title: The impact of the Rasouli decision: a Survey of Canadian intensivists.
abstract: BACKGROUND
  In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown.
  
  
  OBJECTIVE
  To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision.
  
  
  METHODS
  We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses.
  
  
  RESULTS
  We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups.
  
  
  CONCLUSIONS
  Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Cape
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Canada.
authors.forename: Alison
authors.initials: A
authors.lastname: Fox-Robichaud
authors.affiliation: Division of Critical Care, Department of Anaesthesiology and Critical Care, Research Center of the Centre Hospitalier Universitaire (CHU) de Québec, Axe Santé des populations et pratiques optimales en santé, Traumatologie - Urgence - Soins Intensifs, CHU de Québec (Hôpital de l'Enfant-Jésus, Quebec City, Canada.
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
authors.affiliation: Departments of Surgery and Critical Care Medicine, Faculty of Medicine and Dentistry, University of Ottawa, Ottawa, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Seely
authors.affiliation: Department of Anaesthesia, Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Hall
authors.affiliation: Interdepartmental Division of Critical Care, Keenan Research Centre and the Li KaShing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Burns
authors.affiliation: Section of Critical Care, Department of Medicine; Cardiac Sciences Program, Division of Cardiac Surgery, University of Manitoba, Winnipeg, Canada.
authors.forename: Rohit K
authors.initials: RK
authors.lastname: Singal
authors.affiliation: Division of Critical Care Medicine, Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dodek
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
authors.forename: Sean
authors.initials: S
authors.lastname: Bagshaw
authors.affiliation: Deparment of Ethics, London Health Sciences Centre, University of Western Ontario, London, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Sibbald
authors.affiliation: Divisions of Critical Care and Palliative Care, Department of Medicine, University of Toronto, Toronto, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Downar
mesh_terms: D000328:Adult; D002170:Canada; D000066491:Clinical Decision-Making / Q000941:ethics*; D003422:Critical Care / Q000941:ethics* / Q000379:methods*; D005260:Female; D019538:Health Care Surveys / Q000592:standards; D006801:Humans; D007362:Intensive Care Units; D007603:Jurisprudence; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000941:ethics* / Q000331:legislation & jurisprudence; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence; D000078329:Workforce
keywords: Bills, Laws and Cases; Clinical Ethics; Decision-making; Demographic Surveys/Attitudes; End of Life Care