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

Home , Vernon Jubilee Hospital

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 disease, 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

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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

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244 bc medical journal vol. 58 no. 5, june 2016 bcmj.org editorials

The lies we tell

lied. I lied to my wife. attempt to protect them from harm. If a common situation in which patients It’s out in the open now, so I we, as physicians, want to continue to lie to doctors. Both patients’ lies put Ican talk about it. She celebrated a be seen by the public as some of the them, me, and the public at risk, and special birthday this year and, because most trusted professionals, then we I did not feel comfortable in continu- she is the Queen of Surprise Parties, I need to live up to that. ing as their doctor. On that topic, all felt the need to throw her a surprise I will say is that there is a right way party in return for all the good sur- and a wrong way to fire a patient. As I prises she has given me. Planning her Physicians may found out more recently, if you don’t party involved secrets, lies, subter- lie, deceive, and do it correctly you may receive a pale fuge, conspiracy, deception, dishon- misrepresent, for yellow envelope in the mail contain- esty, evasion, and misrepresentation. I example, in order to ing an unpleasant letter of complaint was hiding my phone so she couldn’t get a patient to comply and, ultimately, reprimand. see texts from her friends and family What I learned from the recent with treatment. members who were in on the surprise. subterfuge surrounding my wife’s I made up cover stories to explain my birthday celebration is that lying is tir- behavior. In the weeks leading up to I also remember two patients I ing. It took work to build the lies and the surprise I found myself waking up fired many years ago over lies they keep them from being discovered. frequently in the night worried that I told me. I didn’t like being manipu- It disrupted my normal sleep pat- would inadvertently let the secret out. lated and, after discovering their tern and made me worry about being In the end, the party was a huge suc- lies, I felt that they had damaged the found out. Except for the obvious cess and my wife enjoyed spending doctor-patient relationship irrepara- case of a surprise birthday party for a an evening surrounded by many of bly. Both patients lied to cover their loved one, I don’t think it is worth all her close friends and family. All was misuse of opioids. I think that this is that energy. —DBC forgiven. All of this got me thinking about the lies we may tell our patients and about the lies they tell us. Physicians may lie, deceive, and misrepresent, for example, in order to get a patient companion to comply with treatment. This very cruises paternalistic approach will invariably FREE backfire on the physician. Doctors may also withhold information, for example, to avoid giving the patient bad news. Hopefully, those attitudes are long gone. Recently, I tried to tell a frail, BC Medical Journal “What better way to get those CME elderly patient that I believed that credits and see the world indeed!” her life was nearing its end. She had CME Cruise —Romy Anastasio MD, end-stage chronic disease. As she lay Hamilton ON Canada in her hospital bed, becoming weaker 12-Night Quintessential Mexican and more drowsy, I started to tell her gently what I thought was happening. Family Practice Refresher She politely disagreed with me, as if February 09–21, 2017 to say that she didn’t want to know San Diego, CA, USA • Roundtrip what was to come. I didn’t push it, and she passed away peacefully 2 For more information: 1-888-647-7327 days later. Hopefully she heard what I [email protected] • www.seacourses.com was trying to tell her. I don’t like giving patients bad news, but I know that honesty is appreciated more than any

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 245 personal view

Letters of less than 300 words are welcomed provided they do not contain material that has been submitted or published elsewhere; they may be edited for clarity and length. Letters may be e-mailed to [email protected], submitted online at bcmj.org/content/ contribute, or sent through the post and must include your mailing address, telephone number, and e-mail address.

International medical requirements suggested by IMG advi- The enrollment requirements for graduates: The hurdles sors. Using Canadian resources and practice-ready programs in Canada, to practising in Canada supports, I passed the Medical Coun- such as the requirement to be in a cur- International medical graduates cil of Canada’s exams with honors, rent practice as a fully licensed phy- (IMGs) come to Canada with hope for scored high in my language exam, fin- sician, mostly benefit newcomers. a better life. However, for the major- ished preceptorship in anesthesiology New IMGs who were practising in ity of them, the life they start in Can- and family medicine, and was tem- their home countries become superior ada is far from what they’d imagined. porarily licensed for almost 3 years. to the IMGs who have been practis- For most of them, their professional Nonetheless, I could neither enroll in ing in Canada with a special licence lives come to an end. a residency program, due to the huge and who have become familiar with Most IMGs know there will be competition among IMGs, nor be suc- electronic medical record systems, hoops to jump through in the licen- cessful in one of the practice-ready patient-centred practice models, sure process, but what surprises them assessment programs. As a result, I’ve and Canadian culture. The govern- are the unexpected hurdles. In short, become a professional nobody, and ment of Canada is hiring physicians we are suffering from the Canadian I’m currently working in retail. After from outside Canada who have only government’s lack of transparency, the project that I was licensed for obtained working visas, passed the consistency, and fair execution of re- was terminated in 2013, no program MCCEE, and passed the language cruitment management plans regard- existed to bridge my qualifications exams. This is happening while hun- ing IMGs. to the next level. Instead, additional dreds of sophisticated IMGs are liv- My current professional situation hurdles—a new language exam and ing in Canada. If they were given the in Canada exemplifies this misman- a requirement to practise in my home chance to use their expertise beyond agement. I have fulfilled most of the country—were put in front of me. Continued on page 248

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246 bc medical journal vol. 58 no. 5, june 2016 bcmj.org president’s comment

Thoughts on professionalism

istorically, three recognized health care system itself, are impact- etal norms, and a political environ- professional careers existed: ing the way physicians practise medi- ment that has trouble planning and Hmedicine, law, and the clergy. cine. Many of these changes have us visioning for anything longer than a The people whom each of these pro- feeling burned out and, yes, skepti- single election cycle or government. fessions served looked for guidance, cal of the future of health care. We As a result, when changes occur in legitimate leadership, and a strong struggle with a fragmented system any of these areas, our core profes- sense of hope. The people expected in which our patients are said to sionalism can be challenged. outstanding service, the safety of fall through the cracks, yet it is our In medicine, professionalism is trusted relationships, and the lead- very much about building and main- ers of these professions to practise taining these relationships as we strive and conduct themselves in an ethical to provide quality patient care. And, manner. as an association of doctors, we must Since I didn’t choose a career in In choosing to deepen and expand our leadership in law and I’m not a member of the cler- uphold the virtues of quality of care to and for our patients, gy, I can only speak to the valued pro- and this can’t be accomplished with- professionalism and by fession of medicine. And in medicine out professionalism. Professional- today, those long-established tenets holding one another ism encompasses the attitudes, skills, continue to be held in high esteem. accountable, we can behaviors, attributes, and values that Physicians take great pride in our enhance our are expected from those to whom profession’s longstanding traditions professional satisfaction society has extended the most notable of altruism, the use of scientific evi- and the patient privilege of being considered a pro- dence, and the value and merits of the fessional. experience, and provide social contract. As doctors of medi- We doctors are extremely fortu- cine we strive for professionalism in the highest standard of nate. Years ago we chose, and today every aspect of our working lives. It health care. we get to experience, a humbling and is the cornerstone of our relationships meaningful professional career. We with patients, with one another, with are highly educated; indeed, we are other health care providers, and most the experts in modern-day medicine, certainly with society. As of late it has and we simply must not take that for become increasingly difficult to live patients and society who are look- granted. We get to be who we want to up to those standards. ing to us as the medical profession be in the context of the responsibil- What does it mean to be a doctor for meaningful solutions. This is a ity of being a doctor. We are a profes- within the landscape of BC today? great burden to carry, yet, at this time sion that is entrusted with serving our Our College feels that the social when the corporatization of medicine patients to the best of our abilities and order has changed. And I sense feel- is the single biggest challenge to our expertise. And that, dear colleagues, ings of angst and discomfort among professionalism, we have significant is a great honor. In choosing to uphold our colleagues in the many areas of and determined obstacles ahead that the virtues of professionalism and by the province that I travel to. Over the require us to unite and rally strongly holding one another accountable, we last decade I have witnessed, and our as a profession. can enhance our professional satisfac- peers are experiencing, the de-profes- Health care is delivered through tion and the patient experience, and sionalization of medicine—a sense a network of relationships that en- provide the highest standard of health that the foundation of our profession- compasses many different health care. And isn’t that what being a doc- alism is being eroded. care professionals, administrators, tor is all about? Medicine is changing faster than and government, and of course our —Alan Ruddiman, MBChB ever before and we are at a crossroads. patients are central to this. These re- Doctors of BC President Advancements in medical treatments lationships, which are at times chal- and therapies, combined with soci- lenging, are influenced by individual etal changes and changes within the behavior, constantly changing soci-

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 247 personal view

Continued from page 246 their Canadian experience, and pro- sure that IMGs, like Canadian-trained bureaucratic work, they would also be tect your own investment? physicians, meet the required high able to fill the gaps in Canada’s health —Shirin Rostamkalaee, MD standards expected of all physicians. care system. Whistler The College looks to the College of To sum up, there are many quali- Family Physicians of Canada (CFPC) fied IMGs living in Canada who have College replies and the Royal College of Physicians passed exams such as the MCCEE, British Columbia has a long history and Surgeons of Canada (RCPSC) to MCCQE1, MCCQE2, and NAC- of relying on international medical determine substantial equivalency in OSCE, fulfilled various levels of graduates (IMGs) to deliver compe- training requirements. training, and built good professional tent medical care to patients. In fact, Family physicians who have com- reputations. On top of that, both the 20% of all physicians practising in pleted their CFPC-recognized post- IMGs and the government of Can- the province are IMGs. As Dr Ros- graduate medical training in family ada have spent thousands of dollars tamkalaee points out, many organ- medicine from the United States, Unit- on exams and training. Despite this, izations play a role in ensuring path- ed Kingdom, Ireland, and Australia the regulations and requirements for ways for IMGs to help them establish can be eligible for registration and li- practice-ready assessment programs themselves and set up practice in BC. censure in the provisional class (a reg- like the Saskatchewan International The College’s role in the recruitment istration status under the Health Pro- Physician Practice Assessment or the process is to ensure IMGs meet edu- fessions Act) under sponsorship and Practice Ready Assessment–British cational competency and general re- supervision. Similarly, there are 29 ju- Columbia provide newcomers and quirements before they are granted risdictions where specialist training is foreign doctors a better chance to en- registration and licensure. While the recognized by the RCPSC. To advance roll. College will continue to work to- to the full unrestricted class of regis- Ultimately, I am left with one ward positive solutions for recruiting tration, an IMG must satisfy a number question for the authorities: Why IMGs, it is not willing to compromise of requirements, including completing don’t you give IMGs a better chance on the standards for registration and Canadian qualifying exams—just like to practise in Canada by recognizing licensure. The College Bylaws en- Canadian medical graduates.

