Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child''s refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children''s consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.     

Involuntary commitment in Ontario: some barriers to the provision of proper care.

The Ontario Mental Health Act, as amended in November 1978, provides strictly defined criteria for involuntary commitment for psychiatric assessment; the assessment can last up to 5 days. These criteria fail to cover a number of patients who are, in the author''s opinion, in need of compulsory assessment or treatment. Four cases in which there was serious difficulty in giving proper care are described in this paper. The difficulties are discussed and improvements in the criteria for involuntary assessment recommended.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

Detecting and managing elder abuse: challenges in primary care

OBJECTIVE: To determine family physicians'' perceptions of barriers and strategies in the effective detection and appropriate management of abused elderly people. DESIGN: Questionnaire survey; the protocol included an advance notification letter and 3 follow-up mailings. SETTING: Regional Municipality of Hamilton-Wentworth, Ont. PARTICIPANTS: All active nonspecialist physicians who reported seeing elderly patients in their practices were eligible for inclusion. Fifty health service organization (HSO) physicians were randomly selected from among those listed with the HSO Mental Health Program, and 200 fee-for-service physicians were randomly selected from the Canadian Medical Directory. Of the 189 eligible physicians 122 returned completed questionnaires, a response rate of 65%. OUTCOME MEASURES: Physicians'' ratings of the importance of potential barriers in assisting older people experiencing abuse and of the usefulness of strategies for dealing with elder abuse. RESULTS: Physicians identified the following barriers as fairly or very important: denial of abuse, resistance to intervention, not knowing where to call for help, lack of protocols to assess and respond to abuse, lack of guidelines about confidentiality, fear of reprisal, and lack of knowledge of the prevalence and definition of elder abuse. Strategies deemed to be helpful included a single agency to call, a directory of services, a list of resource people, an educational package, guidelines for detection and management, reimbursement for time spent on legal matters, continuing education, revision of fee structure and a central library of resources on elder abuse. CONCLUSION: Although the physicians perceived numerous barriers to their detection and management of elder abuse, they identified many strategies that could be implemented at a local level. Preparation of an algorithm to help physicians is the next phase of this work.     

Death of phone service indicates Canadians not willing to pay for medical advice

The two physicians who started Canada''s first national pay-per-use medical-advice line closed the service after determining that Canadians are not willing to pay directly for their medical services. The issue of public versus private payments will likely be raised during the CMA''s annual meeting later this month.     

Interest in physician-buyout packages grows as more doctors contemplate retirement

Provincial governments are turning to voluntary retirement programs, buyouts and phase-outs to help manage physician supply. Demographic data show that in 1996 nearly 27% of Canada''s active physicians were aged 55 or older and that the average age of retiring physicians was 68. Although 1 goal of such programs is to give willing older physicians the financial ability to retire, provinces also hope to do away with some billing numbers.     

Withholding consent to lifesaving treatment: three cases.

The refusal of children or their parents to consent to treatment that professionals regard as essential always results in a dilemma. Responding to such refusals demands careful and sensitive clinical and thicolegal intervention and close cooperation among professionals, in particular doctors and social workers. Since the introduction of the Children Act 1989 the number of cases in which children have withheld consent to lifesaving treatment has risen, and it is now increasingly recognised that children have a right to have their views legally represented if a local authority or health authority seeks a court''s leave to carry out treatment. Professionals have to consider which legal route, under either the Children Act or the Mental Health Act, is likely to be best for the individual child.     

Physician perspectives on resuscitation status and DNR order in elderly cancer patients

Aim

To evaluate the process of placing DNR order in elderly cancer patients in practice and analysis of physician perspectives on the issue.

Background

Decision not to resuscitate (DNR/DNAR) is part of practice in elderly cancer care. Physicians issue such orders when a patient is suffering from irreversible disease and the patient''s life is coming to an end. Modern practice emphasises the need of communication with the patients and their relatives while issuing a DNR. The decision making process of placing DNR can be quite daunting. The moral and ethical dimensions surrounding such a decision make it a contentious topic.

Materials and methods

We searched the literature to find relevant works that would help physicians and especially the junior health care staff in dealing with the complexities. In this article, we discuss the issues that physicians encounter whilst dealing with a DNR order in elderly cancer patients.

Results

There are no objective adjuncts or guidelines directed towards the approach of placing a DNR in elderly cancer patients. Better communication with the patients and relatives when making such decision remains a very important aspect of a DNR decision. Most health care staff find themselves ill equipped to deal with such situation. Active training and briefing of junior staff would help them deal better with the stresses involved in this process.

Conclusion

There are complex psychosocial, medical, ethical and emotive aspects associated with placing a DNR order. Patients and their loved ones and the junior staff involved in the care of patient need early communication and briefing for better acceptance of DNR. Studies that could devise or identify tools or recommendations would be welcome.     

The road to Wisconsin

In this article Lynne Sears Williams of Calgary describes her family''s decision to leave for the US, where her husband, Dr. Jim Williams, will pursue his career in family medicine. The decision was not made easily, she writes, but eventually a love for Canada was outweighed by her husband''s desire to practise medicine without the financial and other constraints facing physicians in Canada.     

A question of care

The physicians and nurses who care for Canada''s cardiac patients are highly regarded for their technical competence. However, Henry Comor wonders if they now place too much emphasis on the science of medicine and too little on its art. His observations follow a quadruple bypass operation.     

Agricultural medicine: fighting health hazards down on the farm.

