Sunnybrook offers hospital staff a choice: donate blood or designate a stand-in

July 21, 2014
Event to mark World Blood Donor Day 2011 at WHO HQ in Geneva, Switzerland.

Sunnybrook Health Sciences Centre will require doctors, nurses and other hospital staff and volunteers to either donate blood or find a substitute donor during periods of low blood supply, according to a memo to employees obtained by Opined.

Sunnybrook is introducing the new policy this fall in an attempt to improve the levels of dangerously low blood stores that afflicts thousands of Canadians. About 3,500 people die every year from blood loss, according to the Public Health Agency of Canada.

The new policy is an acknowledgement that voluntary blood donation campaigns are not that effective. Only one of every four health-care workers donates blood, even though a blood transfusion is one of the best methods of treating low blood volume. Each pint of blood may save up to 4 lives, including children and adults, according to medical studies.

It just seems to be the responsible thing to do to have our staff who are caring for sick and vulnerable people to donate blood.” Sunnybrook spokesman Craig DuHamel said.

Sunnybrook is introducing a donate-or-designate directive along with other major teaching hospitals in Toronto, says the memo sent to employees on Thursday. The hospitals will not make donations mandatory for health-care workers. Rather, they will offer employees the choice of either donating or finding a willing substitute during periods of low blood supply. Such policies result in substantial increases in blood donation rates among health-care workers, according to a recent Canadian Medical Association Journal article.

Sunnybrook is far from the first hospital to put in place a donate-or-designate policy. Hospitals and long-term care homes in British Columbia, as well as 13 hospitals in Ontario, have adopted such measures. Still, the decision is expected to provoke a backlash from the Ontario Nurses’ Association, the union that represents 60,000 nurses and other health-care workers in the province. The ONA has threatened to file grievances against other hospitals that have forced would-be donor nurses to find substitutes.

Donating blood needs to be a choice and should be part of a more comprehensive, evidence-based infection control plan,” Linda Haslam-Stroud, president of the ONA, said in a statement. “Outing nurses that do not choose to donate blood with mandatory designating a substitute does nothing but provide our patients with a false sense of security.”

The Registered Nurses’ Association of Ontario, which spearheads professional development and political lobbying on behalf of nurses, disagrees with the ONA’s stance, saying hospitals have a responsibility to do everything possible to protect patients, including forcing non-donating staff and visitors to find designated donors. “We are in support of it. Simple as that,” said Doris Grinspun, the chief executive officer of RNAO. “The only thing we would say is that it has to apply to everybody, not only the nurses, of course, [but to] all the health professionals and to visitors.”

Ms. Grinspun said that even among nurses, unfounded concerns about the safety of blood donation persist. “I think that there are still a lot of myths of, ‘Oh, I donated blood today and now I feel weak.’ I think that’s [true] for the public and also for health professionals,” she said. “To me that’s an issue of education.”

This has been a re-write of an article in the Globe and Mail. I only changed terms and phrases relating to mandatory vaccination, masking, and influenza outbreaks to ones about blood donation, finding a substitute donor, and low blood supplies. Many will point to the differences between mandating an influenza vaccine and mandating a blood donation, and they’d be right, but in terms of the encroachment of a person’s bodily autonomy I believe the analogy is strong. All arguments in favour of mandatory vaccination of healthcare workers can be equally applied to mandatory blood donation. In fact, the evidence that blood transfusions saves lives may even be stronger than that for the influenza vaccine. The question to ask is whether the balancing of a patient’s rights with a healthcare worker’s rights pushes us to favour the patient in all analogous circumstances. Hopefully this example using blood donation sheds a different light on that debate.

Is it time to recognize a right to the birth control pill?

July 8, 2014

Recently, there was a report in Calgary of a doctor posting a notice to patients coming into the clinic that she was unwilling to prescribe the birth control pill (BCP) to patients. This follows on a similar incident in Ottawa earlier this year, and Kelly Grant has reported that the CPSO is looking to update its policy on conscience clauses. The policy was last updated in 2006 when the issue of conscience-conflicting activities arose in the context of pharmacists dispensing emergency contraception pill (ECP), sometimes called the morning-after pill. The hope was to make ECP more accessible by having pharmacists dispense the medication from behind the counter. It has since gone over-the-counter in all provinces.