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Family physicians and specialists Hurrah! Application I am sure that the BC Medical who have completed their postgradu- complete Quality Initiative has the best inter- ate training in a jurisdiction not rec- I finally finished my application for ests of patients at heart, but I think ognized as being equal to Canadian reappointment. their agenda has been overtaken by training programs by one of the two Initially, after hours spent scan- bureaucrats, risk managers, and law- national colleges may be eligible to ning documents and attaching them yers when the result is one more hoop participate in a practice-ready assess- to the electronic application, I was for physicians to jump through before ment (PRA) program, which involves informed by the department head that obtaining privileges. It is starting to a competency assessment. British the application was incomplete. After feel like privileges are not such a priv- Columbia launched its PRA-BC pro- three more phone calls (in the end I ilege! gram for eligible family physicians had to e-mail the documents in order —T.W. Barnett, MD, FRCPC last year, which requires candidates to for them to be attached to the applica- North Vancouver complete a rigorous and comprehen- tion) it was finally accepted. sive 12-week clinical field assessment following their successful completion olive fertility centre is pleased to announce of a number of examinations conduct- ed as part of the orientation process. The UBC family medicine program is one of four postgraduate residency training programs that accepts IMGs in the first iteration of CaRMS. The UBC Faculty of Medicine offers services and evaluations to allow physicians who have trained outside Can- ada to compete for and obtain medical residency positions that will lead to registration and licensure with the College. These positions and resources are generously funded by the government of BC. The College is proud of its robust standards and requirements for IMGs to help ensure they can safely enter the practice of medicine. This high level of scrutiny is yet another example of what British Columbians have come to expect from the regulator of the medical profession so that they can Dr. Niamh Tallon has joined our team. receive the best possible care. Dr. Tallon is a Reproductive Endocrinology —Heidi M. Oetter, MD and Infertility specialist. Registrar and CEO, College of Physicians and Surgeons of British Contact us at 604-559-9950 Columbia or email [email protected]

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bc medical journal vol. 58 no. 5, june 2016 bcmj.org 249 premise

The resident experience in Cape Town, South Africa

Two residents from the UBC Rural Family Medicine program traveled to Cape Town, South Africa, for elective rotations in trauma and emergency medicine. Here they provide an overview of the steps to being accepted as a supernumerary resident, how to obtain temporary licensure with South African authorities, and their experiences in a foreign health care system.

A.W. Battison, MD, K.S. Wade, MD

rimary care physicians in Brit- to a higher level of care. District Hospital (KDH), where we ish Columbia often work in Cape Town is a city of 3.75 million worked as supernumerary residents. Prural and remote areas. Their people located near the southernmost scope of practice is broad and includes point of South Africa and is a popular Participating university emergency medicine. In cases of criti- tourist destination. It is also one of the and hospitals cal injury and illness, there is often no most violent cities in the world. In- Our rotations were overseen by Stel- immediate access to specialist care, equality, poverty, and substance abuse lenbosch University, which is one of and patients must be stabilized prior fuel a high occurrence of violence.3 two medical faculties in the Western to transfer. However, opportunities Predominantly black and colored Cape. The faculty has an internation- for training in trauma and resuscita- townships were established during al office that assists students and resi- tion are limited in Canada. apartheid to segregate the residents dents with elective applications. Note Residents in family medicine are from their white rulers. Although that applications should be submitted rarely expected to manage severe apartheid has officially ended, the a minimum of 1 year prior to planned traumatic injuries or critical ill- socioeconomic conditions in South commencement of a rotation. ness because training largely takes Africa have essentially preserved this The campus of the Stellenbosch place in tertiary hospitals. There, legacy and much of the violence asso- University Faculty of Medicine is understandably, specialty residents ciated with it. Public hospitals receive located at TBH, an 1800-bed pub- take precedence in managing these most of the related fallout. lic teaching hospital located approxi- patients. However, the vast majority The UBC Rural Family Medicine mately 20 km east of Cape Town. It of physicians in rural British Colum- Residency program based in Kelowna serves as the referral centre for many bia are general practitioners and fam- includes a mandatory 1-month rota- ily physicians.1 Recent studies have tion in trauma, which may be com- Dr Battison is a resident in the UBC Ru- shown that only 3% of rural emergen- pleted in Canada or abroad. We had ral Family Medicine program based out of cy departments in BC have access to both completed rotations in South Kelowna. He graduated from UBC medi- CT and only 12% have 24-hour ac- Africa as medical students and were cal school in 2014 and is pursuing further cess to an on-call general surgeon.2 compelled to return. Beyond our edu- emergency medicine training at the Uni- Therefore, it is vital for rural physi- cational goals of learning about trau- versity of Calgary beginning this summer. cians to have the skills and training ma and emergency medicine, we also Dr Wade is also a resident in the UBC Ru- to identify, resuscitate, and stabilize wanted to offer assistance to those in ral Family Medicine program based out critically injured and ill patients, as desperate need and experience life of Kelowna. He completed UBC medical they will inevitably require transfer as residents in a foreign health care school in 2014 and continues to work as a system. We spent our time at Tyger- medical officer in the Canadian Forces, 12 This article has been peer reviewed. berg Hospital (TBH) and Khayelitsha Field Ambulance.

250 bc medical journal vol. 58 no. 5, june 2016 bcmj.org premise of the community hospitals located in Obtaining a licence Our experience the Cape Flats region, which is one of A significant amount of time, paper- The emergency and trauma units in the most violent areas in South Africa.4 work, and phone calls is required to Tygerberg and Khayelitsha District KDH is one such public commu- become licensed as a supernumerary Hospitals are some of the busiest in nity hospital. It is located in the larg- resident in South Africa. Fortunately, South Africa due to the high levels est township in the Western Cape and the international office at Stellen- of violence in the surrounding town- sees a high volume of severe trauma bosch University helps guide students ships. At KDH, postgraduate interns, and late-stage medical illness. Alco- and residents through this process. medical officers, and emergency med- hol and extreme poverty fuel much of The Health Professions Council icine registrars (equivalent to senior the violence. KDH has X-ray, ultra- of South Africa (HPCSA) regulates residents) staff the emergency centre. sound, and basic laboratory services, medical practice. The organization A consultant staff physician is on-call but it does not have a CT scanner, requires university sponsorship and 24 hours a day, but is not necessar- intensive care unit, or access to sur- document verification through the ily in house. On one overnight shift at gical subspecialists. Patients must be Educational Commission for Foreign KDH, we counted nearly 40 patients stabilized prior to ambulance transfer Medical Graduates (ECFMG) and who arrived with penetrating stab to TBH for definitive treatment. ECFMG International Credentials wounds to the chest. The majority of Both TBH and KDH have re- Services (EICS). Notarized copies of these patients were diagnosed with source issues. Both hospitals are se- an applicant’s medical degree and cur- pneumo- or hemothoraces, neces- verely overcrowded. It is sometimes rent licence must be sent to the EICS sitating thoracostomy tube inser- difficult to find proper working equip- for verification. From personal experi- tion. Resuscitations, from obtaining ment, and improvisation is the norm, ence and based on conversations we peripheral intravenous access to rapid not the exception. However, the med- had with other residents, we can con- sequence intubations, are performed ical staff are excellent and provide firm that this process takes a minimum by the medical officers and registrars evidence-based, timely care to sick of 6 months. on duty. We discovered that having patients. Once the EICS verifies the re- training in advanced trauma and life The provincial government heav- quired documents, they send them support and extended focused assess- ily subsidizes the cost of health care. to the HPCSA in Pretoria. Upon also ment of sonography in trauma were The tariffs are income based and set receiving a current Certificate of Pro- vital skills. Day shifts at KDH tended out in the Uniform Patient Fee Sched- fessional Conduct from the College to be more medical in nature, with ule.5 Those who cannot afford to of Physicians and Surgeons of British patients commonly presenting with pay receive services at no cost. The Columbia, the HPCSA then grants a severe illness such as bacterial men- patient’s economic circumstances do temporary postgraduate medical li- ingitis, diabetic ketoacidosis, septic not factor into any diagnostic or thera- cence. This licence allows a resident shock, and complications of HIV and peutic decision making in public hos- to prescribe medications and order tuberculosis. pitals. tests. Continued on page 252

For Jack Chang, M.D.

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 251 premise

Continued from page 251 became frustrating to try to clear a Examples of medical cases we saw: At TBH, the tertiary referral cen- hallway of patients, who were injured Status epilepticus tre, patients are received in a trau- due to seemingly senseless violence, Status asthmaticus ma front room managed by medical awaiting thoracostomy tube insertion. Pulmonary and extrapulmonary officers with trauma surgeons avail- Remarkably, the house staff seemed tuberculosis able as consultants. Most patients are to take it all in stride, working tire- HIV/AIDS transferred from other community lessly to attend to those in need. Immune reconstitution inflammatory facilities such as KDH where initial syndrome (IRIS) stabilization was completed, and man- Conclusion Malaria agement is focused around second- Cape Town is a vibrant, fascinating, Diabetic ketoacidosis ary surveys, advanced imaging, and and often shocking place to train. The Septic shock referral of patients to the various spe- time we spent in South Africa better cialty surgical services. Other poly- prepared us to manage life-threaten- Tetanus trauma patients are brought directly ing injuries and illness, and made us Severe hypoglycemia from motor vehicle and pedestrian grateful for the health care system we Organophosphate poisoning accidents. These patients frequently have in BC. We highly recommend a Massive postpartum hemorrhage require reduction and casting of joint rotation in South Africa to residents Bacterial meningitis and long-bone injuries. Trauma and who are seeking a unique trauma Cryptococcal meningitis medical emergencies are separated experience. at TBH, so the medical management Examples of trauma cases we saw: of traumatized patients is focused on References Hemothorax comorbidities such as tuberculosis, 1. Harbour Peaks Management Inc. British Pneumothorax HIV, and sepsis that may complicate Columbia rural physician programs re- Stab wounds an injury. view, 2008. Accessed 25 October 2015. Gunshot wounds Interactions with nursing and www2.gov.bc.ca/assets/gov/health/ Globe rupture allied health care staff are different in practitioner-pro/rural_review_report.pdf. Open skull fracture the South African medical environ- 2. Fleet R, Audette LD, Marcoux J, et al. Basal skull fracture ment from what they are in Canada. Comparison of access to services in rural emergency departments in Quebec and Increased ICP/brain herniation Physicians and house staff are responsible for all procedures performed on British Columbia. CJEM 2014;16:437- Traumatic brain injury patients, such as intravenous access, 448. Hypovolemic shock phlebotomy, blood gases, and ECGs. 3. Smith D. Calls for inequality to be tackled Cardiac tamponade Health professions often work inde- in South Africa as violent crime rises. The Traumatic amputation pendently of each other, and commu- Guardian. 1 October 2015. Accessed 13 Fracture-dislocations nication is limited. While this system December 2015. www.theguardian.com/ Splenic laceration improved our knowledge and capa- world/2015/oct/01/south-africa-violent Liver laceration bilities with these important proce- -crime-murders-increase-inequality. Perforated viscus dures, it also renewed our apprecia- 4. Everett C. Cape Town: Most violent city in Abdominal evisceration tion for the allied health care workers Africa struggles with entrenched gang and open communication we enjoy in culture. International Business Times. 25 Procedures we performed: British Columbia. November 2014. Accessed 13 December Thoracostomy tube insertion Working in Cape Town hospitals 2015. www.ibtimes.co.uk/cape-town Central lines was a taxing experience emotionally. -most-violent-city-africa-struggles Peripheral IVs The volume of patients can be over- -entrenched-gang-culture-1476375. 5. Western Cape Government. Western Arterial blood gases whelming and, as such, utilitarian policies are necessary and patients Cape Government Hospital tariffs: An CPR who are deemed terminally ill are overview. Accessed 1 November 2015. Endotracheal intubation removed from the resuscitation area www.westerncape.gov.za/general-pub Pericardiocentesis promptly. Tragic cases of untreated lication/western-cape-government-hos Emergency thoracotomy AIDS in young people are a daily pital-tariffs-overview. Phlebotomy occurrence. As well, we were in dis- Closed reductions and casting belief of the sheer number of patients who came in due to stabbings. It

252 bc medical journal vol. 58 no. 5, june 2016 bcmj.org Simple Wealth Strategies for Physicians By Don Murdoch

Incorporation May Still Be Right for You

This is the third instalment of our ‘Simple Wealth Strategies For those who have been cautious about moving forward with for B.C. Physicians’ article series. incorporation, the three key factors to consider remain unchanged. 1. If you are able to earn more income than you currently need to take to As expected, the new Federal Government does intend to implement live on, consider incorporation for the growth of your wealth / investing. changes to the use of corporations by professionals. What may be a 2. If your family circumstances provide income splitting opportunities, surprise to some, is that the changes may not impact many BC Physicians. consider incorporation for income tax savings. You will recall from our earlier article, a key advantage of the use of a 3. If your Medical Practice requires you to borrow funds to invest in the professional corporation lies in the ability to earn income from your assets / operations of your practice, consider incorporation to increase medical practice at a preferred low corporate income tax rate, creating your debt repayment power. earnings from the higher savings within the corporation and paying the remainder of the income tax that has been deferred when the funds are With 16 locations throughout B.C. and more than 70 across withdrawn for personal use. the country, MNP provides support to medical professionals at This remains unchanged for many incorporated B.C. physicians. In fact, all stages in their careers. Contact Don Murdoch, B.C. Leader, the low B.C. corporate income tax rate has been reduced further from Professional Services at 1.877.766.9735 or [email protected] 13.5% to 13% for 2016. The proposed rules are complicated and have not yet been confirmed. The proposed rules may reduce the ability for For more information about MNP’s Professional Services, certain corporate structures to access several annual $500,000 taxable visit our website at income limits at this new 13% tax rate. If you are a B.C. physician practicing in a large group, you should be talking with a knowledgeable www.mnp.ca/en/professionals advisor in order to understand how the changes may impact you and your partners / associates.

