Marika Warren

Guest

Francis Bakewell

DISCUSSION QUESTIONS

• How may trust or distrust manifest in the health care setting?
  • In the patient-provider interaction?
  • In the interaction between providers?
• What are some of the systemic factors that may impact trust relationships between heath care providers?
• How might silo’s in health care impact patient care and patient trust in health care?

RESOURCES

Varga AI, Spehar I, Veggeland F, Skirbekk H. Factors influencing trust among colleagues in hospital settings: a systematic review. BMC Health Serv Res. 2025 Jan 3;25(1):16. doi: 10.1186/s12913-024-12159-6. PMID: 39754115; PMCID: PMC11697850.

Sutherland BL, Pecanac K, LaBorde TM, Bartels CM, Brennan MB. Good working relationships: how healthcare system proximity influences trust between healthcare workers. J Interprof Care. 2022 May-Jun;36(3):331-339. doi: 10.1080/13561820.2021.1920897. Epub 2021 Jun 14. PMID: 34126853; PMCID: PMC8669032.

Corbaz-Kurth S, Weissbrodt R, Juvet TM, Hannart S, Krsmanovic B, Salamin Plaschy I, Terrier P. How does trust emerge in interprofessional collaboration? A qualitative study of the significance, importance, and dynamics of trust in healthcare teams and networks. J Interprof Care. 2025 May 15:1-10. doi: 10.1080/13561820.2025.2495013. Epub ahead of print. PMID: 40370201.

Marika Warren, NSHEN Ethicist

Guests

David Henderson

and

Sarah Manley

Simulated Patient

Theofani Pitsiavas

DISCUSSION QUESTIONS

• Which part of the simulated conversation stood out to you? why?
• Were there any aspects of the conversation where you would have liked more information from the patient about their values and preferences?
• How might you help patients identify their values and preferences?
• How can a conversation like this benefit the patient and his family?
• Edward finds it difficult to talk with his wife and kids about his illness and what happens when he dies. Do you think this is common?
• Discuss different ways to make people (health care providers, patients and families) more comfortable talking about their values and preferences to help determine Goals of Care and Levels of Interventions. How do we ‘normalize’ these conversations?

Marika Warren, NSHEN Ethicist

Guests

Lisa Weatherbee, Professional Practice Lead, Palliative Care, NS Health

and

Sarah Manley, Manager of Planning and Development with Palliative Care Network, NS Health

Discussion Questions

DISCUSSION QUESTIONS

• How can health care providers prevent their own biases from influencing the patient’s decisions around goals of care?
• How might you help patients identify their values and preferences?
• In the podcast they talk about the importance of identifying and documenting Goals of Care and Level of Interventions in many different situations and that it should not be limited to end-of-life. In your opinion, when should conversations about Goals of Care take place?
• Discuss different ways to make people (health care providers, patients and families) more comfortable talking about their values and preferences to help determine Goals of Care and Levels of Interventions. How do we ‘normalize’ these conversations?

RESOURCES

The resources shared in this podcast were developed collaboratively by the Nova Scotia Health Palliative Care Network, the Integrated Acute and Episodic Care Network, and the Interprofessional Practice and Learning Team. This partnership ensured a comprehensive and inclusive approach to supporting care across settings.

• Goals of Care (Clinical Practice Support/ Library Guide) https://library.nshealth.ca/GoalsofCare

[note: this website includes links to resources developed for health care providers and resources developed for patients and families, including the patient education pamphlets individually linked below]

• Talking about your Goals of Care and Levels of Intervention: https://www.nshealth.ca/patient-education-resources/2208

• Nova Scotia Green Sleeve Information for Patients, Families, and Substitute Decision-Makers https://www.nshealth.ca/patient-education-resources/1833

• Conversations about Serious Illness (Clinical Practice Support/ Library Guide) https://library.nshealth.ca/SeriousIllness

• Palliative Care (Clinical Practice Support/ Library Guide)

https://library.nshealth.ca/PalliativeCare

Host, Andrea Frolic

and special guest

James Downar, MDCM, MHSc, FRCPC

DISCUSSION QUESTIONS

• What surprised you about psychedelics research and its potentials in treating end-of-life patients’ psychological distress?
• Dr. Downar describes several challenges associated with conducting research with psychedelics for treatment of psychological distress in end-of-life patients.  Do you think that the regulatory barriers to research on psychedelics are ethically justifiable?
• Do you think it is morally imperative to be more risk tolerant when it comes to making psychedelics accessible to end-of -life patients as a way of treating psychological distress?

