, this information was not available.

Our results are consistent with published literature demonstrating that adoption of a closed catheter system with a securement dressing improves catheter stability and can decrease the risk of phlebitis. The Infusion Therapy Standards of Practice guidelines recommend that all PIVs be protected with an engineered stabilization device (O’Grady, Alexander,

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deRosenroll, A.

Graph 3: Compliance with new products by study centre

Graph 4: Rates of PIV failure; ongoing surveillance* *combined data from both study sites & Burns, et al., 2011; Gorski, Hadaway, Hagle, McGoldrick, Orr & Dolellman, 2016). Although we cannot apportion the relative contribution of each new product, results indicate that use of both products together was responsible for substantial improvement in patient outcomes.

It must be emphasized that none of the improvements could have been accomplished without the educational initiatives that were put in place. Without proper use of the new products and procedures, our clinical outcomes may not have demonstrated such improvements. Therefore, in-house education was paramount. We elected to provide this education in several formats, easily accessible to all staff and clinicians: • live in-service instruction on each unit and monthly classroom sessions • computer-based learning • video demonstrations and self-learning guides • printed materials. cvaa.info

Ensuring that different formats were available increased the accessibility and adoption of the new procedures for all staff, regardless of their preferred learning style, and helped to remove barriers to the implementation of change. The keys to effective education, especially in the presence of resistance to change, are understanding, determination and persistence.

Conclusions In an increasingly complex healthcare environment it is incumbent upon healthcare providers to be involved with the evaluation of new technologies, including product evaluation, clinical applications, safety, efficacy and reliability (Gorski, Hadaway, Hagle, McGoldrick, Orr & Dolellman, 2016).

During this assessment, we have confirmed the need to evaluate new products, while maintaining professional standards of practice. Education is an integral part of this Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 11

Peripheral Intravenous Catheters: Improving Outcomes Through Change in Products, Clinical Practice and Education

process. We believe that the improved patient outcomes would not have been possible without extensive continuing education of the healthcare professionals directly involved in implementing the change. Equally important is a process for collecting data in order to quantify whether these changes have improved patient outcomes.

Standardization of PIV use and care is best accomplished by a designated team of trained vascular access nurses.8 The continued surveillance, education and expertise provided by our vascular access teams is vitally important in on-going assessments of patient outcomes and best practice standards (Graph 4).

In conclusion, the author believes to have achieved the objectives of improving the securement and integrity of patients’ PIV sites while decreasing the risks of blood exposure and injury for healthcare providers.

Acknowledgements The author would like to acknowledge the team at BD and their Signature Solutions™ Program for their invaluable assistance in providing educational and administrative support, as well as the vascular access teams at the Royal Jubilee Hospital and the Victoria General Hospital for their contributions during our conversion process and with maintaining and promoting safe, effective, and high-quality vascular access.

Disclosure Statement Becton, Dickinson and Company, in the form of its BD Signature Solutions™ team, provided funding and support for this initiative, including the Island Health Authority Poster presentation, as well as providing the products used in the assessments.

Adele deRosenroll has no other conflicts to declare.

Énoncé de divulgation Cette initiative, y compris la présentation par affiche à Vancouver Island Health Authority, a reçu l’appui et le soutien financier de Becton, Dickinson and Company, par l’entremise de son équipe BD Signature Solutions™, qui a aussi fourni les produits utilisés dans le cadre des évaluations.

Adele deRosenroll n’a aucun autre conflit d’intérêts à déclarer.

About the Author Adele deRosenroll, RN, BN, Assistant Adjunct Professor UVIC School of Nursing, is the Nurse Educator for vascular access at the Royal Jubilee and Victoria General Hospitals in Victoria, B.C. She also collaborates with other Island Health Hospitals and Home and Community Care. Her clinical expertise includes PICC insertion, PIV insertion and care and maintenance of all vascular access devices. She is also involved with the nursing program at Victoria University as an adjunct associate professor for vascular access education.

