In British Columbia, five people die every day due to unregulated drug overdoses. Many of these deaths occur after an overdose leads to cardiac arrest. For most, resuscitation marks only the beginning of a precarious journey. The hours and days afterward, known as the post-resuscitation care period, can be a critical tipping point for recovery or decline. Yet, this period remains under-researched for patients who experience an overdose. Harjeev Sudan, a PhD student in Neuroscience, co-supervised by Dr. Judy Illes, Director of Neuroethics Canada and Dr. Mypinder Sekhon, Head of the Division of Critical Care Medicine, is working to change that.
What Happens During and After an Overdose
Opioids, which are involved in a majority of overdoses in British Columbia, act on the respiratory system to suppress the drive to breathe. Naloxone can often reverse an opioid overdose, but it may not work if the drugs are mixed with other toxic substances. Without fast treatment, oxygen deprivation can cause the heart to stop. And as the drug supply becomes more toxic, naloxone is less likely to be effective.
“In the case of an untreated overdose, breathing can cease altogether, leading to cardiac arrest,” Harjeev explains. “A lack of oxygen to the brain quickly leads to neuronal damage while the heart is stopped. But the damage doesn’t necessarily stop if the heart restarts—the brain often experiences additional injury due to swelling and inflammation after resumption of oxygen and blood flow.”
Harjeev’s thesis focuses on ICU care and ethics for patients who remain unconscious after resuscitation due to post-cardiac arrest brain injury after drug overdose. “I’m really interested in how we can better understand and address the needs of this vulnerable group in the critical care setting,” she says.
Currently, Harjeev is using clinical data to map patients’ care trajectories after overdose. In the next phase of her work, she will be examining the important ethical considerations for this population going forward.
Ethics along the spectrum of care for people who use drugs
Harjeev first became interested in the ethics of substance use care after reading an op-ed by doctoral candidate Quinn Boyle and Dr. Judy Illes on forced treatment for opioid use disorder.
“I was really inspired by that piece,” she reflects. “It pushed me toward exploring evidence-based, supportive measures for people who use drugs.”
Later, she would collaborate with Quinn, a PhD candidate supervised by Dr. Thomas Kerr, Director of Research with the BC Centre on Substance Use, on a commentary to discuss the refusal of care among patients after an overdose. Harjeev and Quinn, along with their supervisors, argued that people who use drugs do not inherently lack decision-making capacity if they refuse healthcare after an overdose.
“Just because someone uses drugs or refuses care doesn’t mean they lack decision-making capacity,” Quinn says. “It ignores the entire context in which the healthcare is taking place.”
Harjeev notes that stigma against people who use drugs is pervasive, and healthcare systems are not immune.
For many, refusing care is not a simple choice, but a protective decision in response to anticipated stigma, mistreatment or institutional consequences such as incarceration, threats to housing, or risks to child custody.
“We argued that patients actually demonstrate intact decision-making capacity by refusing care if they feel unsafe, unheard, or worried about the negative impacts they might face,” Harjeev explains.
Community-based healthcare and harm reduction services, such as clinics and overdose prevention sites in Vancouver’s Downtown Eastside, they suggest, can sometimes better meet the needs of people who use drugs. Located in neighbourhoods where patients feel safest, these programs provide harm reduction resources, basic medical care, post-overdose support and psychosocial services, and tend to see higher patient retention and trust.
“There’s literature showing these services are effective at engaging people who use drugs in crucial health care and treatment like opioid agonist therapy, as well as reducing all-cause mortality in addition to being well-received by patrons,” Quinn notes (see Kennedy et al. 2022, Kennedy et al. 2019, and Olding et al. 2023). “Expanding these services, including outreach into the community, could help ensure care is both compassionate and respects patient autonomy.”
Empathy and Humility in Practice
In Quinn’s doctoral research on the ethics of using neurotechnologies to treat opioid use disorder, interviews with people who use drugs often shifted away from the intervention itself to their relationships with healthcare providers.
“They told me the ways in which providers interact with them needs to change, regardless of the treatment modality being used” he says. “Many described feeling dehumanized when interacting with the healthcare providers, pointing to stigma, criminalization, and discrimination as issues in the healthcare system.” Quinn noted that this is especially true for Indigenous people who continue to experience both overt and covert racism in health care encounters.
Quinn adds that humanizing care requires a trauma and violence-informed approach, which recognizes the impacts of trauma and violence while promoting safety, collaboration and respect. But, it can also be as simple as a kind word. “Participants gave examples of what humanizing care has looked like for them – it could be something as simple as health care providers making small talk, like, ‘oh, you look so much better today.’ These small gestures of compassion and attentiveness, that we often take for granted, matter.”
Harjeev agrees and suggests that empathy and humility can go a long way.
“Empathy and humility can look like many things,” Harjeev adds. “Interpersonal empathy, understanding what someone might be going through; cultural empathy and humility, knowing that people come from different backgrounds and have different values and perspectives. There’s also prognostic humility, acknowledging the limits of our ability to predict outcomes when lives are on the line, which applies especially in end-of-life settings.”
End-of-Life Care
People who use drugs, especially given the ongoing toxic drug supply crisis, are more vulnerable than the general population to younger cardiac arrest and death. When at the end of life, they are are less likely to receive palliative care in clinics or at home, and have representatives to share their values in end-of-life decision-making. Socioeconomic inequities, such as poverty and marginalization, only compound these challenges and make access to compassionate care more difficult.
This makes decisions about the end-of-life ethically complex, which Harjeev explores in a new paper here. Clinicians usually use one of two ethical standards: medical futility, which considers when treatment is no longer medically useful, and the best interest standard, which looks to the patient’s own values and wishes.
“We caution against relying solely on either standard,” Harjeev says. “It’s very difficult to predict a patient’s outcome with certainty. There’s a risk associated with withdrawing care when there is a chance for recovery—so it’s important to practice prognostic humility, especially when providing care for a vulnerable patient.”
Research shows that errors and biases can occur in prognostication, and the application of clinical guidelines can vary widely, highlighting the need for careful, thoughtful decision-making.
“As far as I’ve seen in two years of research, the post-overdose period is when patients are at their most vulnerable. They’re often unconscious, and it can be difficult to know their wishes and priorities when it comes to life-sustaining treatments,” Harjeev reflects. “Coupled with misconceptions and stigma around this population of patients, it’s imperative that we better understand the needs of these patients during critical care. I am eager to continue my research and see how we can better understand and improve care.”
August 31 is International Overdose Awareness Day, a global event to raise awareness of overdose and reduce the stigma of a drug-related death.
