Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Hospital policies on life-sustaining treatments and advance directives in Canada.

OBJECTIVE: To determine the prevalence and content of hospital policies on life-sustaining treatments (cardiopulmonary resuscitation [CPR], mechanical ventilation, dialysis, artificial nutrition and hydration, and antibiotic therapy for life-threatening infections) and advance directives in Canada. DESIGN: Cross-sectional mailed survey. SETTING: Canada. PARTICIPANTS: Chief executive officers or their designates at public general hospitals. MAIN OUTCOME MEASURES: Information regarding the existence of policies on life-sustaining treatments or advance directives and the content of the policies. RESULTS: Questionnaires were completed for 697 (79.2%) of the 880 hospitals surveyed. Of the 697 respondents 362 (51.9%) sent 388 policies; 355 (50.9%) sent do-not-resuscitate (DNR) policies (i.e., policies that addressed CPR alone or in combination with other life-sustaining treatments). Of the 388 policies 327 (84.3%) addressed CPR alone, 28 (7.2%) addressed CPR plus other life-sustaining treatments, 10 (2.6%) addressed advance directives, and the remaining 23 (5.9%) addressed other life-sustaining treatments. Of the 355 DNR policies 1 (0.3%) stated that routine discussion with patients is required, 315 (88.7%) restricted their scope to terminally or hopelessly ill patients, 187 (52.7%) mentioned futility, 29 (8.2%) mentioned conflict resolution, 9 (2.5%) and 13 (3.7%) required explicit communication of the decision to the competent patient or family of the incompetent patient respectively, 110 (31.0%) authorized the family of an incompetent patient to rescind the DNR order, 224 (63.1%) authorized the nursing staff to do so, and 217 (61.1%) authorized physicians to do so. CONCLUSIONS: Although about half of the public general hospitals surveyed had DNR policies few had policies regarding other life-sustaining treatments or advance directives. Existing policies could be improved if hospitals encouraged routine advance discussions, removed the restriction to terminally or hopelessly ill patients, scrutinized the use of the futility standard, stipulated procedures for conflict resolution, explicitly required communication of the decision to competent patients or substitute decision-makers of incompetent patients and scrutinized the provision allowing families and health care professionals to rescind the wishes of now incompetent patients.     

Sharing death and dying: advance directives, autonomy and the family

This paper critically examines the liberal model of decision making for the terminally ill and contrasts it with the familial model that can be found in some Asian cultures. The contrast between the two models shows that the liberal model is excessively patient-centered, and misconceives and marginalises the role of the family in the decision making process. The paper argues that the familial model is correct in conceiving the last journey of one's life as a sharing process rather than a process of exercising one's prior or counterfactual choice, and concludes by suggesting a policy framework for the practice of familialism that can answer the liberal challenge that familialism cannot safeguard the patient from abuse and neglect.     

Anorexia nervosa,advance directives,and the law: A British perspective

This article will explore whether the law should allow people with anorexia nervosa to refuse nutrition and hydration with special reference to the English decision in Re E (Medical Treatment: Anorexia). It argues that the judge in that case made the correct decision in holding that the patient, who suffered from severe anorexia nervosa, lacked capacity to make valid advance directives under the Mental Capacity Act 2005 of the United Kingdom, and that medical procedures that are apparently against her wishes should be carried out for the sake of preserving her life. The law should generally not permit patients with anorexia nervosa to decline nutrition and hydration, precisely because their autonomous ability to make such decisions has been substantially circumscribed by this psychiatric condition.     

The paramedic ambulance: a Canadian experience.

Prehospital critical care provided by specially trained ambulance attendants in New Westminster, BC during a 27-month period was studied. Although the most important benefit of the improved care was the prevention of sudden death in a large proportion of persons with crises due to coronary artery disease, the skills learned to provide basic life support are applicable to a wide variety of other disorders that can result in death before the patient reaches hospital.     

Wetland mitigation and compensation: Canadian experience

Since Canada’s accession to the Ramsar Convention on Wetlands in 1981, the nation’s commitment to wetland conservation and management has increased significantly. This includes the adoption of one of the World’s first national wetland conservation policies by the Government of Canada, and the adoption of complementary policy and legislative initiatives by most of the 13 provincial and territorial jurisdictions. Numerous habitat ‘no net loss’ and environmental assessment policies, regulations and guidelines for incorporating mitigation processes into development decisions affecting wetland resources are used throughout Canada. The governments of Canada and six provinces have so far adopted wetland mitigation measures. These are in addition to comprehensive wetland fish and wildlife habitat initiatives, such as the species and habitat joint ventures delivered in Canada through the North American Waterfowl Management Plan by all jurisdictions and numerous non-government partners. This paper examines the current policies, regulations and programs, as well as past implementation experience with wetland mitigation and compensation in Canada.     

