Matt Morgan: Changing global medical practice through a press release has put EBM into ICU

Releasing the results of the Recovery trial quickly, may have saved lives. But without the data available yet, the results cannot be scrutinised. Matt Morgan considers this complex decision

The authors were left with an impossible choice. Staring at the bold statistics showing that a simple, cheap drug may save tens of thousands of lives, what else could they do? One day of hesitation could translate into actual lives lost. A dad, a mum, a son. 

The response to the news that dexamethasone may reduce covid-19 deaths by as much as a third was as predictable as the rain when lockdown was eased. A chorus of cheer was followed by delicate, tentative questions about “the data”, then a loud roar of criticism. As yet, there is no pre-print of the findings and the researchers have said that the full results will be published shortly. 

Although the statistics are clear, that is all that we have. Until the results are posted on a pre-print server, or published in a peer reviewed journal, we cannot scrutinise the findings more closely. Instead, potentially the biggest medical discovery of our generation was announced by email in just 234 words, and that included “Yours sincerely.” Some say that covid-19 has murdered evidence based medicine. 

History is written by the winners and it’s too early to count the casualties. Yet nuance is still needed, even in a crisis. It is possible to be right in the moment, yet wrong in time. Many decisions in the pandemic may prove “right for covid” but “wrong for all”. Our prolonged lockdown in Wales is undoubtedly “right for covid”, by preventing more covid related deaths. But the dead don’t care why they died and longer lockdown may have many other consequences, such as undiagnosed cancers, or delays to treatment. This may even be the cause of more deaths overall when the accountancy is complete. Changing global medical practice through a press release may be “right for covid”, potentially saving tens of thousands of lives, by expediting what could be a life saving treatment. But putting the frail process of evidence based medicine into intensive care, with uncertain chances of survival, may ultimately prove “wrong for all”. Future standards may crumble, public belief in press-release medicine grows, transparency and peer review die. 

Covid-19 has shaken up life’s snow globe. The scene left when the flakes have fallen will be different from before. Different in many ways, and some will be good. Perhaps now is the time to resuscitate the ageing body of evidence based medicine. Resection of the maligned peer review process may give room for a life saving transplant. Bayesian platform adaptive trials have arrived, throwing p values under the bus. The discovery of the Higgs boson was announced globally through iterative, collaborative, mathematical automated process rather than by a man wearing a tie on an expensive podium to a bunch of his friends. Medical publishing is already learning from our colleagues in the STEM world by adopting pre-print servers. But the manner of this announcement shows there is still some way to go. 

Matt Morgan, Honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. 

Twitter: @dr_mattmorgan

Competing interests: None declared

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Covid-19: Intensive care and caring intensely

When we get through covid-19, and rest assured we will, these Intensive Care Unit (ICU) doctors, will march lockstep with others and argue for more beds, staff, and kit. We are not casting blame, but hospitals were full-to-the-brim well before covid-19. Minimal redundancy means decreased ability to surge. We need a grown-up chat about what we now understand to be our healthcare, especially given the likelihood of future viral waves. Let us garner support for that project by offering insights from the ICU covid-19 here-and-now. 

As we say when delivering unwanted prognoses, we hope to be wrong. Unfortunately, we suspect no single pill nor potion will swoop in and save the covid-day. Remdesevir (originally developed for Ebola) showed promise but attempts to obtain it via compassionate release are often soul-crushingly unsuccessful (“the patient is too sick”), just as they were for non-ICU colleagues (“patient not sick enough”). Alternatively, it’s a case of “cometh the virus, cometh the vaccine”, but again don’t hold your breath: not the best metaphor, we grant you. Over 70 vaccines are under development, with many targeting the virus’s spike protein: those crowns (coronas) from which it got its deceptively benign name. Before you throw up your mask in celebration, no vaccine is expected in 2020, even though the peddle has been pushed to the metal.