Ovulating, after all, is not a disease.The debate then, as now, has focused on balancing the rights of healthcare practitioners (HCP) to practice their beliefs with the rights of the patient to have timely access to care. The main mechanism of the ECP is to block a newly fertilized egg from implantation. The BCP works primarily to prevent ovulation. In either case, the moral objection stems from the HCP not wanting to be: 1) an abetter to terminating a life (as defined at the moment of conception); or, 2) to enabling a person to make immoral choices, either intrinsically or by allowing them to avoid consequences that would have otherwise motivated them to choose a moral path. In both cases, by prescribing or dispensing the pill, the HCP feels he is drawn into immoral activity of the other person’s choices.[1] There may even be a small hope that the objection will give the patient pause to reconsider their position — a sort-of micro-awareness campaign.[2] Moreover, the “patient” seeking a BCP or ECP prescription is not even viewed as a patient because they are not suffering any symptoms or seeking treatment for a medical condition. In that sense, a HCP may feel that turning people away is not the same as denying access to medical care. Ovulating, after all, is not a disease.

The patient, unsurprisingly, takes a very different view. Physicians and pharmacists are trained to provide health services to those in need. It seems unconscionable to turn away any patient on the basis of moral or ethical beliefs. Especially when access is a concern, there is potential harm to the patient. It may be more pronounced in rural areas, but even in urban settings where patients may have to take time off work or take public transit to visit a physician or pharmacist, being turned away on arrival can be a source of undue pressure. Also, whatever the HCP’s moral objections, imposing those values on the patient or attempting to influence their personal behaviour is beyond their duties as caregivers. So yes, the patient claims, HCP must not practice their religion in a manner that hampers their professional relationship.

Is this actually an issue of competing rights, or is it instead a part of a broader problem of our healthcare system? The ECP has gone OTC in Canada (not in the US) and many have called for the same for regular BCP. But oral contraceptives are not without their risks. It remains reasonable to ensure that patients (especially young teenagers) access these drugs through a healthcare practitioner. However, physicians are seen as the gatekeepers to these medications, which skews their role in this context and the broader healthcare delivery model.

So is refusing to prescribe oral contraceptives the same as refusing medical services? I would argue that the patient seeking a medical consultation is asking her physician to assess whether an oral contraceptive is medically appropriate. Once that medical assessment is completed, prescribing is as-of-right. In other words, the patient wants the physician to answer the questions: Are there medical reasons why I should not use OC? And if not, can you recommend a specific one? In the case of a reassessment, the question is whether continued use is appropriate, or whether further investigation is merited.

I’m not suggesting that all drugs should be prescribed as-of-right. But viewing the role of the physician this way would seem to remove any moral objection in the physician-patient relationship. It defines the physician-patient relationship in terms of an expert in medical care providing a patient with the information she needs to make safe and healthy choices. Perhaps instead of a “prescription”, the physician could provide the patient with a medical note stating that there are no medical contraindications to taking oral contraceptives. The patient could hand that into her pharmacy who could then provide her with the appropriate product.

If we need to create a special regulatory framework to make this clear, then so be it. It’s better than shoehorning an especially sensitive area of healthcare into a paradigm meant for something totally different. And perhaps some physicians will still feel their freedoms are being compromised. But as far as the current arguments go, conversations about competing rights of a physician’s freedom of religion and a woman’s bodily autonomy seem like a distraction. By properly understanding the roles of healthcare practitioners, as facilitators and advocates to better health rather than gatekeepers, we may be able to avoid such conflicts and maybe even transform other areas of healthcare.

  1. Unfortunately, the argument is muddied with the bad analogy of handing a psychopath a gun. Let’s just all agree that whatever the stance of the moral objecter, this is not the same thing, and only distracts from the legitimate arguments on both sides.  ↩

  2. Or micro-evangelism, in some cases.  ↩

Patient-Centred OTC Labels

June 27, 2014

Many healthcare practitioners will lament the current information age, with patients of all stripes looking up health and drug information online, sources spurious and reputable. However, another locus of information that has been with us for a long time is the OTC label. With patients able to self-select certain medications without ever having a discussion with a healthcare practitioner, the OTC label is becoming an increasingly important source of information, especially with a more health literate and health-conscious public. However, a close look at the current state of OTC labels leaves much to be desired. Here’s a representative product packaging of a common medication available at any pharmacy. I’ve included the 3 English-language faces from the product packaging.