Au sujet de l’auteure Adele deRosenroll, infirmière autorisée, B. Sc. inf., professeure auxiliaire adjointe, école des sciences infirmières, Université de Victoria; Infirmière enseignante, Accès vasculaire Island Health, RJH/VGH, Victoria, Colombie-Britannique.

REFERENCES Brady, B., Bruno, F., Marchionni, C., & Paquet, F. (2016).

Prevalence and maintenance practices of peripheral intravenous catheters. Vascular Access, 10(2), 11–18. deRosenroll, A., Fleming, S., & Switzer, J. (2015). Achieving improvement through change in products, clinical practice and education. BDM–Island Health Posters.

González López, J., Arribi Vilela, A., Fernández Del Palacio, E., et al. (2014). Indwell times, complications and cost of open versus closed safety peripheral intravenous catheters: A randomized study. J Hosp Infect., 86(2),117–126.

Gorski, L., Hadaway, L., Hagle, M.E., McGoldrick, M., Orr, M., & Dolellman, D. (2016). Infusion therapy standards of practice.

Journal of Infusion Nursing, 39(Suppl. 1), S17, S40, S51–S52, S64, S72–73, S91, S95–98.

Helm, R., Klausner, J., Klemperer, J., et al. (2015). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing , 38(3), 189–203. doi:10.1097/ NAN.0000000000000100 Infusion Nurses Society (INS). (2011). Standards of Practice. Journal of Infusion Nursing, 34(1S), S12–13, S46–47, S57, S65–66.

Millam D. (1996). The history of intravenous therapy. Journal of Intravenous Nursing, 19(1), 5–14.

O’Grady, N.P., Alexander, M., Burns, L.A., et al. (2011). Guidelines for the prevention of intravascular catheter related infections.

CDC. Available at http://www.cdc.gov/hicpac/pdf/ guidelines/bsi-guidelines-2011.pdf

Page 12 • Vascular Access • Volume 11, Issue 1, Spring 2017 cvaa.info

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Overview of Medical Assistance in Dying: Considerations for the Vascular Access Specialist Aperçu de l’aide médicale à mourir : considérations pour le spécialiste de l’accès vasculaire Daphne Broadhurst, RN, BScN, CVAA(c), Kelly Crotty, RPh, BPharm, and Adele deRosenroll, RN, BN

Abstract Prior to 2015, medical assistance in dying in Canada was illegal.

Effective June 2016, federal legislation allows eligible adults in Canada to request medical assistance in dying (MAiD) to end suffering. Given this profound legal and philosophical shift in end-of-life care, this review paper provides an overview of Canadian legislation and provides healthcare professionals (HCPs) practical guidance for enacting the legislation in a manner that protects the rights of the HCP and is respectful of the patient’s right to end unbearable suffering. Criteria for patient eligibility and the role of the (HCPs) in assessing, preparing for and administering this intervention are described.

Vascular access, a critical step in MAiD, will also be addressed.

Résumé Avant 2015, l’aide médicale à mourir était illégale au Canada.

Depuis juin 2016, la législation fédérale canadienne permet aux adultes admissibles de demander l’aide médicale à mourir pour mettre fin à leurs souffrances. Dans la foulée de ce profond changement tant juridique que philosophique en matière de soins de fin de vie, le présent article de synthèse donne un aperçu de la législation canadienne et offre aux professionnels de la santé un cadre de référence pratique sur l’application de la loi selon une démarche protégeant leurs droits et respectant le droit du patient à mettre fin à des souffrances intolérables. Les critères d’admissibilité du patient et le rôle du professionnel de la santé dans l’évaluation, la préparation et la mise en œuvre de cette intervention sont décrits. L’accès vasculaire, une facette essentielle de l’aide médicale à mourir, sera également abordé.