Unfortunately, viruses are as fascinating as they are awful. They are so sneaky that they highjack our cellular machinery to their nefarious ends. They are so submicroscopic that even bacteria wouldn’t see them if those bacteria magically developed the gift of sight. They are so minimalist—they contain nothing more than genetic material (the plasmid) plus a protective coat (a capsid) plus enzymes (proteases)—that microbiologists still debate whether they are “alive.” This all means it’s a tad difficult to make them “dead.” Just as Dawkins’ argued that lifeforms are the carriers of “selfish genes,” viruses are an even more effective means of getting around.

We have grown accustomed to “I want it now, safe and cheap.” But, even 2021 seems ambitious for a bespoke vaccine, given that the process usually takes a decade. It’s uncertain work, as illustrated by our zero-for-four result against the coronaviruses that cause the common cold. Next, we face the realisation that few companies make vaccines: all hail those that do. Presumably, we will also require an (im)modest 7 billion doses: herd immunity n’all. Which segues into another awkward issue. 

We suggest we use this pre-vaccine wait for a fulsome chat with influential anti-vaxxers. Measles was declared eliminated from the US in 2000 by the World Health Organization (WHO). Fast forward to 2019 and New York City declared a public health emergency because of 100s of measles cases resulting from 1000s of unvaccinated kids. Nowhere needs a covid-vaccine more than NYC, but one year later the president ceased funding the aforementioned WHO. It’s a substantial one-two punch. 

But there’s more, dear reader. Just as there is insufficient slack in healthcare, we have hardly funded our bioscientists to the max. We now expect studies on drugs and vaccines to be fast tracked and rigorous. However, these boffins are not borne overnight, and they require specialized labs. It is not enough to hope something works. Sorry, but currently, no antiviral, antiretroviral, antimalarial or antirheumatoid should be used until specialists have studied long and hard. Indiscriminate use has already caused deaths. In other words, yes, you do have something to lose.

Instead let’s pivot to what should make a difference right now, and what we can control. Doctors often preach from the pulpit of biochemisty, pharmacology and physiology, but we expect covid-19 to be managed as much by society’s humanity, kindness, and grace. If that sounds twee coming from biomedical physicians, we would argue ‘twas ever thus. While our medical industrial complex has a mighty part to play, 20 years of “ICUing” has shown us that our “life support” (machines and tubes) needs your ‘life support’ (the ability to look after yourself and others). So, how do we leverage our best during the worst of times?

Start by accepting that those scientists providing national recommendations are decent and sensible and open to change. As such they need your support. Next, understand that the scientific method is not perfect but it’s better than conspiracy theories and partisan rhetoric. Then let’s focus on caring “intensively” about each other. Fortunately, this also means you don’t need a medical or nursing degree to help. We simply need to decide to cope, much like Canadians do during cold winters, and Brits do during wet summers. 

Too many of us have been inwardly focused (how does this affect me) rather than outward (what do others need from me). You may have tried drinking from a fire hose (of information), but found it didn’t quench your thirst (for usable knowledge or peace of mind). You may have gone through those stages of grief (denial, anger, detachment, bargaining and acceptance) at break neck speed. Regardless it took one of us (PB) weeks to accept that covid-19 should not consume every waking moment.

If we are not careful then we will burnout sooner than this pandemic. I (PB) had to be reminded by my wife to enjoy sunsets and to get my recommended daily dose of joy. This non-medical maven reminded me that most of the world’s best brains—whether medical, political, or logistical—are leaning into this fight. I suggested that the same is true of the world’s best people: parents, teachers, and volunteers. We concluded that while none of us should be complacent, nor should we lean in so far that we collapse. 