RESOURCES

• Kratina S, Lo C, Strike C, Schwartz R, Rush B. Psychedelics to Relieve Psychological Suffering Associated with a Life-Threatening Diagnosis: Time for a Canadian Policy Discussion. Health Policy. 2023;18(4):134-142. doi:10.12927/hcpol.2023.27048  
• Watt CL, Downar J. Whither palliative care. Curr Oncol. 2019;26(3):164-165. doi:10.3747/co.26.4803

Podcasts: Psychedelics: Is it time to change your mind… The Critical Care Commute Podcast. https://podcasts.apple.com/ca/podcast/psychedelics-is-it-time-to-change-your-mind-with-dr/id1651920943?i=1000715746659

with

Marika Warren, NSHEN Ethicist

and

Amanda Porter, Ethics Collaboration Team

Education guide for staff: Working with Patients and Substitute Decision-makers: Home – Working with Patients and Substitute Decisions-Makers (SDMs) – LibGuides at Nova Scotia Health

Patient and family guide: Making Health Care Decisions for Someone Else: Acting as a Substitute Decision-Maker (SDM) | Nova Scotia Health

Ethics Nova Scotia Health’s Library Subject Guide: Accessing Ethics Support – Ethics Nova Scotia Health – LibGuides at Nova Scotia Health

Host, Andrea Frolic

And special guests

Marie-Eve Bouthillier and Delphine Roigt

DISCUSSION QUESTIONS

In 2024, Quebec introduced legislation that allow for advance request for MAiD. The legislation is narrow in scope. You can only enact an advance request for MAiD if you are diagnosed with an illness that is known to lead to incapacity. Moreover, the request is only eligible for the condition it was intended for.  

• It is mentioned in the podcast that a quarter of Quebec’s population are currently without a family physician and that there are ongoing issues with access to care in general. How would you approach the issue of prioritization with regards to people’s access to care for treatment of illness and access to MAiD?
• Ethical concerns associated with advance requests for MAiD include issues around decisions to activate a person’s advance request, issues around resource allocation, and issues around conscientious objection. What do you see as the most pressing ethical issues with advance request for MAiD? Why?
• In your opinion, how should situations be managed when a patient’s advance request for MAiD is activated and the patient (who no longer has capacity for health care decision-making) manifests refusal?

RESOURCES

• Canadian Medical Protection Association (CMPA). Updated Québec MAID legislation. October 30, 2024. https://www.cmpa-acpm.ca/en/news/2024/updated-quebec-maid-legislation [website accessed May 13, 2025]
• Government of Quebec. Advance request for medical aid in dying. https://www.quebec.ca/en/health/health-system-and-services/end-of-life-care/medical-aid-in-dying/advance-request-medical-aid-dying [website accessed May 13, 2025]
• Variath, C., Peter. E., Cranley, L., Godkin, D. Health care providers’ ethical perspectives on waiver of final consent for Medical Assistance in Dying (MAiD): a qualitative study. BMC Medical Ethics, 23,8 (2022). https://doi.org/10.1186/s12910-022-00745-4

Host, Amanda Porter

Special Guest, Dr. Thomas Brothers

DISCUSSION QUESTIONS 

• Dr. Brothers mentions that harm reduction approaches have not historically been incorporated in medical education. What might be some of the reasons for this? 

• Why do you think there is a difference in the standard of care in the community setting compared to in the acute hospital setting with regards to harm reduction for people who use drugs? 

• Why do you think that stigma persists in healthcare? 

RESOURCES 

Brothers, T., Mosseler, K., Kirkland, S., Melanson, P., Barret, L., Webster, D. (2022) Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis. PLOS ONE, 17(1): e0263156. https://doi.org/10.1371/journal.pone.0263156  

Knaak, S., Romie, C., Mercer, S., Stuart, H.: Harm Reduction, Stigma and the Problem of Low Compassion Satisfaction: Tensions on the front-lines of Canada’s opioid crisis. Journal of Mental Health and Addition Nursing. Vol 3 (1) , May 2019. https://utppublishing.com/doi/abs/10.22374/jmhan.v3i1.37  

McKay M., Coldwell, M., Graham, S., Upham, K.: Harm Reduction Position Paper. Doctors Nova Scotia (2023) harm-reduction-position-paper2023.pdf 

Websites: 

• Addictions Medicine Consult Service : https://mha.nshealth.ca/en/clients-and-providers/resources-providers/addictions-medicine-consult-service  [accessed May 12, 2025] 

• Canadian Centre for Substance Use and Addiction: Lived and Living Experience | Canadian Centre on Substance Use and Addiction [accessed March 17, 2025] 

• Nova Scotia Health: What is Harm Reduction. Harm reduction | Nova Scotia Mental Health and Addictions [accessed March 17, 2025]

Amanda Porter, Host

and

Dr. Tiffany O’Donnell, Family Physician, Wije’winen Health Centre

DISCUSSION QUESTIONS

1. Do you think there is a moral difference between providing people who use drug with a safe supply of drugs and providing them with clean needles and a safe space to inject drugs? Why/why not?
2. A lot of effort has gone into addressing stigma associated with substance use disorder, including efforts to make people look at it as a health condition and not a moral failure. Yet, stigma towards people who use drugs persist.
3. Why do you think that is the case?
4. Can you think of different ways to address stigma associated with substance use disorder?