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 253 Guest editorial

Palliative care: Learning to fall

s I walked to his bedside I illness that continues throughout the was struck by the calmness disease process, that improves symp- A in his eyes despite the gaunt toms and quality of life, and that pro- cheeks, the emaciated body, and vides the right environment for per- the struggle of accessory breathing sonal growth and meaning-making. muscles to draw in enough air for Patients expect physicians to the failing lungs. He told me, “I am care for the whole person, not just totally at peace with what is happen- the body. A study of patients with ing and ready to die anytime.” After COPD, AIDS, and cancer identified I acknowledged the wisdom of this emotional support, communication, he asked, “Are you ready to die, doc- accessibility, and continuity as more tor?” My nonverbal response gave me important than competency.1 Yet Dr Romayne Gallagher away: I stepped back. Realizing my physician-author Abraham Verghese body had answered for me, I admitted probably speaks for many physicians “No, I guess not.” when he describes his unease in the All humans struggle with the cer- presence of a dying patient: tainty that our lives will end. Soci- I had always felt inexpert when a ety has developed many defences to patient was near death . . . Give me avoid confronting this fact. In medi- a patient with massive gastric bleed- cine we have changed death from a ing or ventricular fibrillation and I natural completion of the life cycle am a model of efficiency and purpose. to a medical failure and have devel- Put me at a deathbed, a slow dying, oped a technical armamentarium to and purpose is what I lack. I, who till thwart death as long as possible. We then have been supportive, involved, live longer—a great advance—but we can find myself mute, making my vis- take longer to die. This has changed its briefer, putting on an aura of great the event of dying from a few days enterprise—false enterprise. I finger of fevered delirium and sepsis to a my printed patient list, study the lab process that can take many months. results on the chart, which at this Depending on how someone copes, point have no meaning. For someone these months can be a time of intense dealing so often with death, my igno- living, of growing both emotionally rance felt shameful.2 and spiritually as the body declines. What Dr Verghese expresses here Or they can be months of suffering is the helplessness a physician feels induced by poor symptom control, in the face of a patient’s inevitable lack of support to cope with increas- death. As physicians we encounter ing dependence, and the loss of one- death more frequently than the aver- self and one’s dignity. Palliative care age person, and one of our defences is a treatment approach that begins at against the death anxiety present in the diagnosis of serious life-limiting all humans is a medical culture that

254 bc medical journal vol. 58 no. 5, june 2016 bcmj.org Guest editorial

focuses on a collection of organs rather than on a person who is dying from an illness. We use this organ-focused care as emotional armor against the sharp terror of our own death. The technology of medicine, as wielded by the doctor, bravely fights against disease on the battlefield of the patient’s body.3 With the language of fighting there is usually a winner and a loser, and thus death becomes a failure of medicine. For some patients, fighting to the death is the way they wish to end their life, but for most patients, accepting the inevitable brings peace and healing in the face of disease. Physicians have found that they can use self-awareness to stop themselves from putting on the emotional armor that protects them from admit- ting their own mortality, which in turn allows the physician to discuss fears and concerns with the dying patient, to experience being completely present with the patient, and to feel greater compassion.4 This openness leads to exploring which approach to the illness best matches the patient’s preferences and reduces care that is futile or does not feel right to the patient. Many wise traditions from ancient families and when to implement it. References times to the present maintain that fac- The second article describes how to 1. Curtis J, Wenrich M, Carline J, et al. Pa- ing our own mortality leads to a deep- communicate effectively throughout tients’ perspectives on physician skill in ening of appreciation for our lives. the illness trajectory. The third and end-of-life care: Differences between pa- Facing death with patients can bring final article provides background tients with COPD, cancer, and AIDS. humility, compassion, and connection on existential suffering and spiritual Chest 2002;122:356-362. and give greater meaning to the work distress—often the reason a patient 2. Verghese A. My own country. New York: we do. wants death hastened—and describes Vintage Books; 1995. p. 363-364. In this theme issue we focus on therapeutic communication tech- 3. Fuks A. Healing, wounding, and the lan- palliative care, knowing that even in niques that physicians can use to help guage of medicine. In: Hutchinson T, edi- the wake of the Supreme Court deci- individuals cope with their illness and tor. Whole person care. New York: Spring- sion to no longer prohibit physician- achieve healing. er; 2011. p. 83-95. assisted death the vast majority of —Romayne Gallagher, MD 4. Solomon S, Lawlor K. Death anxiety: The Canadians will still choose to die nat- Clinical Professor, challenge and the promise of whole per- urally and will look to physicians to Department of Family Practice, son care. In: Hutchinson T, editor. Whole assist them in living as well as they University of British Columbia person care. New York: Springer; 2011. p. can and for as long as they can before Palliative Medicine Physician, 97-107. they die. To help physicians do this, Department of Family and the first article outlines what pal- Community Medicine, liative care has to offer patients and Providence Health Care

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 255 Romayne Gallagher, MD, CCFP(PC), FCFP, Caroline Baldwin, MD, CCFP(PC)

Palliative care: Therapy for the living Studies have confirmed that suffering can be relieved and patients can live well until they die when palliative care is introduced early and integrated into the management of serious illness.

ABSTRACT: Palliative care arose as n the middle of last century, Brit- ing to gain acceptance as a medical a movement from outside academic ish psychiatrist John Hinton docu- discipline—experience and research medicine in the middle of last cen- Imented the medical deficiencies in have now established palliative care tury as a response to “bad dying.” end-of-life care: “We emerge deserv- as an evidenced-based field of medi- Today, palliative care improves qual- ing of little credit, we who are capa- cine with a defined set of principles, ity of life, patient and family satis- ble of ignoring the conditions which body of knowledge, and skill set. Pal- faction, length of hospital stay, and make muted people suffer. The dis- liative care has expanded from serv- health care costs near the end of life. satisfied dead cannot noise abroad the ing patients with cancer to serving Newer studies have demonstrated a negligence they have experienced.”1 those with any life-limiting diagnosis, survival advantage when palliative At the time he wrote this, patients including multimorbidity and frailty. care is introduced early in the ill- were treated until they died uncom- Much more than passive care is need- ness trajectory. In BC, physicians fortably in hospital, surrounded by ed to ensure a comfortable death, and wishing to acquire more palliative machines, rather than in a place of today palliative care strives to help care knowledge and skills can use comfort, surrounded by family and patients live well until they die. What practice supports provided by the friends. Shared decision making was living well entails is unique to each General Practice Services Commit- unheard of. Palliative care arose from patient and family. tee, including a useful algorithm and a movement outside of medicine as a Helping patients with terminal ill- other clinical tools. In future, the in- response to what was recognized by ness live their remaining life to the tegration of palliative care into the some as “bad dying.” fullest by communicating well and management of all serious illness Both medicine and palliative care balancing interventions to achieve a and greater involvement of the wider have changed much since then. We natural, comfortable death requires community can be expected to help live longer and age with less disability that all physicians embrace essen- more patients live their remaining than ever before. Our system is well life to the fullest and experience a designed to treat and modify acute Dr Gallagher is a clinical professor in the natural, comfortable death. diseases that used to result in death. Department of Family Practice at the Uni- But medicine’s ability to rescue peo- versity of British Columbia and a palliative ple from the cliff of sudden fatal ill- medicine physician in the Department of ness has led to the accumulation of Family and Community Medicine at Provi- morbidities and a longer period of dence Health Care. Dr Baldwin is a clini- disability and dying. Perhaps the most cal instructor in the Department of Family challenging clinical skill these days is Practice at the University of British Colum- finding a balance between prolonging bia and a palliative medicine physician in living and prolonging dying. the Department of Family and Community This article has been peer reviewed. Palliative care is no longer try- Medicine at Providence Health Care.

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tial palliative care knowledge and care may become even more reluctant Research in acute care shows skills. Expecting physicians to diag- if the range of services is perceived to that earlier referral leads to a great- nose, initiate, and maintain treatments include physician-assisted death. er positive impact on length of stay without knowing how to deliver pal- and health care costs.14 Research has liative care is akin to expecting a pilot Outcomes of also revealed that patients and fami- to take off and transport passengers palliative care lies received significantly less benefit safely without knowing how to land Palliative care services (inpatient, when they felt they had been referred the plane. Having essential pallia- outpatient, and community) have re- “too late.”15 Late implementation of tive skills and being aware of what peatedly been found to improve pa- palliative care can result from poor specialized palliative care can do for tient and family satisfaction with communication, health care pro- people with advanced illness is the care, to improve symptom control and vider lack of awareness of palliative standard of care today. quality of life, and to reduce health care therapies, physician reluctance care utilization in the last months of to discuss end-of-life issues due to Definition of palliative care life.1,12,13 These benefits are seen in prognostic uncertainty, and patient Palliative care supports patients, their patients with cancer, neurological dis- or family reluctance to consider pal- loved ones, and treating clinicians by ease, multimorbidity and frailty, and liation due to persistent myths about addressing physical, social, psycho- organ failure. palliative care. logical, and spiritual suffering. This is done using advanced communication techniques to establish goals of care Table. Palliative care myths and realities. and then matching treatments to these Myth Reality individualized goals and providing Opioids shorten life. There is no evidence that opioids shorten life when dosed sophisticated care coordination.2 Pal- appropriately and titrated to control symptoms. In fact, liative care is no longer reserved for multiple large studies have shown no relationship between opioid dose or dose escalation and time to death. Also, a time when all disease-modifying research confirms that appropriate doses of opioids do not therapies have failed, and can be cause respiratory depression in patients with dyspnea due introduced early in the illness tra- to advanced disease. jectory to prevent psychological and Patients with a history of Physicians have a moral obligation to treat pain in all spiritual suffering through multidisci- addiction should not be patients, including those with addiction. Opioids are often prescribed opioids in the palliative necessary and should not be withheld, even though plinary care. An early definition states care setting. management may be more complex and involve closer that palliative care “affirms life and monitoring, interdisciplinary involvement, and tighter control regards dying as a normal process” of drug dispensing. and that it “intends neither to hasten Palliative care is only for patients It is appropriate to pursue a palliative approach to care who are at the end of life and have whenever disease or its treatment begins to have a or postpone death” (World Health not responded to disease- significant impact on quality of life, quantity of life, or both. Organization, 1990, www.who.int/ modifying therapy. Physicians with palliative care skills can help patients from cancer/palliative/definition/en/). Cur- the time an incurable illness is diagnosed (e.g., by communicating to increase prognostic awareness) and rent definitions continue this theme continuing through the illness trajectory (e.g., by discussing of respecting the process of natural advance care planning). dying. Although involved in dying, Palliative care should be provided Palliative care skills and knowledge can benefit patients palliative care aims to help people live only when patients meet the early in the illness trajectory, as described above. as fully as possible until natural death. criteria for palliative care billing incentives or qualify for the BC There are many myths about pallia- Palliative Care Benefits program tive care (see Table )3-11 and one of (< 6 months prognosis). the newest is that physician-assisted Choosing palliative care means Even when hope for a cure is no longer possible, palliative death is an extension of palliative giving up hope. care allows patients to hope to live as well as they can and care. Physician-assisted death is not for as long as they can. in keeping with palliative care prin- When symptoms are difficult to Specialist palliative care opinion should be sought in this manage, sedation until end of life situation. Experts are available in all health authorities and ciples, and there is a realistic concern is the only option. can be contacted by physicians located outside major that patients who are already reluctant centres. Also, physicians can call the toll-free BC Physician to self-identify as requiring palliative Palliative Care Consultation Line.