Instead of chasing every rumour or tweet, we should find ways to connect. Seriously: do it now and do it properly. It isn’t morbid to let people know what matters to you. We have had “the chat” with family many times. Our weekly zoom catch-up with mates is now the highlight of our covid-week. While we never underestimate the power of community, we are very aware of the limits of Intensive Care. Doctors and nurses deliver excellent multidisciplinary supportive care but no machine can make you (or us) stronger than baseline, and our individual (previously hidden) genetic response will impact how we fare. We don’t like it any more than you, but life is too precious to candy-coat the truth. We will commit to building an ICU fit for the fight. Others will search for magic bullets and dispel magic beans. Regardless, let’s mobilize the very best antiviral yet known: the clever brain alongside the compassionate heart. 

Peter BrindleyDepartment of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Twitter: @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

Competing interests: None declared

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Matt Morgan: A letter from ICU

To those who are elderly, frail, vulnerable or with serious underlying health conditions,

We have not forgotten about you. 

It must be so hard listening to endless news reports that end with “don’t worry, this illness mainly affects the elderly, frail, vulnerable or with serious underlying health conditions,”. What if that is you?

Our passion as an intensive care community is fixing problems that can be fixed. Yet we often meet patients like you who have problems that cannot simply be fixed. As this virus continues to impact on the world, we will meet many more of you. Although we have fancy machines, powerful drugs and talented staff, none of these things cure every disease. All they do is give us time – time to work out what is wrong, time to hopefully treat it and time for people to get better. But sometimes we already know what is wrong, we already know that there is no effective treatment. And so sometimes the machines offer little, intensive care offers no fix. But hope is not lost. We have not forgotten about you. 

As difficult as this is, we will be honest. We will continue to use all of the treatments that may work and may get you back to being you again. We will use oxygen, fluid into your veins, antibiotics, all of the things that may work. But we won’t use the things that won’t work. We won’t use machines that can cause harm. We won’t press on your chest should your heart stop beating. Because these things won’t work. They won’t get you back to being you. 

And If these things are still not enough, we will sit with you and with your family. We will be honest, we will hold your hand, we will be there. We will change our focus from cure but most importantly we will continue to care. We have not forgotten about you. 

Signed,

The Intensive Care Unit

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. 

Twitter: @dr_mattmorgan

 Competing interests: none declared

 

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Peter Brindley and Matt Morgan: It’s time to be super heroes for scientific truth 

Don’t get frustrated, get involved, say Peter Brindley and Matt Morgan

Earlier this week, Simon Stevens, the NHS chief executive criticised celebrities and wellness companies for promoting unproven and potentially harmful therapies. He spoke about the impact that fake health news has on our lives and criticised Gwyneth Paltrow’s wellness and lifestyle company GOOP. Paltrow has previously famously suggested that women are so “unclean” that the only solution is to vaginally insert a jade egg. No doubt many clinicians and scientists have, at some point, likely thrown up their arms and considered giving in. However, rather than despairing about the apparent elasticity of inelastic facts, we are issuing a rallying call: it’s time to fight back. It’s time to be super heroes for scientific truth. 

Step one is to engage the public and stat. Get out there and mingle because grumbling at conferences surrounded by like-minded others will not save the day. This is why medical caped-crusaders such as US obstetrician Jennifer Gunter deserve high praise. She started the popular podcast “Jensplaining” and wrote the Vagina Bible. Her noble, simple, and profound goal is to empower the average person/patient. Ask yourself, is there anything that matters more? Others have initiated a “Pint of Science”, where scientists communicate their ideas with the public in pubs, cafés, and anywhere else where people will listen. Another strategy is for our universities (and professional societies) to support more professorships (and sabbaticals) that focus on the public understanding of science. The point is that public opinion matters, not just published opinion. 

After publication, the average scientific paper is read by just 10 people, and half are not read at all; not even by the author’s mum. Accordingly, we need to spread the truth more than ever. Brandolini’s law states that: The amount of energy needed to refute nonsense is an order of magnitude bigger than to produce it. Hyperbole aside, we are facing something of a culture war. A century ago, Mark Twain argued that “a lie travels around the globe while the truth is putting on its shoes”.  Nowadays lies, and truths, do that travelling at warp speed via social media. Short of hiring Cambridge Analytica, we also need to understand the taxonomy of truth, half-truth, and untruths. Our challenge will be how to encourage broad discussion while resisting non-evidence-based piffle (we are trying to be charitable here). No doctor wants to, nor should, get embroiled in twitter wars, but if you don’t stand for something there is a danger that we could fall for anything. 

