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Palliative Care Palliative Care: Therapy for the Living Communication in Life-Limiting Illness: a Practical Guide Addressing Existential Suffering

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Palliative Care Palliative Care: Therapy for the Living Communication in Life-Limiting Illness: a Practical Guide Addressing Existential Suffering Changing epidemiology of June 2016; 58: 5 Clostridium difficile–associated Pages 241–296 infections New inorganic lead-monitoring guidelines THEME ISSUE The Laboratory Services Act: Recovery of lab-test costs Palliative care Palliative care: Therapy for the living Communication in life-limiting illness: A practical guide Addressing existential suffering bcmj.org June 2016 Volume 58 • Number 5 contents Pages 241–296 A R T I C L E S THEME ISSUE: PALLIATIVE CARE Guest editorial: Learning to fall Established 1959 254 Romayne Gallagher, MD 256 Palliative care: Therapy for the living Romayne Gallagher, MD, Caroline Baldwin, MD 262 Communication in life-limiting illness: A practical guide for physicians Jonathan Pearce, MD, Julia Ridley, MD 268 Addressing existential suffering Alan T. Bates, MD ON THE COVER: The final days of life can be a time of self reflection, peace, and O P I N I O N S healing in the face of dis- ease, and the palliative care that physicians provide can assist patients in this im- 244 Editorials portant journey. Our theme Ah, the good ol’ days. Nary an orphan in sight. David R. issue on palliative care be- Richardson, MD (244); David B. Chapman, MD (245) gins on page 254. The lies we tell, 246 Personal View International medical graduates: The hurdles to practising in Canada, Shirin Rostamkalaee, MD (246); College replies, Heidi M. Oetter, MD (248); Hurrah! Application complete, T.W. Barnett, MD (249) 247 President’s Comment Thoughts on professionalism Alan Ruddiman, MBChB ECO-AUDIT: Environmental benefits of using recycled paper Premise Using recycled paper made with post- 250 consumer waste and bleached without the use of chlorine or chlorine compounds results in The resident experience in Cape Town, South Africa measurable environmental benefits. We are A.W. Battison, MD, K.S. Wade, MD pleased to report the following savings. • 1399 pounds of post-consumer waste used instead of virgin fibre saves: • 8 trees • 760 pounds of solid waste D E P A R T M E N T S • 837 gallons of water • 1091 kilowatt hours of electricity (equivalent: 1.4 months of electric power required by the average home) BC Centre for Disease Control • 1382 pounds of greenhouse gases (equivalent: 274 1119 miles traveled in the average car) Changing epidemiology of Clostridium difficile–associated • 6 pounds of HAPs, VOCs, and AOX combined • 2 cubic yards of landfill space infections Environmental impact estimates were made Linda Hoang, MD, Elizabeth Bryce, MD, Bonnie Henry, MD using the Environmental Paper Network Paper Calculator Version 3.2. For more information visit www.papercalculator.org. 242 BC MEDICAL JOURNAL VOL. 58 NO. 5, JUNE 2016 bcmj.org #115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4 Tel: 604 638-2815 or 604 638-2858 Fax: 604 638-2917 E-mail: [email protected] Web: www.bcmj.org contents D E P A R T M E N T S ( Continued) 275 WorkSafeBC New inorganic lead-monitoring guidelines Sami Youakim, MDCM EDITOR David R. Richardson, MD 276 Pulsimeter EDITORIAL BOARD Book review: The Reservoir, George Szasz, MD (276); GPAC David B. Chapman, MBChB guideline: Asthma in Children—Diagnosis and Management Anne I. Clarke, MD (276); (277); Brian Day, MB Resident Doctors of BC: 2015 award winners CFMS Susan E. Haigh, MD national blood drive: The need is constant, Salima Abdulla, BSc Timothy C. Rowe, MB (278); Correction: Abusive head trauma (278); Doctors of BC annual Cynthia Verchere, MD (279); Willem R. Vroom, MD report: This is leadership Disability insurance: Your financial safety net, Caleb Bernabe (280) MANAGING EDITOR Jay Draper SENIOR EDITORIAL AND 281 Council on Health Promotion PRODUCTION COORDINator Kashmira Suraliwalla Water recycling: A step to better water stewardship and public health associate EDITOR Lloyd Oppel, MD Joanne Jablkowski COPY EDITOR Barbara Tomlin 282 BCMD2B PROOFREADER The person first Ruth Wilson Trish Caddy, MD DESIGN AND PRODUCTION Scout Creative COVER CONCEPT 284 Calendar & ART DIRECTION Jerry Wong Peaceful Warrior Arts 288 Billing Tips PRINTING The Laboratory Services Act: Recovery of lab-test costs Mitchell Press Keith J. White, MD advertisiNG Kashmira Suraliwalla 604 638-2815 Classifieds [email protected] 289 ISSN: 0007-0556 292 Advertiser Index 295 Club MD Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. © British Columbia Medical Journal, 2016. All rights reserved. No part of this journal may be re- Subscriptions produced, stored in a retrieval system, or transmitted in any form or by any other means—electronic, Single issue ................................................................................................................................. $8.00 mechanical, photocopying, recording, or otherwise—without prior permission in writing from