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  • Dr.Michael Gordon Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

    The process of prescribing medications, explaining the risks and benefits has classically been the role and responsibility of physicians with support from other health care providers such as pharmacists. In the modern age with the phenomenal expansion of the digital world, the world of the internet has become a major player. It is common for physicians to have to contend with and integrate into their practice the common phenomenon of family members looking at the internet and other sources for information about medications proposed for their loved ones.
    Key Words: internet, medications, information, responsibility.

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  • If one is in medical practice long enough it sometimes seems like that sense one gets when sitting in a waiting room and picking up a years old copy of Time® magazine and not realize that it is years out of date, as many of the stories seem to be the same or very familiar. I have a 30 year old tuxedo which fortunately comes in and out of vogue cyclically which allows me ( as long as appropriate size accommodating alterations have occurred) to keep wearing it without my feeling that I am “out of fashion”.

    The challenges that face all practitioners and family members who care for those living with dementia are myriad. Cognitive impairment and behavioural issues top the list of concerns expressed by families, with the second layer being impairment of activities of daily living which requires assistances in many basic domains. Over the years the approaches to care especially for those with the range of behavioural issues which might range from withdrawn apathy to agitated aggression and disruption of other people’s function and privacy. The latter often becomes a problem in congregate living situations and may lead to crises when the facility expresses concerns about the ability to continue care of others’ lives are negatively affected.

    In this question for methodologies to decrease these negative or as recently renamed “reactive” behaviours, the typical “medical” approach has generally been pharmacological. This has spawned a whole drug-based industry including regulatory attempts to modify and curtail the use of such medications because of evidence-based negative consequences of the medications which are often additional to the risk of the underlying disease itself. Psychologists, social workers, recreational and music therapists have all added over the years various modalities of interventions with the hope that they might individually or in combination might more safely decrease the degree of behavioural problems without compromising the person’s function, dignity and quality of life.

    With this in mind it was refreshing to see recent references to programs in which “doll therapy” was being utilized as a modality to address some of the behavioural manifestations of those living with dementia living in long-term care facilities. The article that brought the program to mind was recently published in the Feb. 3, 2014 web-based article from Nursing Ethics where the focus of the article was on the ethical implications of the intervention more that the efficacy and clinical impact of the use of dolls in BPSD and other manifestations of those living with dementia.

    It is of interest that the focus of this particular article was on ethics rather than clinical outcomes. One can of course implicate ethics in all clinical interventions in terms of goals, benefits and risks as well as the foundational principle of ethics; autonomy, beneficence, non-maleficence and justice. When one thinks of alternative pharmacology based interventions for BPSD it is hard to imagine how they would measure against interventions whose adverse reactions or almost exclusively of an “ethical premise” rather than manifestations that can affect the clinical outcomes of the disorder with significant adverse cardiac and other documented potential side effects as well as movement disorders. Other articles on the subject of doll therapy and other alternative non-pharmacological modalities of intervention for BPSD seem to be less focused on the ethics than on the efficacy of the intervention and the multiple benefits to the general emotional well-being of the individual beyond the issue of BPSD.

    One of the long-term care facilities to which I provide ethics workshops for the staff that cares exclusively for those living with dementia has had a doll therapy program for many years. At Bloomington Cove LTC facility, the range of doll-based interventions includes individual provision of dolls as well as programs in which groups of residents take part in various forms of care-provision and nurturing activities to the dolls which are of a soft and “cuddly” characteristic. The director of the facility believes strongly that the doll-based intervention brings out the natural and at times vivid desire and latent abilities and wish of almost exclusively female residents to express affection, physical nurturing and emotional attachment that clearly is stored in the repository of their brains and personalities which when tapped release positive feelings and actions which can replace the often disruptive reactive states that BPSD often elicits.

    The ethics focus on this intervention which is not new is encapsulated in the Nursing Ethics article which says, “The use of doll therapy for people with dementia has been emerging in recent years. Providing a doll to someone with dementia has been associated with a number of benefits which include a reduction in episodes of distress, an increase in general well-being, improved dietary intake and higher levels of engagement with others. It could be argued that doll therapy fulfils the concepts of beneficence (facilitates the promotion of well-being) and respect for autonomy (the person with dementia can exercise their right to engage with dolls if they wish). However, some may believe that doll therapy is inappropriate when applied to the concepts of dignity (people with dementia are encouraged to interact with dolls) and non-maleficence (potential distress this therapy could cause for family members). The article continues with, “This article suggests that by applying a ‘rights-based approach’, healthcare professionals might be better empowered to resolve any ethical tensions they may have when using doll therapy for people with dementia. In this perspective, the internationally agreed upon principles of the United Nations Convention on the Rights of Persons with Disabilities provide a legal framework that considers the person with dementia as a ‘rights holder’ and places them at the centre of any ethical dilemma. In addition, those with responsibility towards caring for people with dementia have their capacity built to respect, protect and fulfil dementia patient’s rights and needs.”