J

ack Poelstra was suffering with advanced amyotrophic lateral sclerosis (ALS). He knew that “an ALS death would not be so quick or peaceful... [and] wanted to be able to die on his own terms” (Laucius, 2016). His daughter, April Poelstra, states her father thought, “if you could take an animal in (to be euthanized), you should have the same right” (Laucius, 2016). She promised to help him die. Seeking a physician

willing to invoke the new federal legislation for medical assistance in dying (MAiD), Poelstra met “roadblock after roadblock” including being told, “I’m a supporter, but I don’t know where to start” (Laucius, 2016).

Prior to 2015, medical assistance in dying contravened the Canadian Criminal Code. Recent federal legislation has amended the Criminal Code to allow eligible adults to request MAiD (Government of Canada, 2016). Medically assisted dying is no longer illegal in Canada and the requirement for court approval has been removed. This legislation creates exemption from the offence of culpable homicide in order to permit a medical practitioner (MD) or a nurse practitioner (NP) to provide MAiD to patients who have met all assessment criteria and given consent of their own free will.

Medical assistance in dying is defined as follows: • the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or • the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and, in doing so, cause their own death. (Government of Canada, 2016, Bill C-14).

Given this profound legal and philosophical shift in end-oflife care, this paper reviews Canadian legislation and practice implications of MAiD to guide infusion therapy and vascular access healthcare professionals, to support patients such as Jack Poelstra in their request for relief from end-of-life suffering.

Background The Supreme Court’s ruling on the case of Carter v. Canada laid the foundation for legislation changes governing medical assistance in dying (Parliament Canada, 2016). Gloria Taylor, a patient suffering ALS, declared she “live[s] in apprehension that my death will be slow, difficult, unpleasant, painful, undignified and inconsistent with the values and principles I have tried to live by” (Carter v. Canada [attorney General], 2012, s[54],

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p.21, as cited by Edwards, 2016). Kathleen Carter, after living with chronic pain and debilitation related to spinal stenosis, travelled to Switzerland in 2010 to die through physicianassisted suicide. Taylor, Carter’s family, and other plaintiffs challenged the constitutionality of sections of the Canadian Criminal Code (1985), which stated that “no person is entitled to consent to have death inflicted on him…and everyone who (a) counsels a person to commit suicide, or (b) aids or abets a person to commit suicide, where a suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years” (Edwards, 2016).

On February 6, 2015, the Supreme Court of Canada declared the Criminal Code infringed on the claimants’ rights to life, liberty, security and equality under the Canadian Charter of Rights and Freedoms (Edwards, 2016; Parliament Canada, 2016). The law, Bill 52: Act Respecting End-of-Life Care, came into force in Québec on December 10, 2015. It set out specific requirements for continuous palliative sedation and medical aid in dying. The Canadian federal government passed Bill C-14 on June 17, 2016, legislation allowing eligible adults (see Table 1) to request medical assistance in dying.

Since Bill C-14 has become law, approximately 744 adults have received medical assistance in dying in Canada between June 17 and December 16, 2016 (Slaughter, 2016). The most commonly cited underlying diagnoses included cancer or neurological diseases, specifically multiple sclerosis or amyotrophic lateral sclerosis.

The Process of Medical Assistance in Dying Who Can Provide Assistance?

The legislation permits licensed MDs in all provinces and territories and NPs in specified provinces and territories to administer the medications. Those who can provide a supporting role include: healthcare providers (such as MD, pharmacist or registered nurse), and whomever the person requests to be present (Government of Canada, 2016).

The amended Criminal Code as previously mentioned (Government of Canada, 2016) exempts those specified above from being charged under criminal law. However, all persons involved must follow the Criminal Code and applicable provincial and territorial health-related laws, rules and policies (Government of Canada, 2016).

The Canadian Nurses Protective Society (CNPS) advises all NPs to ensure they have the knowledge, skill and judgment to fulfill their responsibilities in providing MAiD and ensure the cvaa.info

Table 1: Who is eligible for medical assistance in dying?

