This document summarizes a talk on end of life issues in healthcare. It discusses the aging population in Canada, the rise of chronic diseases, lack of access to primary care resulting in overcrowded ERs. It covers challenges around DNR orders and medical futility. It also discusses debates around doctor assisted suicide and palliative care.

1. White Coat, Black Art
Health
Professionals
open up about
their profession
End of Life
From My Side
of The Gurney
End of Life Public Forum
Steelworkers Hall, Sudbury
Dr. Brian Goldman
January 9, 2014

2. Empathy Gap

3. Silver Tsunami!
Seniors: fastest
growing
population
segment in
Canada
• 2008: 4.2 million
•
Canadians > 65
• 2050: 1/4 Canada’s
population
Statistics Canada

4. Crisis of Chronic Disease
• Exemplar conditions:
– arthritis, diabetes, heart disease, cancer, chronic pain,
depression, vision and hearing loss, trauma (MVCs)
• Chronic diseases are the leading causes of death and
disability worldwide
• Canada: 2 of every 3 deaths
• US: accounts for 75% of $2 trillion annual health care
spending

5. A New Normal Across Canada
• 5 million Canadians can’t find a
family doctor (StatsCan)
• Especially true in places like
Sudbury
• Elsewhere, doctors cherry-pick
patients
• Many Canadians have no
access to primary care

6. So, They Come in Droves to the ER
• “Slammed”
• “Inundated”
• “Swamped”
A system in
which
patients are
seen as the
enemy

7. Argot
• “A secret language used by various groups –
including, but not limited to thieves and
other criminals – to prevent outsiders from
understanding their conversations.”
• Derivation: a group of thieves circa 1628
knows as les argotiers

8. Talk in Plain Site

9. Contemporary ‘GOMER’ Slang
• Social admission
• Failure to Cope, dyscopia
• FTD – Failure to Die

10. Why Aren’t We Nice to Elderly
Patients
• Not well trained in geriatrics
• Don’t value the work of geriatrics
• Not high-tech diagnosis and treatment
Dr. Samir Sinha: one of just 250 Geriatricians. We need 500
more!

12. Everybody Dies
• Healthy people don’t die
• When we eradicate today’s diseases,
there will be others
• We spend more $ in the last two years
of life than all other years combined.
• We won’t control health costs until we
tackle the $ we waste at the end of life

13. Medical Futility
• No ‘official’ definitions
• Like bailing a well with
a sieve
• Basically, offering lifeprolonging treatment
without hope of
success
• Health professionals
believe they know it
when they see it

14. ‘Getting’ the DNR
• Do Not Resuscitate: cardiac resuscitation the only
procedure that must take place UNLESS patient or next of
kin refuse it
• No long a question of CPR or ventilator: large & confusing
menu of options
• Getting the DNR = getting a form signed
• Families unprepared to talk about DNR immediately after
learning that a loved one is likely to die

15. ‘Slow’ Code
• Cardiac arrest featuring neither speed nor full therapeutic
'firepower’.
– Hollywood code, light blue code, blue lite code, partial
code
• Mike Evans: “It’s malpractice. If you’re called to a code, you
go.”
• Use of the term reflects deep distress that HCPs feel about
running a full code in a medical futile scenario

16. So, Who’s to Blame?
• Health professionals blame families for not stating their
wishes via advance directives
• Families say their wishes aren’t followed

17. The Surprising View From Listeners
“"It seems to me you are working from an incorrect premise.
Many people feel pressured to receive treatment that
prolongs life against our will. My 97 year old mother-in-law
had a Do Not Resuscitate order. A day before her death, we
found her attached to all the equipment necessary for
resuscitation. It was only after I reminded the doctors that
she had a Do Not Resuscitate that she was permitted to
return to a familiar place."
Adel Elias, Campbell River, BC

18. Clash of Views
•
Hassan Rasouli went into hospital to have
neurosurgery
•
Post-op infection left him on a ventilator in a “near
vegetative state”
•
His MDs applied to the courts to remove life support
•
His family believes he is conscious & fought the MDs
•
SCOC: sided with the family
•
Now about to be transferred to LTC facility

19. • In June 2010, Senator Sharon Carstairs published her
final report on the future of palliative care in Canada:
– 90% of Canadians will reach a stage in their lives at which they
would benefit from palliative care
– 70% won’t receive it
– What we must do is to celebrate death as we do birth

20. • In 1990, Ian
Anderson died of
colon cancer
• His wife Margaret
cared for him at
home
• In 1997, she founded
Ian Anderson House
• There aren’t enough
hospices for patients
who need them

21. Palliative = Panacea?
• True story: patient receiving palliative care for
terminal cancer
• Patient’s usual palliative care MD says DNR
• Patient arrives in the ED of a different hospital with
trouble breathing
• Palliative care MD at the different hospital said full
resuscitation

22. The Rational Patient Who Wants to
Kill Himself
• Nagui Morcos: early
50s, diagnosed with
HD, watched his
father die of HD
• Ended his own life in
April 2012

23. BC Supreme Court of Canada
• Gloria Taylor & 4 other plaintiffs applied for doctorassisted death
• Taylor received an exception that would have
permitted her to have a doctor-assisted death pending
the outcome of the case
• She died of natural causes
• BC Court of Appeal recently upheld federal ban

24. The Latest in Quebec: 2014
• About to become the first province in
Canada to allow doctor-assisted death
• Some believe Quebec will become the
preferred destination for Canadians
who would have gone instead to
Europe.

25. Reaction to Quebec Proposal
• Bioethicist Margaret Somerville: “The
Quebec report is not balanced and reads
like a pro-euthanasia manifesto.”
• “Can we even imagine teaching medical
students how to kill a patient?”
• Judging by surveys, the public interest in
this proposal is not matched by interest
in the medical profession.

26. Unfortunately, many health professionals only learn about empathy when they or their
loved ones experience health care as patients.
I learned more about health care from my parents Sam and Shirley Goldman than I did
from textbooks.

27. Sign Your Advance Directives