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The integration of palliative care of this study and other similar RCTs, cation skills. All physicians must be into chronic disease management and the American Society of Oncology skilled in discussing prognosis, CPR oncology care has been recommend- released a provisional clinical opin- status, goals of care, and suffering.21 ed now for over 10 years,16 but refer- ion in 2012 recommending combined The symptom management and com- rals are still coming far too late for palliative care with oncologic care for munication competencies apply for all this model to be considered effective. any patient with metastatic disease or physicians who provide serious illness Advocacy for earlier referral has led to high symptom burden.19 This recom- care: primary care physicians, general related streams of research designed mendation has yet to be implemented and subspecialty internists, general to answer two important questions: in Canada. and subspecialty surgeons, and pedi- What is the best model for provid- A further systematic review of atric physicians and surgeons. ing palliative care in chronic illness? 28 randomized clinical trials of early Many patients receive end-of-life Does early palliative care have ben- palliative care integrated with usual care through their family physician in efits beyond relief of symptoms? chronic disease management found collaboration with community or hos- benefits to the early inclusion of pal- pital nursing services. Knowing from Benefits of early liative care,20 but there are serious study results that early palliative care palliative care methodological differences between can improve quality and quantity of In the last 10 years there have been all these studies and further research life, it is important for family physi- a number of high-quality randomized is needed to answer two key ques- cians to continue incorporating these controlled trials (RCTs) of early pal- tions: When is the optimal time to new skills and knowledge into their liative care versus usual care in the integrate palliative care into chronic practice. study of outcomes such as symptoms, disease management? What is the Doctors of BC through the Gen- mood, quality of life, and survival. best model for the provision of this eral Practice Services Committee has The best known RCT is a study of 151 care?20 There are many challenges developed a number of learning mod- patients newly diagnosed with meta- involved in end-of-life care research, ules to improve care for patients with static lung cancer.17 Patients were ran- but there will eventually be evidence chronic conditions (see Box describ- domly assigned to receive either usual to support a model that allows us to ing palliative care resources for both oncology care or early palliative care care for patients and families seam- health care providers and patients). integrated with oncology care. Qual- lessly from diagnosis through to death One of these, the End-of-Life mod- ity of life, mood, and survival were and bereavement, helping patients ule, can help physicians identify tracked. Patients receiving early pal- deal with the impact of the disease on patients who could benefit from a liative care had significantly bet- function and quality of life, and sup- palliative approach to care, increase ter quality-of-life and mood scores. porting survivors. physician confidence and communi- They also survived 2.7 months longer cation skills, and improve collabora- than those who received usual care, Incorporating palliative tion with specialist services, patients, despite undergoing fewer chemo- care into your practice families, and caregivers. The module therapy treatments than their counter- Research is improving our under- encourages physicians to keep a data- parts receiving usual care. A qualita- standing of symptom management and base of patients requiring a palliative tive analysis of the difference in the the prevention and relief of suffering, approach to care to ensure timely dis- character of the visits is revealing.18 but the challenge lies in applying this cussion of advance care planning and Patients who received usual oncology new knowledge and changing the care recommends seeing patients regularly care discussed symptoms, the state provided to patients. Essential com- to maintain optimum symptom con- of their cancer, as well as potential petencies in palliative care are being trol and prevent suffering. A number chemotherapy treatment and compli- incorporated into Canadian education of physicians have found the resources cations. Patients who received pal- programs at both the Royal College in the End-of-Life module useful for liative care discussed symptoms and of Physicians and Surgeons and the building palliative care processes into their management as well, but they College of Family Physicians. The the care of their patients with chronic also had the opportunity to increase competencies include basic manage- illness (www.gpscbc.ca/content/end their prognostic awareness and ment of pain and other physical symp- -of-life-module-helps-family-doc strengthen their coping skills during toms, management of anxiety and tors-discuss-planning-death-patients). palliative care clinic visits. Because depression, and specific communi- The module includes an excel-

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lent algorithm with links to symptom immediately prior to death, the use ness trajectory there is an opportunity management guidelines, communi- of palliative skills and knowledge to speak in general terms about the cation tips, and the necessary forms can start much earlier in the illness disease and the involvement of pallia- to ensure that patients receive all the trajectory. tive care at some point along the way. benefits and resources they are enti- Palliative care can be characterized as tled to. Keeping this active document When to introduce palliative care “a way to add an extra layer of support on the office computer gives the phy- In past centuries when no disease- and to allow you to live as well as you sician access to end-of-life tools for modifying therapy was available, the can for as long as you can.” It is also a use throughout the illness trajectory. doctor would spend time discussing way to raise the topic of advance care In BC, all patients who are esti- prognosis after making the diagnosis. planning and help patients understand mated to be in the final 6 months of life Being able to predict the course of the some of the decisions they may need are entitled to support under the Pal- illness and its eventual outcome was to make down the road and identify liative Care Benefits program (www2 dependent on knowing the disease and people they wish to involve in this .gov.bc.ca/gov/content/health/ its natural history and likely compli- process. Patients have repeatedly said practitioner-professional-resources/ cations, and knowing the patient with they expect physicians to initiate this pharmacare/prescribers/plan-p-bc the disease. A good physician was a conversation as part of their care.22 -palliative-care-benefits-program), good judge of prognosis. Because we Estimating prognosis is a devil which provides free access to symp- now have multiple therapies to offer we all wrestle with. Prognostic esti- tom management prescriptions and patients diagnosed with life-limiting mation tools are inherently faulty over-the-counter medications for disease, we often skip over the fact because they only consider physical constipation and other concerns. This that organ failure, neurodegenerative symptoms, signs, and disease indices same program allows health authori- disease, and cancer will eventually and cannot factor in the desire to live ties to provide equipment in the home lead to death. However, prognosis has to see a grandchild born or readiness when appropriate. While such bene- always been important for the patient to “let go.” Nevertheless, patients fits support patients in the 6 months and family, and even early in the ill- who are aware of their prognosis

Box. Palliative care resources

Resources for care providers Resources for patients and families

General Practice Services Committee (GPSC) Compassionate Care Benefits: End-of-Life Tools and Resources: www.esdc.gc.ca/en/ei/compassionate/index.page www.gpscbc.ca/what-we-do/professional-development/psp/modules/ Source of information about benefits available to eligible end-of-life/tools-resources individuals who must be away from work temporarily to Source for useful forms (e.g., Application for Death Certificate, No CPR provide care or support to a family member who is seriously ill form), assessment tools (e.g., Palliative Performance Scale, Edmonton and at risk of dying. Symptom Assessment System), clinical tools (e.g., Joint Protocol for Expected/Planned Home Deaths in BC, Fraser Health’s Hospice Palliative Speak Up: www.advancecareplanning.ca Care Symptom Guidelines), and an algorithm (www.gpscbc.ca/sites/ Source of information about advance care planning and end- default/files/Algorithm_v7%206%20Mar%202015.pdf) that contains links of-life care, as well as about issues related to an aging to many of these resources. population and a strained health care system.

BC Physician Palliative Care Consultation Line: 1 877 711-5757 Canadian Hospice Palliative Care Association: Provides toll-free 24/7 access to a palliative care physician able to offer www.chpca.net symptom management information and other advice. Provides access to an excellent handbook for caregivers (www.chpca.net/family-caregivers.aspx) and other iPal: www.ipalapp.com information about achieving quality hospice palliative care for Free website-based app that works on all mobile devices and desktops all Canadians and increasing awareness of end-of-life care to provide essential information about assessing need for palliative care, issues in Canada. managing symptoms, and communicating. Canadian Virtual Hospice: www.virtualhospice.ca Canadian Virtual Hospice: www.virtualhospice.ca Best overall website for patients and families looking for Source for articles, videos, and online courses on palliative care for information about palliative care, end-of-life care, and grief. health care providers.

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and its inherent uncertainty are able • The patient or family members are the large centres. In addition, physi- to participate more fully in decision distressed despite explanations. cians in British Columbia and Yukon making about further investigations A team approach to care is al- have access to a toll-free phone line and therapy. Informed consent is only ways better for the patient and fam- for palliative care consultations. This truly informed when this issue has ily because it is near-impossible for line connects the physician with a pal- been discussed openly. one person, the physician, to meet liative care physician in Vancouver A palliative approach is certain the complex needs of a patient and who can advise on symptom manage- to be of benefit to patients who are in family struggling with a life-limiting ment and other issues. This service is their final 6 months of life, and crite- illness. Having access to a team de- billable for the calling physician who ria to aid in identifying these patients pends on the size and resources of is seeking assistance. have been developed. Providence the local area. In a smaller commu- Health Care has adapted criteria from nity, the team may consist of the fam- The future of palliative care a consensus report about how to iden- ily physician, home care nurse, phar- Despite decades of effort to make pal- tify those in need of a palliative care macist, and neighbors. Other centres liative care an integral part of medi- assessment in a hospital setting.23 The may have local hospice societies or cal care, there is ample evidence that method begins with the validated physicians with added training in pal- people are still dying without access question “Would you be surprised if liative care. Tertiary palliative care to adequate symptom management this patient died in the next 6 to 12 programs are only found in large cit- and while receiving care that does not months?”24 General criteria for seri- ies, but should always be considered reflect their preferences.26,27 ous illness and disease-specific crite- a resource for smaller communities. A public health approach to pal- ria from the literature are combined Specialist (nonpalliative) physi- liative care may be the way to reori- to identify patients likely to have a cians also should ensure they have es- ent care in advanced serious illness prognosis of 6 months or less. While sential symptom management skills and move forward. This approach there is no way to calculate how mul- as well as the ability to communicate acknowledges that serious illness in- tiple diseases change the prognosis, about diagnosis, prognosis, and ad- volves the whole community and that it is known from several large stud- vance care planning. Specialists can a few specialized health care provid- ies of multimorbidity that the number assist the primary care physician in ers cannot meet all the needs of a pa- of medical conditions can accelerate providing appropriate care for the patient and family affected by serious progress through the illness trajecto- tient by estimating prognosis or indi- illness. It is everyone’s obligation to ry, likely indirectly though the effect cating the patient’s place in the trajec- influence and contribute to the system of increasing disability, which has a tory of the illness. For example, if a of care for someone with advanced direct adverse effect on mortality.25 patient with COPD and shortness of illness. The underlying principles for breath at rest visits the respirologist approaching care in this way are from When to consider specialist and is deemed to be on maximal thera- the Ottawa Charter for Health Pro- palliative care pies (home oxygen and medications), motion (World Health Organization, When to refer a patient to a palliative the respirologist may indicate that the 1986, www.who.int/healthpromotion/ care specialty team depends on the patient has advanced disease and at conferences/previous/ottawa/en/in knowledge and skills of the primary this stage would benefit from small dex1.html), which affirms the need to: care physician and a number of other doses of opioids to manage dyspnea. • Build public policies that support factors. If the primary care physician Informing the patient of this supports health. has up-to-date palliative care knowl- a shared-care approach and allows the • Create supportive environments. edge and skills, specialist palliative primary care physician to provide the • Strengthen community action. care may not be needed. Specialist needed symptom management and • Develop personal skills. palliative care can be helpful when: communicate further about planning • Reorient health services. • Physical and psychological symp- because now everyone is aware of the A public health approach attempts toms and spiritual distress are not prognosis. to involve the whole community in responding to the usual therapies. All the health authorities in Brit- care of patients with serious illness. • The patient or family members or ish Columbia have palliative care pro- It looks to establish health and social health care providers are uncertain grams with experts who can be con- policy that contribute to identifying about or disagree over goals of care. tacted by physicians working outside and supporting those affected by seri-