    In contrast to the ethics focus approach to doll-based therapy another article, published by Carefect, focuses primarily on the beneficence (benefits) impact of such intervention as follows, “Doll therapy provides many benefits for Alzheimer’s patients that engage in it. One of the most important benefits of doll therapy is that it provides Alzheimer’s patients with social interaction and allows them to have the chance to care for someone again instead of just being the person that is being taken care of. Many seniors are calmed by their doll and it can often create a distraction for them from upsetting events. Having a baby doll often reminds Alzheimer’s patients of fond memories of when they were a new parent which can have a very positive effect on them. Many seniors will enjoy rocking their baby doll which can also help them fall asleep if they have trouble sleeping themselves. Family caregivers looking for activities for their loved one can try purchasing baby doll clothes or even actual baby clothes for their loved one to put on the doll. Many of the lifelike dolls are big enough to fit in newborn clothing, so family caregivers can purchase a few outfits for their loved ones to put on their doll. Family caregivers can even consider buying a stroller for the doll so that their loved one can push it around the house and get some exercise while playing with their doll. Many seniors enjoy singing to their doll, so family caregivers can join in or encourage their loved ones to sing on a regular basis. The most important thing though is to make sure that all family members are educated on doll therapy. Many people may find it odd to see their elderly loved one playing with a doll, especially if they were not educated on the way doll therapy works and the benefits of such therapy for people suffering from Alzheimer’s or dementia.”

    What does this mean for those responsible for providing as much as possible sensitive, client-focused, beneficent and the least harmful interventions possible that will allow those living with dementia to experience the least conflict and anguish in their emotional experiences? This should be while promoting as much as possible some semblance of quality of life and emotional connectivity with their world, however distorted or limited as it might be because of their cognitively impaired state. Although as in all aspects of medical and other health care interventions the ethical implications cannot and should not be ignored, we in the healthcare professions must be careful to make sure that our approach is sufficiently balanced with the focus always on the well-being or those we care for and the realization that in a complex world of caring for those with dementia, there may always be some question remaining in the realm of ethics, but these must not supersede the real daily beneficial impact that may accrue to those we collectively care for. Doll Therapy as well as the wide array of alternative therapeutic interventions should be high on our list of considerations as we struggle to make the life of those we care for whose scope of enjoyment and social participation may be limited by their disordered brain functioning.

    This blog was originally published at:

  • For any physician beyond 70 years old, of which I am one, evidence-based medicine as currently configured and taught is a concept that came to us somewhat late in our careers. Despite having a solid scientific education in high school and then later at University even though the latter also exposed me fortunately to a wide range of liberal arts subjects, evidence-based medicine was a late addition to how I configured and digested medical knowledge.

    I studied medicine at the University of St. Andrews (Dundee campus), which is a very old and venerable University and medical school. Dundee which was a remnant of the industrial revolution and pre-war depression during the 1960s when I was there as a medical student and had not risen from the ashes of the end of its core industry, the turning of imported jute into carpet backings: the industry was outflanked by the new synthetic materials that replaced jute in the carpet industry. It was a poor city, with a substantial working class of factory workers and construction workers, with those whose livelihood was from the trades. Because of its connection to the famous University across the Tay estuary and a thriving College of Art and some other fine educational facilities it also had a significant educated and fairly well-off financially tier to its population.

    Medicine was taught in the very old Dundee medical building in the then traditional manner: we had lots of lectures. The lecture halls were very steep with wooden benches and long desks, laboratories with either microscopes for pathology, electrophysiological gizmos that still made recordings on paper that was covered in essence with soot and frequent visits to the autopsy room. Our professors and lecturers varied from well-known authorities who bored us half to death as they in essence read from their only occasionally updated notes, or from their own textbooks if they had written one, to some younger lecturers who tried to bring more excitement into the class, but still provided mostly information/knowledge that one could get from the standard textbooks on the subject they were talking about. When we started our clinical rotations, it was in small groups and as we gathered around the patient with our instructors we listened intently to their knowledge and occasional pearls of clinical and experiential wisdom. What was often heard was, "in my experience" or "it is known that" but virtually never, "the evidence shows" or "the latest meta-analysis of the recent studies on…" reveal that. The idea of using what would now be called evidence-based medicine did not really exist: it entered my own vocabulary and construct of knowledge and translation into practice 15 or 20 years after my graduation in 1966.