A person must meet all of the following criteria: • be eligible for health services funded by the federal government, or a province or territory ■■

generally, visitors to Canada are not eligible for medical assistance in dying.

• be at least 18 years old and mentally competent and capable of making decisions at the time that the service is provided • have a grievous and irremediable medical condition, in which all of the criteria are met: ■■ ■■ ■■

■■

have a serious illness, disease or disability be in an advanced state of decline that cannot be reversed be suffering unbearably from your illness, disease, disability or state of decline be at a point where your natural death has become reasonably foreseeable, which takes into account all of your medical circumstances.

• make a request for medical assistance in dying, which is not the result of outside pressure or influence • give informed consent to receive medical assistance in dying, after being given all of the information needed to make the decision, including information about: ■■ ■■ ■■

medical diagnosis available forms of treatment available options to relieve suffering, including palliative care.

People with a mental illness are eligible if they meet all of the above criteria and: • are not suffering only from a mental illness • death is reasonably foreseeable when considering all the circumstances of the patient’s medical condition • a mental illness does not reduce one’s ability to make medical decisions.

Issues outside the scope of the new law include: a) requests by mature minors; b) advance requests; and c) requests where mental illness is the sole underlying condition.

The federal government has initiated independent reviews, which will be tabled in Parliament and available to the public by December 2018.

Source: Government of Canada. (2016). Medical Assistance in Dying.

practice falls within their provincially or territorially regulated scope of practice (2016). Practice not complying with provincial laws, rules, or standards nullifies the Criminal Code exemption, so participation could be deemed a criminal offence.

What is the Registered Nurse’s Role?

Although other HCPs may initiate intravenous access, this section focuses on the registered nurse (RN) role. As an RN, you must follow all legal, legislative, regulatory and organizational requirements for aiding in the provision of MAiD. The Canadian Nurses Protection Society (2016) clearly defines the nursing role, Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 15

Broadhurst, D., Crotty, K., & deRosenroll, A.

and it is each RN’s responsibility to be aware of current legislation before participating. If any question or concern about correct code of conduct arises, the RN should seek assistance from their regulatory body, or legal advice. An RN is not authorized under current federal legislation to administer the medications used in assisted death. Failure to comply with this limitation would open the possibility of criminal offence charges for both the RN and medical or nurse practitioner who prescribed the medication (CNPS, 2016). The RN directly involved in a patient’s care can provide information on the provision of MAiD, only if requested by the patient. If a patient has requested in writing an assessment of eligibility, the RN involved directly in the patient’s care cannot sign as witness to the request. This safeguards against any perception that the RN has been involved with the patient’s decision to pursue MAiD. The RN who is establishing vascular access for the sole purpose of delivery of MAiD can be considered to be participating in the ending of the patient’s life and, therefore, must have direct communication with the physician or NP who will be administering the medications, or have access to documentation that satisfies all legal requirements before access is established (CNPS, 2016).

Can a Healthcare Professional Give Information About Medical Assistance in Dying to a Patient?

All healthcare providers must be aware that it is a criminal offence to ‘counsel’ (“to encourage, solicit or incite”) a person to seek MAiD (CNPS, 2016). The amended Criminal Code clarifies that “no… healthcare professional commits an offence if they provide information to a person on the lawful provision of MAiD” (Section 241.5.1) and can engage in discussions about MAiD with their patients when specifically requested.

If the HCP has a conscientious objection to providing this information, they are obligated to pass on the request to another member of the healthcare team. Again, to reduce the risk of allegations of counselling, CPNS (2016) advises nurses not to participate in the patient’s written request. Instead, refer a patient’s inquiries to their treating MD, NP or healthcare team member who may be in a better position to respond to questions.

Can a Healthcare Professional Decline to Participate Based on Conscientious Objection?