Every human has bias so let us declare ours loud and proud: proper science is proper wonderful. Moreover, if you want good science then it needs to be funded and defended. However, to date, conventional medical science has not done an adequate job at arguing its case. Traditional science’s cautious and iterative style is also important, but can fall short when it comes to packaging messages that suit the many. Empirical science’s timeline also seems better suited to another age. First, you apply for research funding: 20% of projects are successful; 80% are rejected. Next you have to overcome the vicissitudes of the ethics board, and divine a question that is simultaneously precise, but generalizable. Years later, you hope your results were “positive” because it’s time to publish or perish. It’s hardly surprising, but largely inexcusable, if scientists don’t have energy left over to ensure that anyone actually still cares, let alone changes their behaviour. 

Let us state our bias even clearer: Good science delivers just as bad science hurts. Good science keeps planes in the air and infections out of wounds. However, ironically scientific advancement has also helped life become so comfortable that, at times, we tolerate ideas that don’t pass the rational sniff test. While we point smug fingers at celebrities and wellness experts we academic allopaths should accept where we have erred. Firstly, we forget that our patients don’t read our medical journals, and nor do most of our colleagues. We have also allowed a ludicrous world of 5,000 journals on Pubmed alone, so it’s difficult to separate signal from noise. And don’t get us started on predatory journals. We don’t have the time to understand why so many even exist, unless, as we fear it is to expand reputations and bank balances. 

At the same time that we implore lay people to dial back the pseudoscience, let’s accept the potential for sins and transgressions from medics and scientists. As outlined, there are enough predatory journals that if you have the funds and persistence you can probably get your work displayed somewhere. Moreover, even if a scientific publication is eventually discredited, it presumably once passed our lauded peer review process. “Dodgy academics”—again we’re trying to be charitable here—have shown that the pen is as mighty as the syringe, as demonstrated by the antivax movement. In our medical specialty of intensive care, Joachim Boldt published 90 fraudulent articles in 16 prominent journals before he was found out. [5] 

There is a small but necessary cadre of doctors and scientists doing the tough forensic work required to expose academic fraud. They deserve huge praise. They also need fearless support from our universities. The point is that, in the battle for hearts and minds, we each have a part to play. It may be as small as putting aside a few hours each month to review manuscripts. It may be that in the midst of a busy clinic you smile your way through your 20th debunk. It may be that you teach learners how to critically appraise the literature. For us it includes writing opinion pieces that simultaneously challenge and chastise. 

There is so much important knowledge still to discover. As such, it’s a crying shame that we can’t just focus on novel research; but needs must. Whether patient or provider, we are all being bombarded by pseudoscience masquerading as fact. We know you feel overwhelmed and frustrated, because we do too. However, steel yourself: nothing matters more than the truth. Become a myth buster for science. Alternatively imagine that your lab coat is a super hero cape, and then accept that with great power comes great responsibility.

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

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I’m dreaming of a green Christmas

Most of us see the Christmas holiday season as an opportunity to slow down, take stock, and “just be.” Accordingly, we had planned a predictable article about recommitting to old-fashioned values and taking time off. However, these are not predictable times. We are just a few short sunrises from a new decade and we have had the Xmas stuffing knocked out of us by a three-punch combination: a must-hear podcast, a should-read book, and the announcement of a don’t-miss conference. These brought home compelling arguments that climate change and pollution matter far more than us front liners may wish to know. Moreover, this decade may be our last chance to avert a major disaster. Before you roll your weary eyes, let us be clear: we don’t like it any more than you.