    In the early days of the EBM craze I often felt a hiatus in my teaching and learning when most of the educational sessions I attended were peppered with "evidence" often applied to the new medium of the PowerPoint presentation. I realized what I was missing were the "stories" of medicine. I recalled vividly our professor of Medicine who was the Physician to the Royal Family when they sojourned in Scotland: he was a great story-teller. When he gave a lecture, with an anecdote not infrequently with a vivid background of history and geography as its anchor, it was never forgotten with the essential points embedded in the story that became very personal and meaningful as it related to individual people, and not just "groups of study subjects".

    With this in mind I was delighted to see a recent article in the New York Times entitled "Why Doctors Need Stories" ( Even though the focus in this article was on mental health issues and psychiatry, the essence of the article was the importance of stories woven into how doctors practice medicine. For patients it is very important to not just know the "science" and "evidence" of medicine but to understand the physician's personal view and experience with whatever the illness is. Patients very commonly after a physician explains the "evidence" ask, "What in your experience is the best thing to do". That is the question that physicians must be able to answer beyond the "evidence" as personal observations and experience matter a lot not just to practicing physicians, but also to the individual patients they care for. Abraham Varghese the renowned physician author of Cutting for Stone, captures the importance of touch as part of the physician's instruments of care and emphasizes this through the importance of his many narratives in his Ted Talk on the subject (

    At the end of the day, our patients need not just our knowledge, but our wisdom which is beyond the recitation of the "evidence" from the world of science: what they also need are our narratives, our individual and collections of personal observations and experiences. It is those stories, which may include us as the subjects of the tales, to confirm our humanity to our patients, but also give them a link from the science of medicine to the people to whom medicine is meant to serve.

  • As a physician living and practicing in Canada who has worked in a number of countries with universal health care systems, I found a recent article published in the New York Times, ironically humorous in the sad state of American Medicine that it portrayed. The title of the August 30, 2014 article, Coverage for End-of-Life Talks Gaining Ground started with the following quote: "Five years after it exploded into a political conflagration over 'death panels,' the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year." Many of us recall the absurd contention by Sarah Palin, the vice presidential Republican nominee that the government was planning "death panels," which would be tasked with which of our individual patients, including elders, would be allowed to get medical care or forgo it for budgetary reasons. As was written in Politico in June 26, 2012, Palin charged in an August 2009 Facebook post "that the Democrats' health care bill would empower a 'death panel' of government bureaucrats who can decide who lives or dies. The 2009 claim earned Palin Politifact's "Lie of the Year," but she said "that the president's health care law's Independent Payment Advisory Board makes life-or-death decisions."

    Here we are in 2014, and very slowly and incrementally the American public and physicians in general and bureaucrats in the public and private sector are beginning to accept the medical benefits as well as the humanity and respect for individual dignity and autonomy in patient decision-making by supporting (and that usually means funding) discussions by physicians with their patients and often families about end-of-life wishes. In most jurisdictions where the negative stigma of end-of-life planning has been overcome and what is often in the professional circles is called advance-care-planning exists and is supported, there is ample evidence that it serves patients, their families and physicians and allied healthcare professionals well.

    I have not practiced for many decades in the United States but have had to deal with American family members going through end-of-life situations and although not many, I was not overly impressed with the important transformative leap from invasive and technologically prioritized treatments to palliative care philosophy-based decisional options. In Ontario, Canada, in contrast with where I currently work and have done so for many years in both geriatric medicine and palliative care domains, the active discussions about advance care planning and end-of-life preferences and options are ubiquitous and supported by billing codes for such communications with patients and families.