Bill C-14 acknowledges that not all healthcare professionals will be comfortable with providing or assisting with MAiD. The bill permits any person to withdraw from the process if they feel it is not consistent with their own beliefs and values (Government of Canada, 2016). This, however, creates problems for patients who want to access medical assistance, as our case study illustrated. Provinces, territories and organizations are currently developing strategies to optimize

patient access to this service. In Ontario and Québec, an MD or NP with conscientious objection has to provide a referral for the patient and must pass along the request to another provider in a timely manner. The Ministry has established a clinician referral service to aid in this process (Ontario Ministry of Health and Long-Term Care, 2016).

HCPs must seriously consider their own code of ethics and resolve personal conflicts so they can effectively provide compassionate care with dignity and respect. The decision cannot be made without due consideration and it can evoke many emotions. It is imperative that we respect each individual’s choice so we can provide support in a professional manner.

Organizations such as faith-based institutions may also decline to participate in this service (Ontario Ministry of Health and Long-Term Care, 2016). Institutions are encouraged to develop policies with respect to any and all limits on the provision of MAiD and inform patients of the institutional position, so that the patient can make informed decisions about their care options (Ontario Ministry of Health and Long-Term Care, 2016).

How is a Request for Medical Assistance in Dying Processed?

Patient request. Patients in all settings are able to request MAiD, including acute care, home care, residential care, hospice, etc. However, if MAiD is not available, the patient may need referral to an alternate prescriber or institution.

Providing patients with emotional and physical support is critical for those who have been accepted as eligible for MAiD and for those who have been denied.

Patients are encouraged to include their family and/or caregivers in the discussion and decision process when considering or requesting, an assisted death. The legislation does not require formal notification for families when an individual formally requests this service. “Family members, friends and/or personal caregivers have no ‘right’, legal or otherwise, to intervene in a patient’s choice. “ Federal legislation has built-in safeguards to ensure those who request this service are eligible, can give informed consent, are able to make their own healthcare decisions and request the service of their own free will (Government of Canada, 2016).

In addition, provinces and territories have developed formal processes and forms to which participating practitioners must adhere. The patient must complete and sign a written request that also must be signed by two independent witnesses. The witnesses must understand what medical assistance in dying means, must not benefit from the patient’s death, be an owner or operator of a healthcare facility where the person lives or is

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receiving care, and must not be directly involved in providing the patient with health or personal care (Government of Canada, 2016). The MD or NP must ensure that the patient meets the eligibility criteria and a second independent MD or NP must also provide a written second opinion confirming patient eligibility. Personal communication with MDs in Ontario has indicated that securing a practitioner who is willing and able to complete the second assessment, and works independently from them, can be a significant challenge for community practitioners.

Reflection period. To allow the patient to give due consideration to the decision, the legislation requires a patient to wait at least 10 days between signing the request and the procedure. Exceptions, however, can be made if the patient’s death is imminent or if the patient may soon lose capacity to provide informed consent (Government of Canada, 2016). If the patient cannot give consent at the time of the scheduled procedure the MD or NP cannot proceed even with the patient’s previous consent. The patient may withdraw the request at any time and is provided with an opportunity to withdraw the request just before the procedure commences.

Stages of Medical Assistance in Dying Patient preparation. Given the short time that MAiD has been available in Canada, there is a paucity of literature available to guide the administration process. Most importantly, patients have the right to decide the scheduling of the procedure and who will be present at the time of their death.

Procedural guidelines for the provision of MAiD are being developed on a provincial, territorial and organization level across Canada. It must be stressed that HCPs follow the appropriate guidelines set in their practising jurisdiction.

In all medically assisted deaths it is imperative to explain to the patient and to those who will be present how the process will unfold. The MD/NP should explain the effect of each medication to be delivered and how the patient may feel and appear to those present. Providing a complete understanding of the process at the time of the procedure may help alleviate anxieties or fears that may be anticipated. The prescriber must verify that the patient still wishes to access medical assistance in dying at each step in the process, including right up until it is time for the procedure to begin (Government of Canada, 2016).