the Canada per year ......................................................................................................................... $60.00 British Columbia Medical Journal. To seek permission to use BCMJ material in any form for any Foreign (surface mail) ............................................................................................................... $75.00 purpose, send an e-mail to [email protected] or call 604 638-2815. The BCMJ is published 10 times per year by Doctors of BC as a vehicle for continuing medical Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. education and a forum for association news and members’ opinions. The BCMJ is distributed by Return undeliverable copies to BC Medical Journal, 115-1665 West Broadway, Vancouver, BC V6J second-class mail in the second week of each month except January and August. 5A4; tel: 604 638-2815; e-mail: [email protected] Prospective authors should consult the “Guidelines for Authors,” which appears regularly in the Journal, is available at our website at www.bcmj.org, or can be obtained from the BCMJ office. Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not neces- sarily those of Doctors of BC or the institutions they may be assoicated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omissions, or from the use of information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising. BC MEDICAL JOURNAL VOL. 58 NO. 5, JUNE 2016 bcmj.org 243 editorials Ah, the good ol’ days. Nary an orphan in sight. any hospitals in BC are workload. It seemed expected that There is a current move in our looking for ways to deal we would pony up and take all com- health region away from hospitalists, Mwith unattached, or orphan, ers regardless of time and expense. I and the GPs have been approached patients. These admitted patients fall believe that family physicians should to take over hospital care for orphan into three categories: those who have take care of our own, but should not patients. I guess we proved our worth. a family physician who has privi- take care of Dr X’s hospital patients A lot of resources have been offered leges at another facility, those who while he works away in his clinic just to fund this initiative, such as money have a family physician in the local down the road. Many overtures were for nurse practitioners, administra- community who doesn’t have any made toward increasing payments for tive help, and even paid call. I think hospital affiliation, and those who this added service but little was done. it is unlikely that busy GPs will leap just don’t have a family doctor. Years Therefore, the system eventually at this chance even with the extra ago orphans were quite rare and fell imploded due to the sheer numbers of resources. We have enough of a chal- almost exclusively into the first cat- unattached patients. This might have lenge managing our own hospital and egory. However, as walk-in clinics been avoided if more was offered office patients; there is no capacity proliferated and general practitioners to the gradually shrinking hospital- to do more. Another troubling issue gave up their hospital privileges for a based GP workforce. is that with all these resources being number of reasons—round/call obli- At this point well-funded hos- directed toward caring for orphan gations, committee work, etc.—the pitalist programs became the norm. patients, those patients who are cared number of orphans in the other two Nothing against my hardworking hos- for by their capable GPs are relegated categories blossomed. pitalist colleagues, but as time pro- to being second-class citizens. Initially most hospitals relied gressed the metrics (no idea what this I’m not sure what solution will be on the good nature of those who is but always wanted to use the word) found to this challenging problem, but remained by adopting some form of began to show that patients who were I can’t help but long for the good ol’ Doctor of the Day strategy where cared for by their own GP had shorter days. If every family physician worked orphans were assigned to a privileged hospital stays. I guess there is value in a solo or group practice, took care of hospital family physician. I remem- in knowing your patients’ intimate their own patients, and had an affiliation ber administrators in our hospital details and intricacies. I would like to with their community hospital, most of being very reluctant to remunerate congratulate you GPs for a job well the population would have a GP, and those family physicians for their extra done over the years. orphans would again be a rarity. —DRR New PCOS Clinic Dedicated to: Providing patient care for women with polycystic ovary syndrome, particularly those wishing to conceive Providing on-site integrated assessment of ovaries and endometrium (ultrasound and endometrial biopsy) Inquiries & Referrals PCOS Diagnostic Criteria: Expanding PCOS knowledge in the medical 1. Irregular/no periods or Tel: 604.558.4886 ovulation and scientific community 2. Clinical or biochemical Fax: 604.558.4246 androgen excess 210-604 West Broadway Dr.
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