More and more voices are pleading that we get greener and cleaner, and STAT! As Beth Gardiner outlines in her new book, air pollution is already associated with at least 7 million excess annual deaths (roughly one-in-ten of all world deaths). Whatever the exact toll, air pollution—principally nitrogen oxides and tiny particulate matters called PM2.5—are associated with more human deaths than smoking, AIDS, diabetes, and vehicle crashes combined. Both pollution and climate change will be especially cruel to the poorest in our communities, and are therefore social justice issues, not just inconvenient truths. 

Although 40% of Americans breathe polluted air daily, worldwide it is over 80%. Hundreds of millions already struggle with pollution’s myriad of consequences to their lungs, their hearts or their brains. Pollution is even linked to poor educational and behavioural outcomes. As CO2 builds, extreme weather is expected to increasingly injure, kill, and displace populations. Disease patterns will change, and so too will microbiomes that previously protected us. Increased patient numbers mean we will struggle to squeeze yet more from our overstretched healthcare system. Anyway, Merry Christmas one and all. 

In short, and without any delight, our New Year’s resolutions likely need to be bigger and bolder. Hugh Montgomery and colleagues have set up a new conference—CODA—are unequivocal with their recommendations: change your energy source, get out of your vehicle, forego that trip, put down that steak, and measure and mitigate your carbon footprint. Gardiner is no less Cassandra: clean air acts matter to your patients as much as any machine or pill, and as much as smoking cessation. If we healthcare professionals truly care, rather than just tweeting, we need to speak up and take the side of our current and future patients. This starts by accepting that it is later than you think.

In contrast, we blithely spent the 2010s living large and thinking of carbon dioxide as a gas that pulmonary patients need our help to get rid of. It is now our cities and environment that cannot adequately exhale, but we have yet to make a PEEP (an ICU pun for those in the know). The 2020’s will be an anthropocene: an era where human actions and our population size matters most. We hominids may be saddled with prehistoric brains, and manipulated by medieval institutions, but we have the power of gods. Much like medicine, respectful debates about cause and effect are perfectly fine; inaction and outright denial are not.

If we support the scientific method, and the collective labours of our scientific brethren, then we must accept a clear and present danger to our most important patient and greatest life support: mother earth. Like you, we would rather ignore this, or worry about just one patient at a time. Moreover, when our medical day is done we quite like driving our single-occupant car, consuming a mighty feast, planning our next conference junket, and having as many kids as we please. Beyond the workplace, we don’t really want to contemplate yet more thorny issues. For example, medicine measures success by lives extended, even as the approximate world population balloons by an eye-watering 150,000 each day. Moreover, healthcare funding comes from companies that pollute. These are critical issues to resolve, but much like a gasping patient we can’t just put this off. Unlike that hypothetical patient, we also need to accept our share of the blame. 

The first global estimate of health care related emissions was completed in August 2019. It may not be on your holiday reading list, so we will offer some lowlights. Healthcare was associated with 2 gigatons of carbon dioxide in 2014. This is over 4% of all global greenhouse gas emissions, and as much as 10% of a developed nation’s total. If healthcare were a country we, collectively, would be the planet’s 5th largest emitter, and in-hospital healthcare would be our largest polluter. Few of us have thought about the carbon consequences of the care we offer. However, this complexity is exactly why we need to get informed and involved. Healthcare workers are used to moving in when conversations are needed that others run away from. We are not experts in population growth or urban planning, but we will face their consequences.

Climate science and pollution science is complex and nuanced, obviously. However, International Commissions were unequivocal when they concluded that climate change is the “greatest threat to human health” and stated that “climate change threatens to undo the last 50 years of global health gains.” As doctors, we know that quoting scary statistics is rarely enough. It doesn’t always help being told that global temperatures have already risen by 1 degree, glaciers have lost trillions of tonnes of ice, or that sea levels are rising by a cm every three years. Healthcare professionals are extremely good at speaking up when it suits our bottom line. We also need similar eloquence on behalf of our communities. This Christmas we will take comfort in the fact the we still have a voice. After a quick holiday rest, we will look to mobilize it. 