Vascular access. Vascular access is an essential component in the safe and effective delivery of the prescribed medications for MAiD. In some cases, the patient has an existing venous access for current medications that can be used. It is essential to provide a HCP skilled in peripheral intravenous cvaa.info

(PIV) insertion when MAiD is requested, even if there are challenges to do so. A skilled inserter is vital, so access can be initiated without trauma, delays, and emotional upset to the patient and family.

The Québec Practice Guidelines (2015) recommend an assessment of the venous potential within 24 hours prior to the procedure. If peripheral access is not feasible, central venous access would be required. The preventative placement of two peripheral lines or a central line is not recommended, as it may be difficult to place, painful, and excessive (Collège des médecins du Québec, Ordre des pharmaciens du Québec, Ordre des infirmières et infirmiers du Québec [CMQ, OPQ, OIIQ], 2015). The guidelines do recommend identifying in advance a second potential site, either peripheral or central, to ensure they have the necessary supplies and technical expertise on hand to access this site if necessary.

As outlined in the Québec Practice Guidelines, a venous catheter should be inserted within four hours of the anticipated procedure. One author’s experience has been to initiate the patient’s peripheral intravenous (PIV) after the medical professional has completed the final legal documents for consent, and if vascular access has not already been established. There are no specific site locations or gauge of catheter preferred other than selecting a vein adequate for the size of the catheter gauge and keeping the patient as comfortable and pain-free as possible.

Selecting an antecubital fossa site, if adequate, may be the best option. In one author’s institution, catheters of 22–24 gauges have been sufficient to administer all volumes of medication in the required time. The placement and patency of the catheter must be verified by flushing with 10 mL of normal saline before the procedure begins, to prevent any unnecessary pain and avoid compromising the effectiveness of any of the medications. It is essential to have enough supplies available so that if a second site were required, there would be no delays in obtaining access.

The need for competent vascular access experts cannot be underestimated in this process. Patients are mindfully ready, have said their goodbyes and loved ones have gathered for support. They are anticipating the scheduled arrival of the healthcare providers to carry out their request to end their life and unbearable suffering. Implications of failed vascular access could be emotionally and physically overwhelming. It is a serious and vital role in the process of providing the best experience for all present and their memories.

Medications. There are several medications that may be prescribed for the procedure including an anxiolytic, Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 17

Broadhurst, D., Crotty, K., & deRosenroll, A.

local anesthetic, coma-inducing agent and neuromuscular blockers. Protocols may vary between jurisdictions, and all existing regional guiding documents should be followed.

None of the medications commonly used in the various medical assistance in dying protocols have a significant analgesic effect (CMQ, OPQ, OIIQ, 2015). The patient’s analgesia medications should be continued until the procedure commences, at which time the analgesia is stopped.

The medications are dispensed following a conversation between the pharmacist and prescriber and the receipt of a written prescription. The pharmacist must verify with the prescriber and document that the medication is for the intent of MAiD, ensure all documents have been completed, and that the prescriber has determined the patient meets all the criteria set out in the legislation (Alberta Health Services, 2016). To reduce the burden of drug preparation on the prescriber, pharmacies may dispense the medications in preloaded syringes. All syringes or vials are clearly labelled with the instructions for administration, as well as the sequence of administration (i.e., Drug #1, Kit #1). The kits are provided directly to the physician and a chain of signature is retained.

Registers must be kept for each kit provided. All unused medications are removed from the home by the prescriber and returned to the pharmacy immediately for destruction.

Administration. Given the solemnity of the event, the prescriber must give the procedure their complete and undivided attention from start to finish. The procedure must take place in a quiet environment. As directed in Section 12 of the Act for all end-of-life care, patients in healthcare institutions must be provided a private room for the final days preceding death (CMQ, OPQ, OIIQ, 2015). The Québec Practice Guidelines (2015) also dictate medical aid in dying must be administered by the prescriber personally, and they must stay with the patient until death occurs. It is estimated that the procedure will take 20 to 30 minutes (CMQ, OPQ, OIIQ, 2015).

