Research: End-of-Life

The Joint Centre for Bioethics has formed a strategic partnership with the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital web link in Toronto. The Temmy Latner Centre is Canada's largest palliative care program encompassing two interdisciplinary hospital inpatient consultation services, regional home palliative care programs and education and research programs.


Although people express strong support for living wills, few people have completed written documents; the impact of these documents on clinical practice is modest. Peter Singer, Douglas Martin and colleagues have called into question traditional assumptions related to advance care planning and developed new models that explain some of these apparent discrepancies. The work was funded by the National Health Research and Development Program and the Physicians' Services Incorporated Foundation and has been published as two papers in Archives of Internal Medicine. The work has fundamental implications for research and practice with respect to advance directives and advance care planning.


Although end-of-life care is increasingly a focus of institutional and national quality improvement efforts, what it means has not been well established. Peter Singer, Douglas Martin and Merrijoy Kelner have developed an evidence-based, patient-centred model of quality end-of-life care. The work was funded by National Health Research and Development Program and Physicians' Services Incorporated Foundation, published as an article the Journal of the American Medical Association, and featured in a subsequent article in the Science section of the New York Times.


Healthcare workers are facing a new kind of "right to die" case where patients and/or families want to continue treatment, but healthcare providers disagree. The approach to this is to determine whether or not a case is futile. A JCB/Critical Medicine Program Task Force has developed a new approach that deals with the application of conflict resolution techniques like negotiation and mediation to address the problem. De-escalation of conflict is the focus here. Rather than focusing on a hospital ethics committee model, this innovative framework focused on a conflict-resolution model of negotiation/mediation. In doing so, it relied on enhanced negotiation skills of front-line health workers and individual mediators to resolve disputes. A paper describing the model for the policy on appropriate use of life sustaining treatments was published in Critical Care Medicine (2001).


Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of the study is to develop consensus guidelines on analgesia and sedation. In dying intensive care unit patients that help distinguish palliative care from euthanasia. This research done by Laura Hawryluck, William Harvey, Louis Lemieux-Charles and Peter Singer was published in BMC Medical Ethics, August 2002.


Quality end-of-life care has emerged as an important concept in industrialized countries. Kerry Bowman and Peter Singer argue quality end-of-life care should be seen as a global public health and health systems problem. It is a global problem because 85% of the 56 million deaths worldwide that occur annually are in developing countries. It is a public health problem because of the number of people it affects, directly and indirectly, in terms of the well being of loved ones, and the large-scale, population based nature of some possible interventions. It is a health systems problem because one of its main features is the need for better information on quality end-of-life care. We examine the context of end-of-life care, including the epidemiology of death and cross-cultural considerations. Although there are examples of success, we could not identify systematic data on capacity for delivering quality end-of-life care in developing countries. We also address possible objection to improving end-of-life care in developing countries; many deaths are preventable and reduction of avoidable deaths should be the focus of attention.