    In my office, a large percentage of my patients have cognitive impairment and are therefore accompanied in most visits by one family member or more. I have found among the many discussions that I have with patients and their families related to the "future" and their wishes I use the following little scenario: I ask the patient if they like ice cream, to which invariably the answer is yes. To personalize the discussion, I then follow with something like "what flavor is your favorite?" After I receive the answer I then ask, "so how would you feel if you could never taste ice cream again, and for that matter never taste anything again? In fact you will not even know if you are eating because there would be a tube in your stomach into which something called a feed—not food as you know it—goes. How would you feel about that? Is it something you might wish for?"

    After many such encounters the vast majority of answers are something along the lines of, "that is nothing I would want." Or, "who would want that?" I then may follow with, "but what if it meant you might not be able to live unless it is done?" to which I usually get back, "but life would not be worth much without being able to taste food, would it?" On rare occasions, I have someone who says something like, "well, it depends" or something like, "it will be left to God's will or whatever the doctors say," but more times than not the idea is rejected quite handily.

    I then tell that family that this is just the beginning of what should be conversations about advance care planning that they and I over time can use to determine what the preferences might be should something happen. Some families say that they have had those discussions, and some say they want to have them but do not know how to start, which leaves an opening for me as a physician to pursue the main categories of advance care planning and end-of-life decision-making talks. They do not have to take lots of time and often it is better to do them piecemeal depending on the cognitive status of the patient.

    The most important message is that these conversations are crucial and I see that played out when patients are admitted to the palliative care unit where most of them, although not all, understand what the stakes are, and are prepared to make the best along with the dedication of the health care professional staff to the focus on symptom management and psycho-social issues rather than being mesmerized by elusive technological treatments during this last period of life. And to refer back to the apparently novel component of this in the American Health Care environment, I and other physicians are reimbursed for the time and effort that goes into these discussions. There are codes in the fee-for-service billing manual for those physician who are not practicing under salaried arrangements, that delineate the time period for discussion blocks and the billing codes and amounts that can be billed. These codes are generally noted in the health care record and when submitted to the health insurance plan for reimbursement the diagnostic code is listed (ie, Dementia, Cancer, end stage heart failure), the meeting or counselling session with patient code and the block of time allotted—and that it is—the payment comes along with all the reimbursements for clinical care provided.

    This is the contemporary standard of practice in this century—it must be unless you believe in immortality. Modern medicine has many "tricks" up its ever-expanding sleeve of treatments. This was dramatically described in an opinion piece in the September 7, 2014 review section of the New York Times. Theresa Brown describes the almost tragic results when physicians are so focused on the latest technology available and thereby lose sight of the importance of a death that is not due to a lack of some new medical wizardry but the nature of all things mortal. Her article, "When It's the Doctor Who Can't Let Go" captures the difficulty some physicians experience when they have to let their patients choose some closure in medical treatment and opt for comfort rather than another short-term usually elusive "cure."

    We, as physicians, must help our patients and their families know when it is time to say enough and to prepare for that moment not in the midst of a crises but when the mind is working calmly and one's values and wishes can be interpreted and then documented for future reference so that the end of one`s life is as dignified and supported medically with proper symptomatic care as possible.

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  • When I tell people that what I do professionally...

  • I have for many years enjoyed my family name, Gordon, and all the connections I can make with it. I learned when I was quite young, from my paternal grandfather that the name had been ours for many generations and had not been changed as had those of my childhood friends. I had stored that knowledge deep into the recesses of my memory. When I decide to study medicine in Scotland, the name became a talking point, as everyone assumed that with that name I must in fact have Scottish ancestry. I could only explain that the name was genuine, unsullied by arbitrary or deliberate alteration by American immigration authorities when my grandfather arrived from a small village in Lithuania.

    It was only some years later, during my first trip to Israel that I read a history of Russia by a Scottish historian. There I found a reference to the likely origin of the Jewish Lithuanian and by dint of migration Russian Gordons. It was Peter the Great's desire for territorial expansion that led him to hire a militarily brilliant Scottish mercenary general by the name of Patrick Gordon. It was General Gordon, who successful in many Russian expansionist battles ultimately became a close friend and confidant of the Tsar. A well detailed biography of Peter the Great by Robert Massie explains how Gordon's death was mourned by the Tsar as a loss to his empire. During the later emancipation process, when Russians adopted family names, it appears that my ancestors, in deference and regard to the Tsar's great friend took on the name Gordon. Although there are varying iterations on the origins of that name in Jewish Russian/Lithuanian history, this narrative has always seemed to me to be the most credible.