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ous illness, death, and bereavement. A 6. Bercovitch M, Adunsky A. Patterns of static non-small-cell lung cancer. N Engl J number of cities in Australia, Ireland, high-dose morphine use in a home-care Med 2010;363:733-742. and England have mobilized under the hospice service: Should we be afraid of it? 18. Yoong J, Park ER, Greer JA, et al. Early name Public Health Palliative Care In- Cancer 2004;101:1473-1477. palliative care in advanced lung cancer: A ternational: Developing Compassion- 7. Bercovitch M, Waller A, Adunsky A. High qualitative study. JAMA Intern Med ate Communities (www.phpci.info) to dose morphine use in the hospice setting. 2013;173:283-290. engage people from various sectors to A database survey of patient characteris- 19. Smith TJ, Temin S, Alesi ER, et al. Amer- develop public policy, community ac- tics and effect on life expectancy. Cancer ican Society of Clinical Oncology provi- tion groups, and volunteers to support 1999;86:871-877. sional clinical opinion: The integration of people living with advanced illness. 8. Good PD, Ravenscroft PJ, Cavenagh J. palliative care into standard oncology care. Now that the Supreme Court of Effects of opioids and sedatives on sur- J Clin Oncol 2012;30:880-887. Canada has overturned the prohibi- vival in an Australian inpatient palliative 20. Davis MP, Temel JS, Balboni T, et al. A tion against physician-assisted death, care population. Intern Med J 2005;35: review of the trials which examine early all physicians will be faced with re- 512-517. integration of outpatient and home pallia- quests from people fearful of suffer- 9. Clemens KE, Quednau I, Klaschik E. Is tive care for patients with serious illness- ing who know they now have an al- there a higher risk of respiratory depres- es. Ann Palliat Med 2015;4:99-121. ternative. As other jurisdictions have sion in opioid-naïve palliative care patients 21. Quill T, Abernethy A. Generalist plus spe- shown, the vast majority of people during symptomatic therapy of dyspnea cialist palliative care—Creating a more wish to die a natural death after liv- with strong opioids? J Palliat Med 2008; sustainable model. N Engl J Med 2013; ing as well as and for as long as they 11:204-216. 368:1173-1175.. can. Palliative care, delivered as an 10. Fine RL. Ethical and practical issues with 22. Tierney WM, Dexter PR, Gramelspacher integrated therapy by skilled practi- opioids in life-limiting illness. Proc (Bayl GP, et al. The effect of discussions about tioners, can help prevent and relieve Univ Med Cent) 2007;20:5-12. advance directives on patients’ satisfac- suffering for most people. 11. O’Brien CP. Managing patients with a his- tion with primary care. J Gen Intern Med Physicians: Please be motivated tory of substance abuse. Can Fam Phys- 2001;16:32-40. to learn about palliative care—for ician 2014;60:248-250. 23. Weissman DE, Meier DE. Identifying pa- your patients, for your loved ones, 12. Lorenz KA, Lynn J, Dy SM, et al. Evidence tients in need of a palliative care assess- and for yourself. for improving palliative care at the end of ment in the hospital setting: A consensus life: A systematic review. Ann Intern Med report from the Center to Advance Pallia- Competing interests 2008;148:147-159. tive Care. J Palliat Med 2011;14:17-23. None declared. 13. Rabow M, Kvale E, Barbour L, et al. Mov- 24. Pattison M, Romer AL. Improving care ing upstream: A review of the evidence of through the end of life: Launching a pri- References the impact of outpatient palliative care. J mary care clinic-based program. J Palliat 1. Hinton J. Dying. 2nd ed. London: Penguin Palliat Med 2013;16:1540-1549. Med 2001;4:249-254. Books; 1972. 14. May P, Garrido MM, Cassel JB, et al. Pro- 25. St John PD, Tyas SL, Menec V, et al. Multi- 2. Kelley AS, Morrison RS. Palliative care for spective cohort study of hospital palliative morbidity, disability, and mortality in com- the seriously ill. N Engl J Med 2015; care teams for inpatients with advanced munity-dwelling older adults. Can Fam 373:747-755. cancer: Earlier consultation is associated Physician 2014;60:e272-e280. 3. Morita T, Tsunoda J, Inoue S, et al. Effects with larger cost-saving effect. J Clin Oncol 26. Canadian Hospice Palliative Care Associa- of high dose opioids and sedatives on sur- 2015;33:2745-2752. tion. Fact sheet: Hospice palliative care in vival in terminally ill cancer patients. J Pain 15. Morita T, Akechi T, Ikenaga M, et al. Late Canada. Accessed 30 November 2015. Symptom Manage 2001;21:282-289. referrals to specialized palliative care ser- http://chpca.net/media/400075/fact 4. Portenoy RK, Sibirceva U, Smout R, et al. vice in Japan. J Clin Oncol 2005;23:2637- _sheet_hpc_in_canada_march_2015 Opioid use and survival at the end of life: 2644. _final.pdf. A survey of a hospice population. J Pain 16. Emanuel L, Alexander C, Arnold RM, et al. 27. Canadian Institute for Health Information. Symptom Manage 2006;32:532-540. Integrating palliative care into disease Health care use at the end of life in West- 5. Thorns A, Sykes N. Opioid use in last management guidelines. J Palliat Med ern Canada. Ottawa: CIHI; 2007. Acces week of life and implications for end-of-life 2004;7:774-783. sed 30 November 2015. https://secure decision-making. Lancet 2000;356(9227): 17. Temel JS, Greer JA, Muzikansky A, et al. .cihi.ca/free_products/end_of_life 398-399. Early palliative care for patients with meta- _report_aug07_e.pdf.

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 261 Jonathan Pearce, MD, CCFP(PC), Julia Ridley, MD, CCFP(PC)

Communication in life-limiting illness: A practical guide for physicians Challenging but essential patient-physician conversations about advance care planning, goals of care, and final days of life can help dying patients receive the best care possible.

ABSTRACT: Communicating with ommunication, an essential cussions.4 Furthermore, lack of dis- patients and families affected by part of all clinical practice, cussion related to end-of-life care has life-limiting illness is challenging. C involves particular challeng- been shown to result in higher health Evidence supports using thought- es and rewards when patients are fac- care costs in the final week of life and ful and deliberate communication ing life-limiting illness. These interac- a worse quality of death associated approaches that balance hope and tions are not usually restricted to the with such expenditures.5 reality in a caring and honest way. doctor-patient relationship but occur Communication clearly has value Clinical resources for everyday prac- in the context of family relationships for the care of the patient and fam- tice are available and include infor- and diverse cultural and spiritual per- ily as well as for the stewardship of mation about advance care planning, spectives.1 There is well-established medical resources. All clinicians goals-of-care discussions, and sup- evidence that effective communica- must develop an informed approach port for patients and families in the tion can result in positive clinical out- to communication with patients with final days of life. Physician-patient comes. Patients with advanced can- life-limiting illness and consider conversations will vary with the cer who had end-of-life discussions this skill as essential as taking a his- cultural, personal, and disease di- with their physician were less likely tory, performing a procedure, or pre- versity encountered across clinical to receive chemotherapy in the last 2 scribing a drug. Three of the most practice. What matters most is that weeks of life, had lower rates of ven- challenging conversations involve these conversations occur and are tilation, resuscitation, and intensive advance care planning (ACP), goals not avoided. care use, and overall improved quality of care, and the final days of life. of life.2,3 Importantly, such discussions were not associated with higher rates Dr Pearce is a palliative medicine physician of depression or anxiety in patients.3 with Providence Health Care and a clinical Early discussion of end-of-life wishes instructor in the Division of Palliative Care, and values of hospitalized older adults Department of Medicine, at the University led to improvements in anxiety and of British Columbia. Dr Ridley is a palliative depression scores of bereaved fam- medicine physician with Fraser Health and ily members following the patient’s a clinical assistant professor in the Division death when compared with the scores of Palliative Care, Department of Medicine, This article has been peer reviewed. of relatives who did not have such dis- at the University of British Columbia.

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Advance care planning for possible medical situations ahead need for a substitute decision-maker, Advance care planning began as the of the actual event. For example, a and it is most helpful for the substitute process of documenting patient treat- patient may consider artificial nutri- decision-maker to be present for sub- ment preferences and designating tion acceptable as an intervention to sequent conversations. Even when the a substitute decision-maker to act facilitate recovery from acute illness initial ACP discussion addresses only should the patient become incapable. but not for indefinite use, especially a few introductory questions, it pro- While these are still integral com- if the patient is in a dependent, non- vides an opportunity to offer further ponents of advance care planning, a communicative state. The most effec- resources for the patient to review broader understanding of ACP has tive information for future decision before a follow-up meeting. ACP con- emerged as a process of engaging in making outlines what brings value versations ideally occur early in the conversations related to wishes, val- and meaning to living for the patient illness trajectory in the outpatient set- ues, goals, fears, and hopes of the patient and family.6 The intent is to begin such discourse well before acute illness occurs so that care appropriate to the individual’s preferences can be discerned throughout the illness trajectory. Avoiding end-of-life conversations in Many clinicians have expressed an effort to maintain hope was actually concern that initiating conversations too early in the illness trajectory might viewed as unacceptable by patients lead to increased patient distress and and substitute decision-makers. a sense of impending discontinua- tion of life-prolonging therapies.7 In opposition to this view, a study found that avoiding end-of-life conversations in an effort to maintain hope was actually viewed as unacceptable by patients8 and substitute decision- rather than what might be wanted in ting, but may be initiated in a hospital makers.9 Patients and caregivers have a range of hypothetical clinical sce- or care facility. Sample questions for identified physician discomfort with narios. If specific complications and initiating and continuing ACP discus- such conversations as being a barrier interventions become more likely sions12,13 are outlined in Table 1 . to having them,6 and patients gener- as the disease progresses, then the In British Columbia, the My Voice ally expect their physician to initiate advance care plan can be changed to workbook provides a framework for ACP discussions.10 give appropriate directions. approaching ACP discussions.14 The First implemented in the care of It is important for the physician to workbook begins by asking the pa- patients with incurable malignant dis- initiate an advance care planning dis- tient to think about beliefs, values, and ease, advance care planning is appli- cussion by introducing the topic and wishes for future health care and then cable to all patients regardless of diag- normalizing the conversation as one proceeds to help the patient document nosis or prognosis. While the general necessary to have with all patients. It these in the form of a representation goals of ACP discussions remain sim- is also important to determine what agreement, an advance directive, and ilar across diagnoses, the specific- the patient understands about his or an enduring power-of-attorney agree- ity of conversation will vary with her individual health currently, as ment. It is important to record ACP the disease and its severity. Training this will affect how the conversation conversations in the patient chart and programs for ACP discussions rec- unfolds and establish whether the to obtain a copy of any documents ognize that for healthy individuals, patient has discussed this understand- completed by the patient for future ACP may be limited to designating ing or hopes for future care with any- reference. Many patients, and occa- a substitute decision-maker and a one. In some cases, the initial doctor- sionally some legal professionals and general discussion of life values.11 It patient ACP conversation will be the physicians, are not aware of the dif- can be challenging to make decisions first time a patient has considered the ference between appointing someone