RESOURCES

Canadian Centre for Substance Use and Addiction:Lived and Living Experience | Canadian Centre on Substance Use and Addiction [accessed March 17, 2025]

Jonson, B. Changing Her Tune. DoctorsNS Magazine, Vol 3 (2), June 2023, p16-17. https://doctorsns.com/news-events/doctorsns/archive/2023-06-01

Jonson, B. Dr. Tiffany O’Donnell takes a new approach to addiction medicine. DoctorsNS, Blogpost, August 2023. https://yourdoctors.ca/blog/health-care/dr-tiffany-odonnell/

Knaak, S., Romie, C., Mercer, S., Stuart, H.: Harm Reduction, Stigma and the Problem of Low Compassion Satisfaction: Tensions on the front-lines of Canada’s opioid crisis. Journal of Mental Health and Addition Nursing. Vol 3 (1) , May 2019. https://utppublishing.com/doi/abs/10.22374/jmhan.v3i1.37

McKay M., Coldwell, M., Graham, S., Upham, K.: Harm Reduction Position Paper. Doctors Nova Scotia (2023) harm-reduction-position-paper2023.pdf

Nova Scotia Health: What is Harm Reduction. Harm reduction | Nova Scotia Mental Health and Addictions [accessed March 17, 2025]

Amanda Porter, Host

and

Alana Weatherbee, Program Manager Northern Healthy Connections Society

This episode is the first in our Harm Reduction series, following our 2024 conference on Harm Reduction.

Andrea Frolic, Kirsten Krull and Diana Tikasz

DISCUSSION QUESTIONS

1. Some of the signs and symptoms of occupational stress mentioned in the podcast include: increases in staff absence from work, emotional exhaustion or moral distress, and staff conflict.  Do you see signs of occupational stress in your daily work? – if so, what are these signs and how do they impact your team?
2. This episode mentions the challenge of awork culture that makes “no emotions on the job” the norm. Where does this come from and what are its impacts on staff and patient care?
3. How can employees and leadership work together to mitigate occupational stress, that go beyond individual self-care strategies?
4. Lack of trust in the health care system and occupational stress are connected. Can you think of some possible strategies that may help employees, patients and families regain trust in the healthcare system? 

RESOURCES

An ecological approach to humanizing healthcare organizations for patients, healthcare providers, and communities. Healthcare Management Forum. 2024;0(0). doi:10.1177/08404704241293596

Simpson, A. V., Cuna, M. P., Clegg, S., Rego, A., & Marco, B.  (2024).  Organizational compassion:  a relational approach.  Routledge.  

Trzeciak, S., Roberts, B. W. & Mazzarelli, A. J.  (2017)

Compassionomics:  Hypothesis and experimental approach.   Medical Hypotheses, 107, p. 92-97. 

Trzeciak S, Mazzarelli A. Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. Pensacola, FL: Studer Group; 2019.

Dr. Mark Downing, Infectious Disease Specialist, Nova Scotia Health

Discussion Questions:

• How did infection prevention measures impact access to care for patients and loved ones during the pandemic? 

• What were your thoughts and feelings about the effects of infection prevention measures in your personal or professional life during the pandemic? 

• Visitor restrictions have been widely debated – perhaps more than any other infection prevention measure.  

• Why do you think this is the case?  

• How might visitor restrictions impact access to care for the individual patient? 

• Under what circumstances do you think visitor restrictions are justified?  

• Discuss the different competing priorities between the individual patient’s autonomy, obligations towards roommates or other patients, and protection of workforce. 