    During the pogrom-dominated anti-Jewish period in Russia around the turn of the 20th century many Jews left Russia, including my ancestral village of Eysheshuk I near Vilna and made their way to the United States, then British Palestine and South Africa. When I was sitting my oral examination in Midwifery in Dundee Scotland, then still part of the University of St. Andrews, my examiner was the "prof" (professor and head of the department) himself. As I sat down he said, "You're the Yank" in his mellifluous Scottish dialect which by this time had become music to my Brooklyn English ears. "Surely" he continued, "with a name like Gordon, you must be Scottish." I responded with a "yes and no, but if you would like to hear the story, I would be happy to tell you." He nodded yes and with my eye on the clock above his head, ticking out the 10 minutes of oral examination time, I recounted the tale. With 30 seconds left, he interrupted with "Oh dear, Oh dear, we're running out of time, followed by 'give me three symptoms or signs of eclampsia'". I knew the answer "cold" as it was one we all prepared for knowing how important the subject was. As I turned to leave the room I saw him write a 10 and say, "very good, very good" in broad Scottish.

    That event resulted in a prize in midwifery much to the shock and surprise of my classmates as it was not my "strong" subject. With the 500 pounds I spent 5 months doing midwifery and gynaecology at the Rambam Hospital in Haifa, which resulted in epiphany in my life which circuitously resulted in Aliyah some years later. My return to North America and settlement in Canada is complex but I have always responded to the name Gordon with the question to determine if the person was perhaps a landsman and if they are aware of the history of the name. This has resulted in many warm interactions and sharing of family histories.

    This was personified on a recent invitation to Vancouver to attend a conference as a presenter. After the acceptance I received a request to attend a meeting of the newly established Vancouver chapter of the Israel Medical Association, having been involved in the Toronto chapter for many years. Once accepted I received an email form Dr. Paula Gordon, a Vancouver radiologist who trained at Mt. Sinai Hospital early on in my career as a clinical teacher.

    At the IMA meeting, Dr. Marla Gordon, an elder-care focused primary care physician at whose house we were meeting introduced herself and reminded me that years earlier she had asked me via-email about my knowledge of the derivation of our name. Also at the meeting was Dr. Rhona Gordon, a family physician with a major focus in Obstetrics and newborn care, is married to the president of the Vancouver IMA. We spent much of the post-meeting time comparing our family histories and our understandings of the movements through Europe and North America of our respective Gordon families. We concluded the we were for sure Landsman (a Yiddish term for people of the same geographic area—which in 18th and 19th century Eastern Europe usually meant the same village or district. I could add these three to other Gordons living in Israel who also I knew as émigrés from Eyshoshuk or other parts of Lithuania.
    This experience reminded me of the importance of keeping people with cognitive impairment as grounded as possible with ideas, events, people and associations that they can relate to and which are meaningful. The use of photographs is very important in helping those living with dementia relate to important people and events in their life. The nice thing about the use of photographs is that they can be shown and discussed time after time without the person getting bored as they may have little recollection of having looked at the pictures recently. ( It has been shown that familiar and personal music is also useful to those living with dementia and the fact that the person can related to their music has been demonstrated to bring back important memories that may result in revitalization of the person even within the context of dementia and may also be useful when dealing with behavioural issues such as agitation (

    What could be defined and an expansion of one's historical connections also resulted in a recognition of the importance of individual roots and relationships. As physicians dealing with dementia we should also try and explore and find those aspects of our patient's lives and experiences with which they can connect, and if we can add to or enhance that connection, all the better for a fulfilling and meaningful and ultimately more successful clinical experience—for the patient and for the physician.

  • When one thinks of music and movement, the natural association is dance. In all parts of the world and in all cultures, there is some musical expression through dance, ranging from what may appear to be relatively simple rhythmic movements to compelling drum beats to complex ballets with narratives and dozens if not more dancers doing intricate steps to full blown orchestras. Anyone that has raised children recalls how even very young children, will move and shake to rhythmic music and the massive industry in all western countries of dance lessons starting with child students attests to its natural attraction and ability to fulfill what appears to be an intrinsic human desire.

    I recall as a child being taken to ballet, modern dance, musicals with dance and even the renowned Rockets at the Radio City Music Hall by my mother who herself had been a serious amateur dancer in her youth and then a lifelong ball-room and late-life folk dancer with her seniors' centre on West End Avenue in Brooklyn. There was even a period of my pre-teen years when my mother attempted to teach me ballet steps at home which very soon was transposed into my desire to learn to dance to Rock and Roll, using my sister four years my junior as my every accommodating dance partner. Even many years after, in our mature and pre-senior years, at family celebrations we often could still do a dance number to something of the order of Rock Around the Clock or the theme song for Saturday Night Fever. She has continued to engage with multi- cultural folk dancing whereas I have slowed down considerably in my abilities to participate although I enjoy watching others, dance especially my children and more recently my granddaughters.

