In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called "Levels of Intervention" (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form's use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.

Different care settings in Quebec use levels of medical intervention forms, also called levels of care (LOC), to determine the code status of patients and to improve end-of-life care planning. It is not currently possible to know whether the levels of care in hospitals benefi t patients and staff in facilitating the decision making process of treatment options and resuscitation measures. No study, to the best of the authors' knowledge, has been published about LOC, particularly in Quebec and Canada. This literature review was undertaken on levels of care in order to clarify this topic. Relevant articles are discussed under different themes that are pertinent to LOC. The themes addressed in this article include care at the end of life, do-not-resuscitate orders, treatment withdrawal, and decision making at end of life. RÉSUMÉPlusieurs milieux de soins au Québec utilisent des formulaires de niveaux d'interventions médicales (NIM) ou de niveaux de soins afi n de déterminer le statut de code des patients et d'améliorer la planifi cation des soins en fi n de vie. Il est actuellement impossible de savoir si les NIM font bénéfi cier les patients et le personnel en centre hospitalier d'une prise de décision plus facile à l'égard des traitements offerts et de la réanimation car aucune étude, à la connaissance des auteures, n'a été publiée à leur sujet, particulièrement dans un contexte canadien et québécois. Une recension des écrits fut entreprise au sujet des NIM afi n d'éclaircir le sujet, et les articles conservés sont discutés sous des thématiques liées aux NIM. Les thèmes abordés sont les soins en fi n de vie, les ordonnances de non-réanimation, l'arrêt de traitement et la prise de décision en fi n de vie.

confusion observed among U.S. parents, even those generally supportive of vaccination (Kennedy et al. 2011). The time and resources spent by the public health community debunking claims of the alleged risks and overstated benefits of vaccines may actually perpetuate these concerns, a variation of the "backfire effect" described by Nyhan and Reifler (2010). Likewise, time spent defending vaccines and vaccine policies, including mandatory vaccination requirements, is time not spent making the positive case for the clear benefits of vaccination for individuals and communities.Childhood vaccination requirements in the United States have been described as a "safety net" that, in tandem with comprehensive promotional and educational activities, helps to ensure high vaccination rates when substantial support for vaccination already exists (Abramson and Pickering 2002). Influenza vaccination requirements ought to be understood similarly, supplementing, but not replacing, concurrent efforts to build support for vaccines and confidence in their safety, necessity, and value among HCP. The more that mandatory vaccination becomes the public "face" of U.S. vaccination efforts, the greater the impediments are to preserving and growing this vital trust in vaccines and vaccine policy. Even if evidence, experience, and ethics justify the current use of mandatory influenza vaccination policies for health care personnel, the need to employ these measures may suggest that the time has come to dramatically reimagine U.S. vaccine promotion and education, seeking to establish a new vaccine narrative for a new era in medicine and public health.

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