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Table 1. Questions for advance care planning conversations with patients.12,13 medical decision making, goals-of- care discussions occur during the Introduce the topic “One thing I like to do with all my patients is to discuss advance course of illness. Many goals-of-care care planning. Do you know what this means?” discussions will include considering “Is this something you would feel comfortable discussing whether it is time to shift from a dis- today?” ease-modifying therapy to a palliative “Is there someone you would like to be present with you for care approach that minimizes or ratio- these conversations?” nalizes medical interventions to focus “What do you understand about your illness or what’s happening on therapies likely to increase patient to you?” comfort and improve quality of life. Assess prior knowledge “Do you have an advance care plan? Do you know what I mean There are significant barriers to by this?” goals-of-care discussions, including “Have you done any of the following: written a living will, patient and family factors, physician appointed a health care representative, completed an advance discomfort in initiating the conversa- directive?” tion, and systemic pressures and dy- namics. This last barrier can involve Identify substitute “If decisions about your care needed to be made in the future decision-maker (if no and you were unable to speak for yourself, whom would you ambiguity or uncertainty regarding plan prior to review) want me to ask about your care?” who is the most responsible clinician.10,15 Evidence can guide when Explore prior “Have you talked to your substitute decision-maker, family, or conversations other health care providers about your wishes or preferences and how these discussions occur. With for health care that may come up (e.g., resuscitation)? May I ask respect to timing, it can help to an- what you discussed?” swer the so-called surprise question: “Could a loved one correctly describe how you would like to be “Would you be surprised if this pa- treated in the case of a terminal illness?” tient died in the next 6 to 12 months?” A response of “no” indicates the time Understand values “What is important to you as you think about this topic?” is likely right for a goals-of-care dis- “Where do you fall on a scale with the following endpoints?” cussion.16 In general, patients with a 1 = Let me die without medical intervention, except for control of progressive disease, decreasing func- pain and symptoms. tion, or an acute episode necessitat- 5 = Do not give up on me no matter what; try any proven or ing hospital admission or changes in unproven intervention possible. treatment are those who would benefit Determine end-of-life “If you could choose, would you prefer to die at home, in from a focused goals-of-care discus- care preferences hospice, in residential care, or in hospital?” sion. Goals of care may be established between a clinician and patient at the in a power-of-attorney agreement to Goals of care bedside, on admission to hospital, make financial decisions and naming For patients with advanced illness, iteratively over multiple outpatient a substitute decision-maker in a rep- whether their primary diagnosis is visits, or at a more structured fam- resentation agreement to make medi- progressive organ dysfunction, motor ily meeting after hospital admission. cal decisions. It is important to clarify neuron disease, cancer, or some other Family meetings are common and are this distinction. life-limiting disorder, there comes a thought to improve communication, In addition to the My Voice work- time in the illness trajectory when a bereavement outcomes, length of book designed for use in British discussion of goals of care becomes stay, and resource utilization.17 Columbia, other resources and inter- essential to providing patient-focused In a goals-of-care discussion phy- active tools for patients are available care. Goals of care is a vague term sicians will often explain the medi- through the Speak Up program.12An that should not be considered synon- cal context of the treatments being additional resource for patients is the ymous with code status, although this offered, what the risks and benefits Engage with Grace tool, which poses is anecdotally often the case. While are, and guide patients and families to five questions to encourage further advance care planning is intended to explore patient expectations in terms conversation.13 be done well ahead of any need for of prognosis and level of function.

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The following outlines one approach what are your most important goals?” questions described above involve to a goals-of-care discussion. • “What are your biggest fears and assessment that is not a standard part worries about the future with your of medical history taking; physicians 1. Find out how much information health?” are not accustomed to asking about a the patient and family wish to have. • “What abilities are so critical to patient’s values, and these may take Give the patient and family permis- your life that you can’t imagine liv- several conversations to elicit fully. sion to ask questions and explore their ing without them?” When a goals-of-care discussion understanding of the patient’s disease • “If you become sicker, how much is successful, a collaborative plan and future. are you willing to go through for the emerges, grounded in the clinician’s • “Please ask for clarification or more possibility of gaining more time?” medical knowledge and guided by the detail if you like, or let me know if patient’s priorities. Some conversa- you’re hearing more detail than you 4. Incorporate values and prefer- tions can evoke significant emotion feel you need.” ences information into recommen- and lead to conflict. A patient and fam- • “Before we talk in detail, it would dations for a treatment plan and ily may request futile interventions, help me to know what you under- present possible options. This may refuse to discuss unwanted outcomes, stand about your illness.” include shifting the focus of care to or become angry and blaming. In these • “Can you tell me your understand- symptom management rather than situations, tools may be needed to help ing of your medical situation right active treatment of the underlying dis- clinicians break bad news, display now?” ease. Use discretion when discussing empathy, and conduct effective family • “What do you expect your health plans that are not true options (e.g., meetings. Physicians should remind will look like in the future?” patient might want to go home, but themselves to use open body language given your diagnosis and the patient’s and appropriate eye contact,18 respond 2. Summarize the medical situation. function this is not an option). to emotional cues,19 and check under- Know the patient’s medical history standing of patients and family mem- well enough to summarize it without 5. Discuss options and your recom- bers.20 Many physicians are familiar reading off the chart and refer back to mendation. This may occur either with the SPIKES model,20 which was the chart only for details when needed after sitting in silence during the designed to help deliver bad news to (e.g., size of lesions, lab values, medi- meeting or after allowing hours or cancer patients and can be used in a cation doses). days to pass so that the patient and variety of health contexts.21 Another • Maintain eye contact with the pa- family can digest the information and evidence-based approach used by ex- tient and any family present to get a confirm a plan. perienced clinicians is the VALUE sense of understanding. model,22 which is more appropriate • Use simple language and define 6. Check understanding. Sum- for goals-of-care discussions because medical terms if used. For example, marize information heard from the it focuses on gathering information “Your creatinine is high, meaning patient and family and clarify what from the patient and family rather than that your kidneys aren’t working changes, if any, will be made directly on relaying information: well.” after the meeting or when you will • V alue and appreciate what the fam- • Check understanding along the way. confirm a care plan. ily said. For example, “Does that make sense?” • A cknowledge emotions. Keep in mind that the process is • L isten. 3. Ask questions regarding values a dynamic one and the order of steps • U nderstand: ask questions that al- and preferences. Find out what is outlined above can vary. Whatev- low one to know the patient as a important to the patient at this time er the order, the steps in a goals-of- person. (e.g., place of care; burden of treat- care discussion should focus on the • E licit questions from the family. ment that is acceptable; important patient rather than clinical values: While many goals-of-care dis- upcoming milestones; tasks, hobbies, the patient’s quality of life, important cussions clarify the types of inter- pastimes, and occupational, family, or upcoming milestones, and perception ventions to be initiated for patients, social engagements that are important of wellness are more important than others address the possibility of to maintain).10 vital signs, laboratory values, or find- withdrawing life-sustaining thera- • “If your health situation worsens, ings on imaging. Undoubtedly, the pies. The perceived moral difference

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between withholding and withdraw- quality of care and clearer, shorter, and thirst at end of life, prognosis, ing therapies can vary among cultures, and more collaborative discussions signs of imminent death, the abil- regions, and individuals. However, in and decisions as the patient’s condi- ity of unresponsive patients to sense the Canadian setting, the ethical and tion and needs change further.10 their surroundings, and how family legal equivalence of withholding and members can support a minimally withdrawing interventions is well es- Final days of life responsive or unresponsive patient. tablished.23 It is always important to Supporting a patient and family mem- In general, it helps to encourage fam- help families differentiate between bers through the final days of the ily members to be present as they the decision to withhold or withdraw patient’s life can be daunting, particu- are able, and to observe any end-of- therapies from euthanasia/physician- larly if this is not a common occur- life spiritual traditions important to assisted suicide as these are ethically rence in your clinical practice. It can the patient. As well, you can help by distinct acts. For example, a physician be difficult to diagnose dying because going over natural changes in breath- might need to explain that withdraw- of ongoing hope that the patient will ing, intake, and alertness at the end of ing or not escalating use of a therapy get better, because of mixed informa- life as outlined in Table 2 . does not hasten the dying process but tion about the overall status of the A handout about imminent death instead avoids extending life artifi- patient, and because of failure to rec- for family members is a useful re- cially and allows for a natural death. ognize signs and symptoms of immi- source available in many institu- Overall, empathetic, direct, and nent death.24 Even when clinicians tions (e.g., “As Death Approaches” 25 honest responses to questions and accurately identify the dying process from the Vancouver Island Health Au- exploration of questions, fears, and and families and patients are accept- thority). Such resources can remind emotions will help find common ing of this, addressing questions and clinicians about important topics to ground. Goals-of-care discussions concerns from patients and family discuss, and allow family members take time and effort, but are worth- members can be difficult. Common to review information later when they while because they lead to improved questions relate to issues of hunger feel less overwhelmed.

Conclusions Table 2. Common family concerns and information physicians can provide in final days of life. Communicating with patients and families facing life-limiting illness Level of alertness Alertness is less at the end of life, although brief periods of lucidity/ energy can occur. involves challenges. In conversations about advance care planning, Patients may be able to hear and feel touch when unresponsive, and informing family members of this can help them be present with the goals of care, and final days of life, patient. clinicians are faced with the delicate task of balancing hope and reality in Oral intake Patients usually do not feel hunger or thirst and oral intake is significantly reduced. a caring and honest way. These discussions also require us, as clinicians Patient indication of hunger or thirst should guide intake. and individuals, to confront our own Changes in breathing Irregular breathing with apneic pauses may indicate a prognosis of understanding and experience of hours rather than days. death and dying, which can be inher- Wet breath sounds can occur and are unlikely to be uncomfortable, ently discomforting. How such con- but may be reduced with repositioning or decreasing the production of saliva and phlegm with medication (e.g., scopolamine, versations occur will vary with the glycopyrrolate). cultural, personal, and disease diversity encountered across clinical prac- Circulation Peripheral pulses decrease and hands and feet may become mottled and cool. tice. Of greatest importance is that these conversations do occur and are Bowel and bladder Patients are often incontinent and insertion of an indwelling urinary not avoided. In talking to our patients, function catheter may be appropriate. we will come to know them better and Agitation and Patients often settle with reassurance from family and care help them receive care in a way that confusion providers and in response to a calm environment. most respects who they are. Ongoing agitation may be reduced with medication (e.g., methotrimeprazine, midazolam).