Hartigan I, Kelleher A, McCarthy J, Cornally N. Visitor restrictions during the COVID-19 pandemic: An ethical case study. Nursing Ethics. 2021;28(7-8):1111-1123. doi:10.1177/09697330211005078  https://journals.sagepub.com/doi/full/10.1177/09697330211005078  

Campbell L, Morley G. The Ethical Complexity of Restricting Visitors during the COVID-19 Pandemic, BMJ Quality & Safety 2023;32:689-692. https://qualitysafety.bmj.com/content/32/12/689.full 

with Host, Amanda Porter and special guest speakers:

Tara Rutherford, Health Services Manager, Musquodoboit Valley Memorial Hospital

Roberta Duschene, Director of Rural and Community Sites, Central Zone, Halifax

Discussion Questions

• How might community engagement in the recruitment process of new physicians contribute to sustain access to health care in rural communities? 
• Can you think of ways to engage community members in approaches that can help sustain access to care in rural communities where there is no on-site physician available? 
• In your opinion, what is a reasonable expectation about how far you might need to travel to access some forms of care? (Such as, for example, emergency care) 
• If you had, for example, one part-time primary care physician covering an entire zone, what kind of service would you think should be prioritized?” What do you think?  

Resources:  

Simpson, C. and McDonald, F. (2017) Rural Health Ethics. Springer 2017 http://www.springer.com/us/book/9783319608099  

Szumer, R.T.O., Arnold, M. The Ethics of Overlapping Relationships in Rural and Remote Healthcare. A Narrative Review. Bioethical Inquiry 20, 181–190 (2023). https://doi.org/10.1007/s11673-023-10243-w  

How Living in Rural Locations can Affect Access to Care

with

Dr. Christy Simpson

Ethics Collaboration Coordinator, Dept of Bioethics, Dalhousie University

Discussion questions:

1. What are our obligations as a society to ensure access to care for people living in rural communities who take on higher-risk occupations that are necessary to sustain our communities?
2. In your opinion, what is a reasonable expectation about how far you might need to travel to access some forms of care?
3. What do you think of the idea of having a specialist or a team of specialists travelling to rural communities instead of having patients travelling to them?
   • What benefits do you foresee with such a strategy?
   • What might be the downsides?

Resources: Rethinking Rural Health Ethics – C Simpson and F McDonald (Springer 2017) http://www.springer.com/us/book/9783319608099

Dr. Fiona McDonald

• Associate Professor, School of Law at the Queensland University of Technology, Australia
• Adjunct Associate Professor, Department of Bioethics, Dalhousie University

Discussion questions:

1. What stood out the most to you in this discussion about care close to home?  

• Why? 

2. What does care close to home mean to you?  

• What values do you associate with care close to home? 

3. In her outline of the barriers associated with care close to home, Fiona McDonald describes aspects of healthcare that represent a barrier to care close to home including:  

• General medicine is valued less than specialty medicine  

•   Individual care providers may be reluctant to practice in rural areas due to concerns about work-life balance.  

4. Do you agree that these are significant barriers?   

• What are some of the things that may help address these and other barriers?  

Resources:  

Moving care closer to home: three unanswered questions  – Danielle Jefferies, Blog post published September 20^th, 2023:

https://www.kingsfund.org.uk/blog/2023/09/moving- care-closer-home-three-unanswered-questions  

Rethinking Rural Health Ethics – C Simpson and F McDonald (Springer 2017) http://www.springer.com/us/book/9783319608099  

with Melanie Goodday

Therapeutic Classroom Teacher, IWK Health

In this podcast episode, Marika Warren and Melanie Goodday talk about how they prepare for a clinical ethics consultation. the discussion is based on a case about involuntary COVID-19 vaccination of a minor receiving inpatient psychiatric treatment. The case was published in the Journal of Clinical Ethics in the fall 2022. A full reference to the case is included here:

Kious, B.M., Hesse, T., Baese, P.L. (2022) Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment. Case Report.  Journal of Clinical Ethics, 2022 Fall; 33(3):236-239.

Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment – PubMed (nih.gov)

with

Theresa Hawkesworth, 

Director, External Relations and Special Projects with Nova Scotia Health

Emotions in Ethics Consultations

with

Dr. Ange Cooper  

Psychologist, Assistant Dean Faculty Wellness 

Dalhousie University Faculty of Medicine

with

Jocelyne Tranquilla

Grief is a common experience in health care both for those who are receiving care and for those who are providing care. We hope our discussion today will provide an opportunity to explore grief and grief support through an ethics lens.

Resources

https://www.nshealth.ca/bereavement

https://www.mygrief.ca/

https://www.refugeingrief.com/

https://whatsyourgrief.com/

https://www.centerforloss.com/

https://grief.com/

Ethics During Crisis

with

Marika Warren

Christy Simpson

Lisbeth Witthoefft Nielsen

In this episode Marika Warren, Christy Simpson and Lisbeth Witthoefft Nielsen discuss the TV series ‘Five Days at Memorial’ and how ethics can help in a crisis.