Oxygen therapy should be stopped as soon as the procedure commences. This is done to avoid prolonging the period of apnea and delaying the time until cardiac arrest occurs (CMQ, OPQ, OIIQ, 2015). An anxiolytic may be given first to relax the patient. It has an action onset of three to five minutes.

Parenteral local anesthesia is usually administered second to prevent discomfort from the subsequent injection of coma-inducing medication. Injecting the medication slowly over approximately five minutes induces an artificial coma.

Administering it too rapidly could result in the loss of venous access. The coma must be deep enough to prevent the patient from feeling any effects of the neuromuscular blocker. If there

is any question about the depth of the coma, the dosage may be increased. It is possible that cardiopulmonary arrest could occur during the coma induction phase. Even if this occurs, the neuromuscular blocker still must be given.

Death may occur very rapidly following the injection of the neuromuscular blocker. Respiratory arrest occurs first.

However, there may be up to a 20-minute delay between respiratory arrest and cardiac arrest (CMQ, OPQ, OIIQ, 2015). The prescriber is directed to advise those present before the procedure commences that the heart may continue to beat for some time after the patient is no longer breathing (CMQ, OPQ, OIIQ, 2015).

Follow-up. Members of the healthcare team who have been involved in the patient’s care, or who have been present or participated in the MAiD process, may experience grief.

In our recent experience, organizations are learning that healthcare providers involved in any steps of the process benefit from debriefing and support post-procedure. In Québec, an interdisciplinary group of support is available to help the treating team in all centres.

Reporting. All information and documentation related to any request (whether accepted or not) for MAiD must be documented in the patient’s record (CMQ, OCP, OIIQ, 2015). A copy of the completed medication administration record must also be kept on file. Requirements for completion of the certificate of death and notification of the coroner or other institutions may vary between jurisdictions.

Conclusion MAiD legislation marks a monumental shift in healthcare policy, end-of-life care and patients’ rights. It may require reflection and resolution of personal conflict for some healthcare professionals who see their role as only to support life. Assisting in a patient death can be stressful and emotional. Debriefing and engaging in dialogue with coworkers about experiences is fundamental so improvements in practice can be made and support for HCPs can be provided in this developing role.

Healthcare professionals are, however, obligated to be aware of the legal, ethical, and practical implications of MAiD. We must ensure we are knowledgeable about current legislation and regulatory body and institutional policies and procedures, as federal and provincial legislation are evolving and being challenged.

Medical assistance in dying provides patients with a sense of control over the end of their lives. The goal is to

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Overview of Medical Assistance in Dying: Considerations for the Vascular Access Specialist

respect patient’s end-of-life decisions in their pursuit to avoid unbearable suffering. It is our duty to provide safe, compassionate, competent, and ethical care. Institutions have made considerable efforts to ensure that the legislation can be enacted. As vascular access specialists, we need to advocate for early assessment to ensure the appropriate device and the appropriately skilled clinician is available to assist with the insertion of the device, which is a critical part of the process.

About the Authors

are undervalued for their contributions in promoting and maintaining excellent patient care, increasing patient satisfaction, decreasing complications and overall costs to organizations.

Au sujet des auteures Daphne Broadhurst, IA, B. Sc. inf., ACAV(c), Spécialiste Clinique, Medical Pharmacies, Ottawa, Ontario.

Kelly Crotty, membre de l’Ordre des pharmaciens, B. Pharm., Medical Pharmacies, Ottawa, Ontario.

Daphne Broadhurst, RN, BScN, CVAA(c) is a clinical specialist with Medical Pharmacies. She is the Past President of CVAA and is working on her Master of Nursing degree at present. Daphne has just accepted a three-year term position at Griffith University, Australia as an Adjunct Research Fellow.