    The general assumption probably held by most individuals that with physical and especially neurological disability, the ability to engage or think about participating in dance would likely naturally diminish. For people living with conditions that impose physical challenges to free and fluid movements, the idea of dancing is more often a dream than a reality. It is likely that it would not even enter the consciousness of most people with neurological disorders, especially those like Parkinson's Disease might be able to participate in, respond to and benefit from music, especially when it is within a framework of dance.

    With this in mind the recent article in October 25th issue of The Globe and Mail, by Gayle MacDonald, "Unlocking the secret of Dance" was exhilarating and inspiring. In a partnership with the world-renowned Canada's National Ballet School, with the collaboration and influence of some its most prominent members and in a cooperative effort with among others Toronto's York University and my own Baycrest Geriatric Health Care System, it is hoped that in addition to the great joy satisfaction that all the participants appear to be getting from the program, scientific research studies will demonstrate the mechanism of responsiveness and hopefully clinical improvement.

    Dance appears to provide a number of benefits to those living with Parkinson's disease which affects seven million people world-wide including approximately 100,000 in Canada and a million people in the United States. It has been established that dance improves characteristics like balance, gait, posture and other physical measurements beyond the social joy and satisfaction from what is in essence a group and social undertaking. Studies are underway to try and determine what the dance does to the brain and the mechanisms by which improvements may occur and whether or not they are sustainable and may be an important adjunct to commonly used medication therapies that are not without their problems.

    It has been well known for many years that those living with Parkinsonism can improve their gait by listening to rhythmic marching-type music and some have learned to use ear-phone-directed march music from iPods and other similar devices to provide the compelling rhythmic background to assist in their walking. (Neuroscience and Biobehavioral Reviews: Into the groove; Can rhythm influence Parkinson's disease? Cristina Nombela, Laura E. Hughes, Adrian M. Owen, Jessica A. Grahn, 2013. In my own practice I have often taken my patients with such movement disorders and while walking with them up the corridor outside my office I hum loudly a well-known John Philip Sousa March, The Stars and Stripes Forever which most people recognize. Quite a lot of the patients and the family are amazed how all of a sudden the person who had been struggling with gait and speed would be walking alongside me to the loudly hummed musical refrain. If the result is good I instruct the person or family member to get some recordings of such marches or others if they are ones that resonate and put them on an iPod type device and place the march when the person wants to go for an enjoyable walk, for the purposes of actual exercise, or as one might in a garden or along a neighbourhood street.

    If this Parkinson's ballet dance project proves successful it may result in a wide range of programs that bring dance and music to many individuals living with Parkinson's disease and provide a creative and satisfying and in many ways liberating enterprise for them.

  • In North America, although Canada and the United States are separate countries, and each State and Province have their own areas of jurisdictional responsibility, both countries share the legal formulation that Supreme Court rulings set precedential interpretations of the law. Jurists, lawyers and legislators on both sides of the border often draw freely from each other's jurisprudence. Thus, the recent Rasouli decision by the Canadian Supreme Court should make physicians and policy makers on both sides of the border look carefully at the ruling's implications.1 It would then be prudent for those given the mandate to protect at the same time the integrity of responsible, ethical and professionally sound health care to avoid the potentially negative impact this current ruling can have on patients at the end of life and those whose professional duty is to assure the most humane care possible.

    As gracefully and forcefully explained and commented on by one of Canada's foremost ethicists, Arthur Schafer, the potential implications for the future of health care are profound. To quote, "The Supreme Court of Canada's 5-2 decision in Rasouli is a clear victory for the family. Sadly, it is a loss for common sense and common humanity. It is also a blow against physician integrity and potentially damaging to the Canadian health-care system."2 As Schafer explains in his article, "The salient facts in this case are these: Hassan Rasouli has been unconscious and on life support since October, 2010. He is in a near-vegetative state with no realistic prospect for recovery. Although his body will inevitably deteriorate further, he can be kept alive, almost indefinitely, in a hospital intensive-care unit: He needs a tube down his throat so that he can breathe, a catheter in his bladder, large central tubes for fluids and medications, frequent surgical removal of infected skin tissue to prevent gangrenous infections, suctioning of his lungs to remove fluids that would choke him".