Therapeutic abortion and its psychological implications: the Canadian experience.

Approximately 9 months after a legal therapeutic abortion, 188 Canadian women were interviewed. One half were single and the rest were married, separated or divorced. They were matched closely for a number of demographic variables with control women who had not had abortions. Neurotic disturbance in several areas of personality functioning was assessed from questionnaire responses. Out of 27 psychological scales, differences between the abortion and control groups were found on only 3: in general, women who had had abortions were more rebellious than control women, abortion tended to be associated with somewhat greater depression in married women, and single women who had had abortions scored higher on the shallow-affect scale. However, all the personality scores were well within the normal range. Perceived social support was strongly associated with favourable psychological reactions after abortion. Use of contraceptives improved greatly after the abortion, when over 90% of women reported using contraceptives regularly.     

Ruptured uterus in pregnancy: a Canadian hospital's experience.

Between 1966 and 1985, 15 cases of complete rupture of the uterus in pregnancy were identified among 52,854 deliveries at Foothills Provincial General Hospital, Calgary, for an incidence rate of 0.3 per 1000 deliveries. Previous cesarean section (in seven patients) was not the only predisposing factor: a history of dilatation and curettage (in two patients) or laparoscopy (in one) were also implicated. Long, obstructed labour did not appear to be a factor. Rupture also occurred in patients at low risk. The most frequent immediate complication was hypotension, in five patients. The rupture site was repaired in 11 of the patients; the other 4 underwent hysterectomy. Close surveillance and prompt intervention are the keys to good fetal and maternal outcome.     

Recent trends in neonatal mortality: the Canadian experience.

In Canada between 1958 and 1977 the neonatal mortality dropped by more than 50%. the decline was most prominent from 1963 and was almost entirely due to an improvement in neonatal birthweight-specific mortality, which suggests an improvement in perinatal medical care. The timing and pattern of the decline are similar to those reported for the United States. There was a transient increase in the incidence of low and very low birthweight in both countries in the late 1960s. The cause of this increase remains unexplained.     

Caffeine: a well known but little mentioned compound in plant science.

Caffeine, a purine alkaloid, is a key component of many popular drinks, most notably tea and coffee, yet most plant scientists know little about its biochemistry and molecular biology. A gene from tea leaves encoding caffeine synthase, an N-methyltransferase that catalyses the last two steps of caffeine biosynthesis, has been cloned and the recombinant enzyme produced in E. coli. Similar genes have been isolated from coffee leaves but the recombinant protein has a different substrate specificity to the tea enzyme. The cloning of caffeine biosynthesis genes opens up the possibility of using genetic engineering to produce naturally decaffeinated tea and coffee.     

Sexual knowledge and attitudes of general practitioners in Wessex.

A survey of the sexual attitudes and knowledge of general practitioners in Wessex found that GP trainees and those in practice for less than 10 years were less conservative and better informed than doctors in practice for 20 years or more, The results suggest that the attitudes of the doctors are determined by their early environmental influences rather than their clinical experience.     

First-year family medicine residents' use of computers: knowledge,skills and attitudes.

OBJECTIVE: To identify the computer knowledge, skills and attitudes of first-year family medicine residents. DESIGN: Cross-sectional survey of family medicine residents during the academic year 1993-94; sampling began in July 1993 and ended in October 1993. SETTING: Canada. PARTICIPANTS: All 727 first-year family medicine residents, of whom 433 (60%) responded. OUTCOME MEASURES: Previous computer experience or training, current use, barriers to use, and comfort with and attitudes regarding computers. RESULTS: There was no difference in age or sex between the respondents and all first-year family medicine residents in Canada. French-speaking respondents from Quebec were underrepresented (p < 0.001). Only 56 respondents (13%) felt extremely or very comfortable with computer use. The most commonly cited barriers to obtaining computer training were lack of time (243 respondents [56%]) and the high cost of computers (214 [49%]) but not lack of interest (69 [16%]). Most residents wanted more computer training (367 [85%]) and felt that computer training should be a mandatory component of family medicine training programs (308 [71%]). CONCLUSIONS: Computer knowledge and skills and comfort with computer use appear low among first-year family medicine residents in Canada, and barriers to acquisition of computer knowledge are impressive. Computer training should become an integral part of family medicine training in Canada, and user-friendly applicable computer systems are needed.