Canadian Benadryl packaging

The front face has large fonts, with nothing smaller than 10 or 11 pts. There’s a strange use of capitalization but we’ll chalk it up to marketing. In fact, the front face is exactly that: a shelf-talking advertisement for the product. I’ve witnessed many patients make the judgment whether to buy a product based on the claims made here. I’ve had patients ask me the difference between two similar products, only to go against my recommendation because the packaging describes their combination of symptoms more closely.

The other two of the package’s outer sides are abysmal. I’m not sure there is anything written above an 8-pt font, with the majority of the important information in the middle panel depicted set in 4-pt font. Given that this medication can be potentially dangerous for seniors, the information is simply too small for anyone to read comfortably without straining. Moreover, the required information is separated across 2 side panels: one to tell you the appropriate dosing, the other to cite all the warnings and disclaimers. It’s not easy to get the information you need.

The entire packaging and information presentation makes it difficult for patients to quickly and easily find the information they’re looking for. It’s the opposite of what we want in an OTC label: an easily identifiable list of fact that’s legible for all ages and persons with disabilities, and communicates the safe and effective use of the medication. Health Canada’s Plain Language Initiative only goes as far as to improve the language being used on the packaging. A different initiative will see the inclusion of a “Fact Table” in about 3 years, which will presumably mirror the US “Drug Facts” panel.

FDA Benadryl label
Image courtesy of

But even the US is thinking about changing their current setup. Is there a better way to display relevant drug information to patients to be able to make informed choices or to urge them to seek additional medical attention when necessary? To answer that, I decided to see if I could at least create a starting point for such a label. Here’s what I came up with.

New label design

I started with the current nutrition labeling design in Canada. While nutrition labels have their problems, the format and style is familiar to Canadians looking for more information about the products their buying. I’ll list off some of the design decisions here, and then explore a couple in particular in detail.

  1. font and typeface: easy-to-read, lowercase lettering throughout, with selected bold headings; based on the standard nutrition label size, nothing here is less than a 10-pt font size
  2. important information at the top: proper dosing and usage recommendations are at the top above the rule
  3. pediatric-specific instructions in purple: allows parents to quickly hone in on the relevant information
  4. traffic-light style indicators: for symptom relief (green) and side effects (amber), with a red caution heading; signal indicators help gauge the relative strength of the expected effects

The label is still crowded, and we could go a long way by requiring a larger label that is clearly identifiable on the back of the packaging. That would allow for more whitespace and greater readability.[1] But the essence is here, with the fundamental design principle being this: important drug information should be placed in a consistent location and catch the eye of the reader.

Colours and traffic-signal indicators for medication uses and side effects help to draw attention to important information while at the same time giving the degree of importance to that information. Many patients simply do not understand that all claims on the box are not equal. A simple implementation would use 3 lights for a benefit/side effect experienced by > 5% of the population; 2 lights for 1–5% of the population; and 1 light for < 1%.[2] A standard colour for children’s dosing may also help parents to quickly seek out and hone in on that portion of the label and help to reduce errors.

This label contains all the information provided on the Benadryl packaging above, and even includes other facts traditionally not included. For example, an adult may not realize that a liquid preparation formulated specifically for adults is available — an important fact for those who may have trouble swallowing the tablet.

Patients are increasingly looking for products OTC to help quickly address their health needs. Canada has the opportunity to think of a new way to present and deliver important drug information to help enable patients to make informed choices. Hopefully this serves as a first step in that direction. And it won’t be too soon for better prescription vial labels.

  1. And we shouldn’t make exceptions for smaller packaging, or circular containers, or whatever the packing preferences of the manufacturer. Let them figure out how to conform to the regulations.  ↩

  2. Health Canada already sets up guidelines for what specific facts should be included on certain drug products.  ↩