Adele deRosenroll, infirmière autorisée, B. Sc. inf., Professeure auxiliaire adjointe, école des sciences infirmières, niversité de Victoria, Infirmière enseignante, Accès vasculaire, Island Health, RJH/VGH, Victoria, Colombie-Britannique.

Kelly Crotty, RPh, B.Pharm, is a clinical pharmacist with Medical Pharmacies Home Infusion Pharmacy in Ottawa, Ontario. A graduate of the University of Toronto Pharmacy program, for the past decade she has focused on providing complex medication therapy to patients in the comfort of their own home.

Alberta Health Services. (2016, June 6). Medical assistance in dying (MAID) pharmacy protocols.

Canadian Nurses Protective Society (CNPS). (2016, July 7).

Medical assistance in dying: What every nurse should know.

Retrieved from http://cnps.ca/MAID#np1 Collège des médecins du Québec, Ordre des pharmaciens du Québec, Ordre des infirmières et infirmiers du Québec (CMQ, OPQ, OIIQ). (2015, November). Medical aid in dying: Practice guidelines.

Edwards, M. (2016). Changing laws on medical assistance in dying: Implications for critical care nurses. The Canadian Journal of Critical Care Nursing, 27(3), 18–23.

Government of Canada. (2016, December 21). Medical assistance in dying. Retrieved from https://www.canada.ca/en/healthcanada/services/medical-assistance-dying.html Laucius, J. (2016, October 7; a). She helped her dad die on his terms—now she’s telling his story. Ottawa Citizen. Retrieved from http://ottawacitizen.com/news/local-news/shehelped-her-dad-die-on-his-terms-now-shes-telling-his-story Ontario Ministry of Health and Long-Term Care. (2016, November 11). Medical assistance in dying. Healthcare Professionals. Retrieved from http://health.gov.on.ca/en/ pro/programs/maid/ Parliament Canada. (2016, February). Medical assistance in dying: A patient-centred approach. Report of the Special Joint Committee on Physician-Assisted Dying. 42nd Parliament, 1st session. Retrieved from http://www.parl. gc.ca/content/hoc/Committee/421/PDAM/Reports/ RP8120006/pdamrp01/pdamrp01-e.pdf Slaughter G. (2016, December 28). At least 744 assisted-deaths in Canada since law passed: CTV News analysis. CTV News.

Retrieved from http://www.ctvnews.ca/health/at-least744-assisted-deaths-in-canada-since-law-passed-ctv-newsanalysis-1.3220382#_gus&_gucid=&_gup=GSEmail&_ gsc=eL2KSTK

Kelly’s pharmacy has provided the pharmacy services for multiple MAiD cases in their region. She lends her experience here so other professionals can consider the implications and make informed decisions to participate or not.

Adele deRosenroll, RN, BN, Assistant Adjunct Professor, UVIC School of Nursing, is the Nurse Educator for vascular access at the Royal Jubilee and Victoria General Hospitals in Victoria, B.C. She also collaborates with other Island Health Hospitals and Home and Community Care. Her clinical expertise includes PICC insertion, PIV insertion and care and maintenance of all vascular access devices. She is also involved with the nursing program at Victoria University as an adjunct associate professor for vascular access education.

Adele’s career started in Halifax, N.S., where she worked as a staff nurse on medical and surgical units, and then as the educator for these practice areas. Moving to Ottawa, she added hemodialysis to her nursing skill set, then on to Victoria to continue in hemodialysis, IV therapy, and for Canadian Blood Services, as the clinical coordinator.

She has a passion for promoting safe, evidence-based practice through education and is an advocate to support specialized teams of vascular access registered nurses. She feels they cvaa.info

REFERENCES

Volume 11, Issue 1, Spring 2017 • Vascular Access • Page 19

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