The delegation of a medical act to persons other than physicians may be appropriate in certain restricted circumstances in the interests of good patient care and efficient use of health care resources. The CMA''s Guidelines for the Delegation of a Medical Act were established to help physicians when they decide to delegate a medical act to a person other than a physician. Such delegation does not absolve the physician of responsibility for the care of the patient; it merely widens the circle of responsibility for the safe execution of the procedure.     

The Social Background and Finances of Medical Students at Dalhousie University

Factors that may affect the supply of physicians in the Atlantic Provinces were examined by studying the social and financial background of Dalhousie medical students. In contrast to the regional population, they were predominantly of city origin and from well-educated, well-to-do families. Their median annual costs were $1915 for single and $4420 for married students. Earnings and family contributions each furnished about a third of the single student''s funds. The wife''s earnings constituted one-third, and the largest single source, of the married student''s funds. Loans accounted for 18% and 12% respectively of their income. Twenty-two per cent of students had had some interruption of their pre-medical studies for financial reasons.The major unknown factor in the problem is the number of qualified and aspiring students who do not reach medical school.Direct governmental subsidization of the medical student may well be necessary if the increasing need for physicians is to be met.     

Concern mounts as transfusion medicine loses its lustre

Transfusion medicine is in trouble. Several factors, ranging from the tainted-blood scandal to changes in the way the system operates, mean that young physicians are avoiding the specialty. Dr. Antonio Giulivi of the Red Cross says the issue is serious because these specialists act as the system''s overseers, and this fact won''t change when the Red Cross gets out of the blood business in September.     

Understanding of elderly patients' resuscitation preferences by physicians and nurses.

We compared the understanding by family physicians and nurses of their elderly outpatients'' preferences for cardiopulmonary resuscitation and mechanical ventilation under 3 scenarios reflecting varying qualities of life. Physicians and nurses correctly predicted patients'' treatment preferences in from 59% to 84% and 53% to 78% of cases, respectively, for the various decisions. For most decisions, neither physicians nor nurses were significantly more accurate in their predictions than expected by chance alone. Moreover, nurses and physicians did not significantly agree with one another in their predictions of patients'' preferences for any of these decisions. These results suggest that while nurses'' and physicians'' perceptions of patients'' preferences for life-sustaining treatment are not necessarily similar, neither nurses nor physicians systematically understand their elderly patients'' resuscitation preferences.     

The Formation and Function of the Children's Psychiatric Research Institute,London, Ont

The Children''s Psychiatric Research Institute was established in February 1960 by the Mental Health Branch of the Ontario Department of Health. Its formation was the result of co-operative efforts by the Ontario Association for Retarded Children, the University of Western Ontario and the senior members of the Mental Health Division of the Ontario Department of Health. It was established in London, Ontario, because of the interest in research in this area of medicine on the part of the University of Western Ontario Faculty of Medicine.Children suspected of being mentally retarded are accepted on referral by physicians or social agencies in southwestern Ontario. A multi-discipline team examines these patients for causal pathology, levels of function at intellectual, social and emotional parameters, and family relationships and reactions. In-patient facilities are available if required for additional investigation. The opportunity provided by the Institute and its patients for research and teaching is utilized through its close relationship with the University of Western Ontario. A postgraduate course in problems of mental retardation is offered to interested physicians.     

Volunteers,doctors take palliative care into the community.

The face of palliative care is changing. In Ontario''s St. Catharines region there has been a concerted effort to make it more of a community-based procedure. A local college even teaches a 2-year course in palliative care. The trend is expected to continue because Canadians are living longer, and more frail elderly people will be dying at home. Dr. Sandra Hartman, a palliative-care consultant, says physicians interested in palliative care must remember that there is more to it than providing medical assistance. She considers bereavement counseling for the patient''s family a necessary part of follow-up preventive care.     

COMMUNITY MENTAL HEALTH SERVICES—Operation in San Jose

Recent attempts to cope with the growing and costly problem of mental illness are progressively emphasizing prophylaxis and early detection and treatment. California has joined this trend forcefully since the passage of the Short-Doyle Act in 1957.San Jose is one of the communities with a Community Mental Health program, financed 50 per cent by the local government and 50 per cent by the State of California. It implements its program by offering consultative services to the city''s public health nurses, police officers, teachers, social workers, ministers, sanitarians and members of staffs of a number of public and private agencies.Results of the program have been: (1) Increased demand for education in mental health; (2) growing number of requests for case consultation in lieu of patient-referral to already overburdened psychiatric facilities, and (3) growing recognition by consultees of the importance of their own self-awareness.     

Trends in the Supply and Distribution of Physicians in Saskatchewan: January 1962 to June 1964

Using all the readily available sources of information, a study was designed to describe the changes in supply and distribution of physicians in Saskatchewan during the inception of the Province''s controversial Medical Care Insurance Act. Baselines were obtained in January 1962, and comparisons made in June 1963 and June 1964. The physician:population ratio was 1:1037 in January 1962 and 1:980 in June 1964. The average yearly physician turnover rate of 10% was exceeded in 1960 and in 1961 and then levelled off. The levelling off continued from January 1962 to June 1963. But between June 1963 and June 1964 the total number of physicians was sufficient both to re-establish the rising trend of the previous decade and to offset some of the losses of 1960-1962.     

MDs seen as key players in move to encourage active living in Canada

Despite participACTION''s preaching about the need to stay physically active, only a small percentage of Canadians exercise regularly at the level recommended for fitness. Nicole Baer discusses the issue with physicians and experts in the field, and also looks at American efforts to introduce Physician-based Assessment and Counselling for Exercise.