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Competing interests munication about serious illness care 18. Egan, G. The skilled helper. 4th ed. Pacific None declared. goals: A review and synthesis of best Grove, CA: Brooks/Cole; 1990. practices. JAMA Intern Med 2014;174: 19. Epstein R, Hadee T, Carroll J, et al. “Could References 1944-2003. this be something serious?” Reassur- 1. Ernecoff NC, Curlin FA, Buddadhumaruk 11. Respecting choices. Frequently asked ance, uncertainty, and empathy in re- P, et al. Health care professionals’ re- questions. Accessed 8 December 2015. sponse to patients’ expressions of worry. sponses to religious or spiritual statement www.gundersenhealth.org/respecting J Gen Intern Med 2007;22:1731-1739. by surrogate decision makers during -choices/FAQs. 20. Baile WF, Buckman R, Lenzi R, et al. goals-of-care discussions. JAMA Intern 12. Speak Up. What is advance care plan- SPIKES—A six-step protocol for deliver- Med. 2015;175:1662-1669. 2. Mack J, Cronin A, Keating N, et al. Asso- ciations between end-of-life discussion characteristics and care received near death: A prospective cohort study. J Clin Oncol 2012;30:4387-4395. It is always important to help families 3. Wright AA, Zhang B, Ray A, et al. Associa- differentiate between the decision to tion between end-of-life discussions, patient mental health, medical care near withhold or withdraw therapies from death, and caregiver bereavement adjust- euthanasia/physician-assisted suicide ment. JAMA 2008;300:1665-1673. 4. Detering K, Hancock A, Reade M, et al. as these are ethically distinct acts. The impact of advance care planning on end of life care in elderly patients: Ran- domised controlled trial. BMJ 2010; 340:c1345. 5. Zhang B, Wright AA, Huskamp HA, et al. ning? Accessed 18 March 2016. www ing bad news: Application to the patient Health care costs in the last week of life: .advancecareplanning.ca/what-is with cancer. Oncologist 2000;5:302-311. Associations with end-of-life conversa- -advance-care-planning/. 21. World Health Organization. To err is hu- tions. Arch Intern Med 2009;169:480- 13. Engage with Grace. One slide project. Ac- man: Engaging with patients and carers. 488. cessed 7 December 2015. www.engage 2012. Accessed 1 December 2015. www 6. Johnson S, Butow P, Kerridge I, et al. Ad- withgrace.org/content/theoneslide.pdf. .who.int/patientsafety/education/curri vance care planning for cancer patients: A 14. British Columbia Ministry of Health. My culum/course8_handout.pdf. systematic review of perceptions and ex- voice. 2013. Accessed 1 December 2015. 22. Lautrette A, Darmon M, Megarbane B, et periences of patients, families, and health- www.health.gov.bc.ca/library/publica- al. A communication strategy and bro- care providers. Psychooncology 2015; tions/year/2013/MyVoice-AdvanceCare chure for relatives of patients dying in the doi:10.1002/pon.3926. [Epub ahead of PlanningGuide.pdf. ICU. N Engl J Med 2007;356:469-478. print]. 15. You JJ, Downar J, Fowler RA, et al. Barri- 23. Sprung C, Paruk F, Kissoon N. The Durban 7. Patel K, Janssen D, Curtis J. Advance care ers to goals of care discussions with seri- World Congress Ethics Round Table Con- planning in COPD. Respirology 2012; ously ill hospitalized patients and their ference Report: I. Differences between 17:72-78. families: A multicenter survey of clini- withholding and withdrawing life-sustain- 8. Hancock K, Clayton JM, Parker SM, et al. cians. JAMA Intern Med 2015;175:549- ing treatments. J Crit Care 2014;29:890- Truth-telling in discussing prognosis in ad- 556. 895. vanced life-limiting illnesses: A system- 16. You JJ, Fowler R, Heyland DK, et al. Just 24. Ellershaw J, Ward C. Care of the dying atic review. Palliat Med 2007;21:507-517. ask: Discussing goals of care with patients patient: The last hours or days of life. BMJ 9. Apatira L, Boyd EA, Malvar G. Hope, truth, in hospital with serious illness. CMAJ 2003;326:30-34. and preparing for death: Perspectives of 2014;186:425-432. 25. Vancouver Island Health Authority. As surrogate decision makers. Ann Intern 17. Powazki R, Walsh D, Hauser K, et al. Com- death approaches, 2009. Accessed 1 Med 2008;149:861-868. munication in palliative medicine: A clinical December 2015. www.viha.ca/NR/ 10. Bernacki RE, Block SD; American college review of family conferences. J Palliat rdonlyres/1B4DCED7-CA43-466A-9968 of Physicians High Value Task Force. Com- Med 2014;17:1167-1177. -53D630A22AD8/0/gen_80.pdf.

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 267 Alan T. Bates, MD, PhD, FRCPC

Addressing existential suffering Physicians can feel better equipped to deal with a dying patient’s emotional experience by considering some relevant contributions of existential philosophers and being aware of possible interventions, including manualized therapies.

ABSTRACT: Existential distress is “ t feels as though I’m traveling fur- not really understand what it means. often present in terminal illness and ther and further into a cave that’s It sounds like something we might may be associated with syndromes Igetting darker and narrower, and have studied at university if we had such as depression, anxiety, and de- there’s no way to go back.” not been so busy taking all the medi- sire for hastened death. Physicians Patients with terminal illness ex- cal school prerequisites. Fortunately, with expertise in managing physi- press existential suffering and spiri- a physician does not need to be a cal pain may feel unequipped to tual distress in a number of different philosophy major to understand the address social, psychological, and ways. Hearing a patient say the words core concepts of existentialism and spiritual aspects of pain. Through a above, a physician may feel paralyzed use that understanding in the care of brief exploration of the foundations or poorly equipped to respond. What patients. of existentialism and existential psy- can you really say when a patient has Clearly, talking to patients about chotherapy, this article aims to de- a progressive terminal illness? There death is key to helping them cope with mystify existentialism and provide is no denying the illness, and no de- anxiety about it. By taking something practical tips for addressing exis- nying the patient’s experience of it. as nebulous as death and discussing tential suffering, even in parents However, the feelings of dread, pow- it in more concrete terms in regular and children with terminal illness. erlessness, and loss of control that a conversation, we can make death less Formalized interventions that as- physician may experience on hearing frightening and unpredictable for our sist patients with existential issues these words can be used to help the patients. And in that same spirit, by are recommended. Physicians are patient. Experiencing these emotions considering some relevant contribu- encouraged to get support in ex- shows our capacity to understand or tions from a few existential philoso- ploring domains that they may feel perceive some of what our suffering phers and thinkers, we can feel better are outside their scope of practice, patients are feeling. Though initially equipped to do this. such as spirituality, and encouraged difficult for us to experience, these to adjust boundaries in the doctor- feelings can become a guide to what a Kierkegaard patient relationship in palliative care patient needs help with. Søren Kierkegaard is widely regard- settings. With the aid of a physician ed as the father of existential philoso- who addresses existential suffering, Foundations of existentialism it is possible for patients to transi- and existential psychotherapy Dr Bates is a provincial practice leader for tion from feeling hopeless to feeling Existentialism is something we have psychiatry with the BC Cancer Agency and more alive than ever. usually heard of, but few of us know a clinical assistant professor in the Depart- much about. And lots of us feel intim- ment of Psychiatry at the University of Brit- This article has been peer reviewed. idated by the term because we do ish Columbia.

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phy.1 His work often focused on per- Nietzsche sciousness”7 in order to discover what sonal choice and commitment, and Friedrich Nietzsche is intimately is really important in life, and patients how everyone lives as a “single indi- associated with the concept of nihil- sometimes describe this as a kind of vidual.”2 Kierkegaard also explored ism, which in turn is related to exis- “silver lining” to being terminally ill. the emotions of people making sig- tential nihilism—the idea that life has Unfortunately, this can also be expe- nificant life decisions, and certainly no meaning or purpose. Patients at the rienced as a terrible realization that there can be often a number of these end of life may experience a kind of much of life was not spent on what the to make at the end of life in a modern existential nihilism and say that their patient now views as most important. medical system. existence has been meaningless or Martin Heidegger extended Kier that there is no longer any point in Frankl kegaard’s idea of living as a single in- being alive. Nietzsche argued that our Viktor Frankl was an Austrian psy- dividual to dying as a single individu- primary driving force is not mean- chiatrist who spent 3 years in Nazi al, proposing that death is an entirely ing or happiness, but rather the “will concentration camps. In contrast to personal experience that must be taken to power” or pursuit of high achieve- Nietzsche’s “will to power,” Frankl on alone.3 Patients do sometimes ex- ment and reaching the best possible maintained that “will to meaning” is perience a new and distressing sense position in life.5 If this is our primary the primary driving force of human of aloneness at the end of life, know- driving force, it is understandable that behavior. His experiences in the con- ing that nobody is going to share this patients who have had great success in centration camps are described in his specific experience with them. The their careers or other pursuits may feel book Man’s Search for Meaning,8 feeling of being the only one who can there is no longer any purpose to their which confirms his belief that mean- make choices about how to live out fi- existence once they are seriously ill. ing can be found in any situation, nal days can be overwhelming. Although it may be a manifesta- even in great suffering. He theorized While some at the end of life take tion of depression or some other mod- that finding meaning in difficult situ- great comfort from their faith, oth- ifiable condition, existential nihilism ations gives us the will to continue ers may find their unfortunate cir- is a concept that great minds have living through the worst of circum- cumstance cause them to question it. either supported or struggled with, stances. Frankl’s ideas are now being Kierkegaard theorized that there is no and one that is not easy to dismiss out applied in modern evidence-based faith without uncertainty or doubt.4 of hand. However, there are certainly psychiatric interventions for patients He described how faith is not required alternate views that may facilitate a with advanced cancer as meaning- to believe in something tangible like patient’s leap of faith to a more com- centred psychotherapy.9,10 a chair, but is necessary to believe fortable opinion. in something for which there is little Yalom or no evidence. In other words, faith Sartre Irvin Yalom has written extensively is required when there is significant Jean-Paul Sartre argued that “exis- on existential psychotherapy,11 where uncertainty or doubt, and without tence precedes essence”6 and that it is psychiatric symptoms or inner con- uncertainty or doubt there may be not until we have engaged with life flicts are viewed as the result of dif- little role for faith. The concept of a and done things that we can look back ficulties in facing what he describes as “leap of faith” originates in Kierkeg- and see our “essence” reflected in the four “givens” of human existence: aard’s writings, although he does not what we have done. At the end of life, mortality, meaninglessness, isolation, use this exact phrase. One can suggest patients may feel they are returning to and freedom. Existential psychother- to a patient that fear centred on uncer- mere existence. Sartre even suggested apy focuses on identifying which of tainty surrounding death is common that death results in us existing only these existential givens patients are and that the doubt they are feeling may to the outside world, leaving evidence struggling with and helping them to actually be an opportunity to strength- of a uniquely individual experience respond in positive ways. Certainly, en their faith rather than to abandon it. of existence that is no longer pres- acute appreciation of one’s mortality, While not directly related to Kierkeg- ent. The thought of retreating from disconnection from meaning, feelings aard’s ideas, another potentially com- essence to existence only to others of isolation, and uncomfortable free- forting aspect of uncertainty is that it could certainly be a frightening one. dom in making difficult choices can means you have wiggle room or flex- In contrast, Sartre also wrote about all play a significant role in existential ibility and that nothing is set in stone. needing to experience “death con- suffering at the end of life.