    As Schaffer notes, "Mr. Rasouli's physicians propose that he should be given palliative care instead of life support. Continued ICU treatment is not merely "futile"; it is actively harmful. It can keep him alive, of course, but life is not an absolute value. Physician ethics does not permit procedures which on balance are harmful to the patient. Mr. Rasouli's wife, Parichehr Salasel, insists that her husband, as a devout Muslim, would want to be kept alive, even in these circumstances. She is his substitute decision maker (SDM or in American parlance Proxy for Health Care Decisions) and she refuses to consent to his discharge from the ICU and transfer to a palliative care program.

    The judicial nuances and arguments in this case are not as important as the ultimate decision which was that according to the Supreme Court life support can be discontinued only with the consent of the patient or the SDM (proxy). Of equal interest of "rights" of patient autonomy is the hard fact that according to Schaffer, "in Canada, care in an ICU costs almost $1-million a year, per patient. Understandably, the number of ICU beds is limited and admission is strictly controlled." The numbers in the United States would be higher as almost all health care costs in the United States are substantially higher than their comparable cost in Canada.

    The salient argument of Schaffer and one which appears already to resonate through the medical community as well as the administrators of hospitals is that, "The purpose of critical care is to save the life of the patient until the patient can recover to be discharged. The ICU is not intended for patients who can never recover. At present, critical-care doctors err on the side of admission. If they later discover that continued life support is futile, then the patient is discharged and receives palliative care instead."

    If that equation is no longer assured, it could be that there will be a reluctance on the part of ICU physicians to admit patients who have small or marginal chances of ICU benefit if the risks are that treatment will have to be maintained long past the ability of the health care system to provide a degree of meaningful return to function—the use of religious standards could potentially endanger the integrity of the health care system; what limits can one then put on any religious belief that demands continued medical treatment no matter what the anticipated clinical outcome—modern medicine can keep organs going for a very long time.

    As Schafer points out and something that is not addressed adequately by this current ruling but which is one of the foundational ethical principles on which modern medical practice is built is distributive justice. As he notes, "One person's provision is another person's deprivation." It is not hard to imagine a situation where a clinical situation was like Rasouli when the decision was made to admit him to the ICU. What if he had to been deprived of that admission and chance of recovery because another patient like Rasouli is now and whose family demanded continued treatment despite what many would deem to be futile or at least clinically non-beneficial treatment. One can imagine the implications of a patient dying because of ICU deprivation because of someone whose use of the ICU is outside it designated mandate.

    Schafer's final conclusion is, "Cases such as those involving Mr. Rasouli…are comparatively rare. With sympathetic discussion and dialogue, a consensus can usually be reached. But in those cases where agreement is impossible to achieve, physicians are entitled to exercise their professional judgment. If the family disagrees, they can appeal to the courts." That is what happened in this case and the result is now part of the new equation of health care decision making.

    The potential consequences remind me of a conversation I had some years ago with an American obstetrician and gynaecologist who said he had given up obstetrics because of the number of legal negligence cases he was handling at any given time. As he indicated, "Not having a perfect baby is always followed by a negligence or malpractice charge and even if at the end I am vindicated, the stress on my life in addition to my enormous malpractice insurance premiums are just much for me. I will just do gynaecology" Even for those who believe that births should be "natural" and promote the greater use of midwives, when things go wrong, it is physicians who provide the salvage. If they no longer will take on that role….it is the public, the potential mother and child who will be the victims.

    For those of us who do eldercare and long-term care, what we can do is try to promote advance care planning in a way that assures that people address their future wishes and values and make sure SDMs and proxies will carry out their wishes and they really do understand the implications of their decisions. If one cannot be sure a proxy will indeed carry out the instructions it might be necessary to appoint an impartial person rather than a family member so that the emotional impact of what are often heart-wrenching decisions can be made according to ones' expressed wishes and values.


    1. Handelman M. Consent to Life Support: What the Supreme Court Said in Cuthbertson and Rubenfeld v.Rasouli
    2. Schafer A. Right-to-die ruling: Win for families, loss for common decency. The Globe and Mail, Oct. 18 2013
    3. Youn A. Health care act's glaring omission: liability reform. CNN, October 5, 2012
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