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter @docpgb
Competing interests: None declared

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

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Please don’t reply all—why we need to learn e-tiquette

The aeroplane touches down and your holiday begins. “This time I’ll relax” you promise yourself while nervously pacing around the luggage carousal. You finally check-in to your modestly priced hotel room, and you even open an immodestly priced drink from the minibar. Your partner then fixes you with a familiar stare and delivers THE TALK: “Right you, no work for a week”. Before words have left lips, your phone pings to announce that you now have wifi service. You make an excuse, sneak to the toilet, and feel an endorphin rush as you enter your password. Gosh, this many emails after such a short flight: these must be important, after all they know that you are away…

Email #1

Subject:    Fwd:Fwd:Fwd:Fwd:Fwd:Fwd:

It’s Monday, but it’s already been a long week for your clinical director. Yet another three page safety notice about that piece of equipment that hasn’t been used since the 1970s. But if others have to read it then so do you. This email has been passed along like the chain letters of old. You feel dumb as soon as you open it. However, this does not stop you forwarding it to a few more folks: you know, just to keep them in the loop.

Email #2;

Subject:     FYI

FYI presumably means “For Your Irritation.” You develop carpel tunnel syndrome by the time you have swiped through this James Joyce novel. You still can’t establish the point of this dirge. Moreover, the contents are copyrighted and yet simultaneously not the responsibility of the sender the novella length signature tells you. The archaeologist in you is compelled to unearth the original missive. “Goodness me” is not the expression you mutter when you discover it concerns maintenance work that started weeks ago, in a building you never visit and can’t even pronounce.

Email #3

Subject:    URGENT

Not urgent.

Email #4

Subject:    Complaint

You heart sinks while your mind runs through a rolodex of frustrated patients, angry relatives, and huffy colleagues. What did I do; what didn’t I do? You recall something about someone, but the notes are on your desk and a response is expected pronto. You don’t tell your family, but, for you, the idea of you relaxing on this holiday is now stuffed. You promise not to check your email tomorrow, but who are you kidding. In the meantime, it seems best just to stew. 

Email #5

Subject:    Newsletter

A 30Mb attachment takes an eternity to download. Finally you can behold all of its colourful Comic Sans glory. Even though you don’t know the people, you now know that mum and baby are doing well. Another person you didn’t know had arrived is apparently leaving, and someone who you thought had never left is now back. You also learn that hand hygiene is less than 70%. You are so distracted you forget to wash your hands on the way out of the toilet.

Email #6

Subject:     Special invitation

Not special. 

Apparently, your glorious work is revered the world over. So much so that all you have to do is click the email link and share your personal details. You and only 5000 others can then pay to present at a conference in a place that may still be under a travel advisory. You ought to send this one tumbling into the spam folder stat, but hey, at least somebody recognizes your genius. 

Email #7

Subject:   Let me know your availability 

Oh god, the five most dreaded words in the email lexicon have just been typed. There is now no way to escape 50 separate emails whereby everybody feels obligated to cc all. You will soon be informed of such breaking news as “Tuesdays aren’t great for me” and “I’ll try my best to be there but can’t promise”. You wish you could send a pleading email that asks folks only to respond to all if they really must. This presents you with an interesting catch-22, can I really cc all asking people not to cc all?   

Subject:  Cake!

Now we’re talking: you love cake. Instead, this image of gluten-free diabetic-friendly vegan beetroot surprise sends your finger straight to the trashcan icon. Time to head to the pool before Happy Hour ends. After all, your family appears to be having a great time without you. 

Postscript: 

You send yourself one last reminder message. After all, you’ve been meaning to talk to the kids about not overusing their smartphones on this trip. You worry where they get such ideas. Maybe you will Google that. In fact, you could even write an article about digital detox; maybe tonight when everyone else is asleep.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

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