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What is existential of a frustrating day). It is also wrong patient’s spiritual beliefs are, and suffering? to imagine we can treat any of these questions based on the FICA spiritual If you are still not sure how to define spheres in isolation. Opiate medica- history tool17,18 can help you do this existential suffering, you are not alone. tions for physical suffering, for ex- (see the Table ). In a review of existential suffering ample, have significant psychological Although one could argue it is a in the palliative care setting, Boston effects. An important corollary to this religious leader’s role, and not a phy- and colleagues12 reviewed 64 papers is that addressing social, psychologi- sician’s, to discuss spiritual or reli- and found 56 different definitions. cal, and spiritual pain is likely to af- gious matters with a patient at the Themes common to the descriptions fect a patient’s experience of physical end of life, an equally strong argu- of existential suffering included lack pain as well. ment could be made in support of a of meaning or purpose, loss of con- role for the physician by posing ques- nectedness to others, thoughts about What is the physician’s role in tions about training: What exactly is the dying process, struggles around the face of spiritual distress? the training religious leaders receive the state of being, difficulty in find- Looking at social, psychological, and to provide this kind of care? Is their ing a sense of self, loss of hope, loss spiritual suffering, spiritual distress is training accredited in some way or of autonomy, and loss of temporality. likely to be viewed as the most remote based on evidence of effectiveness? Cicely Saunders introduced the from a physician’s core training. Do religious leaders know more than concept of total pain, which encom- Many equate spirituality with reli- palliative care specialists? These passes physical, social, psychologi- gion and, understandably, physicians questions are posed here not to di- cal, and spiritual suffering.13 Spiritual are reluctant to discuss religions they minish the important role of religious factors (e.g., belief in life after death), may know little about. Physicians are leaders (some of whom do have spe- psychological factors (e.g., sense of about half as likely as patients to hold cialized training in working with dy- self), and social factors (e.g., con- a particular spiritual belief.14 Even if ing patients) in caring for patients at nectedness to others) can easily be a physician follows a religion, he or the end of life, but rather to suggest seen in the descriptions of existential she might be concerned about being that physicians’ knowledge and train- issues listed above, so perhaps exis- intrusive,15 and some guidelines for ing should make them confident that tential suffering is best thought of as communicating with patients about they, too, have something to offer. In distress within these three spheres of spiritual issues caution against dis- Boston and colleagues’12 summary of total pain. However, it is important to cussing your own religious beliefs, how existential suffering is defined in note that the divisions between these stating they are generally not rel- the literature, many of the definitions different sources of pain are artificial evant.16 However, it is possible to focus on meaning and purpose, and as all three spheres are connected. For bring wisdom from the world’s major these are concepts for which modern instance, we have all had the experi- religions into therapeutic discussions evidence-based medical interventions ence of physical pain being exacerbat- about illness and death without intru- have been developed.9,10 ed by emotional context (e.g., hitting sively promoting a particular faith. Central to whatever role physi- your head on something in the middle It is always helpful to know what a cians play when helping patients deal with spiritual distress is the need for adequate support. Feelings such as Table. Questions based on the FICA spiritual history tool to help physicians address issues of sadness, isolation, inadequacy, or faith and belief with patients. hopelessness can be experienced by Faith and belief “Do you consider yourself spiritual or religious?” physicians caring for seriously ill “Do you have spiritual beliefs that help you cope with stress/difficult times?” patients, and it is important for phy- “What gives your life meaning?” sicians to seek help for themselves. A concept discussed in psychother- Importance “What importance does spirituality have in your life?” apy supervision is parallel process, “How has your spirituality affected your experience of this illness?” whereby issues that arise between a Community “Are you part of a spiritual community?” patient and a therapist are mirrored “Does this community provide you with support?” in the interactions of the therapist “Can you reach out for help?” and the therapist’s supervisor. This Address in care “How would you like me to address spiritual issues in your health care?” and other evidence shows that phy-

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sicians need connectedness and sup- treat depression and anxiety, can also Assisting with patient loss port to cope with their own existential be effective in treating terminally ill of identity distress.19 In addition, providing the patients. For example, patients with Loss of identity or a defining role in best possible care to dying patients serious illness sometimes describe a life is a common part of existential generally involves recruiting assis- complete loss of identity, a problem suffering. Assisting patients to see tance from others when that luxury is that can be addressed using CBT to that many things (possibly core val- available. Just as with other kinds of help patients identify this generaliza- ues, relationships, interests, skills) clinical challenges, it is always a good tion or “all-or-nothing” thinking and have not been changed by their diag- idea to seek advice from peers who aid them in recognizing core parts of nosis can be very therapeutic. For have likely had similar experiences. themselves that remain unchanged. example, a father who feels he is no In larger centres, palliative medicine, Depression and hopelessness have longer fulfilling his role as a parent psychiatry, social work, and spiritual been found to be the strongest in- because his illness prevents him from care are all services to consider in- volving in a dying patient’s care. In Canadian hospitals, most spiritual care providers are associated with the Canadian Association for Spiritual Existential suffering is associated with Care and are experts in supporting an individual patient’s spiritual beliefs a number of clinical issues, including without promoting any of their own. reduced quality of life, increased anxiety Some hospitals also have a professional ethicist or ethics team to help and depression, suicidal ideation, and desire with ethical dilemmas. for hastened death. Recognizing existential How can physicians address suffering can therefore alert us to the likely existential suffering? presence of symptoms we can address. As summarized by LeMay and Wil- son,20 existential suffering is associated with a number of clinical issues, including reduced quality of life, increased anxiety and depression, sui- dependent predictors of desire for playing catch with his son can bene- cidal ideation, and desire for hast- hastened death in terminally ill pa- fit from being educated about how ened death. Recognizing existential tients22 (stronger than poor physical he is fulfilling another role: model- suffering can therefore alert us to the function), and these are also both ing for his son how to get through likely presence of symptoms we can symptoms physicians can address. an extremely difficult experience. address. Anxiety, depression, suicidal As well as alerting us to the pos- By demonstrating how to maintain ideation, and desire for hastened death sible presence of clinical issues, exis- relationships and recruit support, a are addressed regularly by physicians tential suffering sometimes presents parent provides an invaluable lesson (particularly psychiatrists) in other as another symptom. For example, if for a child. Some parents also like to settings, and there is good evidence a patient with serious illness begins create legacy projects for their chil- that our interventions work in the complaining of new-onset insom- dren, such as writing cards for each palliative care setting as well. For nia, a clarifying statement and ques- birthday up to a particular age. Older example, Holland and colleagues21 tion can elicit further information: parents are often concerned about showed that both fluoxetine and “Sometimes people are afraid they’re burdening adult children with hav- desipramine were effective in treat- not going to wake up. Is that some- ing to care for them. They are used to ing depression and improving quality thing you worry about?” Answers giving rather than receiving care and of life in women with advanced can- will often provide evidence of anxiety the role reversal can be quite upset- cer. Psychotherapeutic interventions and existential suffering that require ting. In these cases an older parent can such as cognitive-behavioral therapy a broader approach and more than an benefit from knowing that allowing (CBT), which is used routinely to order for zopiclone. adult children to pay back just a small

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fraction of the care they have received “Who’s supporting you right now?” and knowing how they want to spend over many years helps them with communicates a greater impression their time as a silver lining to a diag- their own feelings and ability to cope. that you care about how they are go- nosis of terminal illness. Unfortu- There are clearly exceptions, but in ing to cope with their grief. nately, this is sometimes paired with general parents tend to speak highly guilt or remorse related to a sense of of their children and enjoy telling Adjusting boundaries not having spent their time well up clinicians about their children’s posi- Holding a patient’s hand for any to that point. Some patients may also tive attributes. “Where did they get length of time would be a boundary feel there is now no opportunity for that from?” is a simple, yet often very violation in many medical settings, anything other than dying because of effective question for helping parents particularly for psychiatrists who the large amount of time they “wast- reflect on positive things they have tend to avoid touching patients at all. ed.” Helping patients with existential passed on to their kids. Yet given that loss of connectedness suffering realize they are still alive Children with terminal illness are to others is such a common theme in is often key. Some argue that hope is another unique population. Adults’ definitions of existential suffering, an act rather than a feeling. Children praise of children frequently involves few things are more therapeutic than generally have a remarkable way of telling them about what they are capa- holding the hand of a dying patient achieving hopefulness on their own. ble of achieving. Children may lose who is otherwise alone. Similarly, Youth in hospice generally have the their sense of self-worth if they know placing a gentle hand on a patient’s same desires and interests as other there is nothing they can become as shoulder as you arrive or as you leave young people, such as wanting to an adult.23 How to best address exis- the bedside can communicate a con- make friends and being interested in tential concerns in children depends nectedness or caring that might be sex.28 strongly on developmental stages.24 difficult to convey appropriately in As children, we develop an un- words. Best practice is always to ob- derstanding of death-related con- Supporting family members serve appropriate boundaries in the cepts, including universality (all liv- Family members experience distress doctor-patient relationship, but there ing things die), irreversibility (once and require support as well. We all in- is good reason to shift these bound- dead, dead forever), nonfunctional- ternalize aspects of our parents, and aries in some palliative care settings. ity (all functions of the body stop), when a parent is dying both young and and causality (what causes death). adult children may feel a core part of Using formalized interventions Perhaps a new application of these themselves or their life is dying. Re- Formalized interventions include concepts to the patient’s own situa- lated to children feeling that their pur- meaning-centred psychotherapy, an tion is what can lead to a sense of op- pose or worth is in “becoming” some- intervention developed at Memorial portunity—that silver lining—rather thing to please encouraging adults, Sloan Kettering Cancer Center and than existential suffering. Patients children may feel a loss of identity or aimed at helping patients with ad- with terminal illness know they are purpose with a parent’s death. Simi- vanced cancer reconnect with experi- not a unique exception to universali- larly, family members often grieve ential, creative, attitudinal, and his- ty, and they often know what is going not only the loss of their loved one, torical sources of meaning;9,10 Dignity to kill them (a personalized causal- but also the loss of their caregiving therapy, created by Harvey Chochinov ity). They are also likely experienc- role, especially if the person has been and colleagues in Winnipeg;25 and ing irreversible physical deteriora- ill for a long time. Educating family Managing Cancer and Living Mean- tion (nonfunctionality). They have members about how common these ingfully (CALM) psychotherapy, de- fallen into the same cave as everyone feelings are and letting them know veloped by Gary Rodin and colleagues else, it is getting darker and narrower that these feelings will generally be- in Toronto.26,27 LeMay and Wilson as time goes by, and they even know come less painful over time can re- present a review of other manualized what unfortunate companion is push- duce distress. In expressing condol- therapies for existential distress.20 ing them along. Hopefully, they can ences to family members, we com- also realize they are still free to ex- monly say something like “I’m sorry Helping patients find a plore some of the cave’s more beau- for your loss” or “This must be very silver lining tiful features, to draw or write on the difficult” to convey empathy. Fol- Many dying patients see their new- walls, to show courage in exploring lowing up such statements by asking found realization about being alive some of the uncharted alcoves, and

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to map out some of the more treach- ual. New York: Oxford University Press; 24. Bates AT, Kearney JA. Understanding erous terrain for others who will 2014. death with limited experience in life: Dying follow. 11. Yalom ID. Existential psychotherapy. New children’s and adolescents’ understand- York: Basic Books; 1980. ing of their own terminal illness and death. Acknowledgments 12. Boston P, Bruce A, Schreiber R. Existential Curr Opin Support Palliat Care 2015;9:40- The author wishes to thank Dr Patricia suffering in the palliative care setting: An 45. Boston and Dr Sharon Salloum for their integrated literature review. J Pain Symp- 25. Chochinov H. Dignity therapy: Final words comments on a draft manuscript and tom Manage 2011;41:604-618. for final days. New York: Oxford Univer- Ms Amanda Wanner from the College of 13. Bodek H. Facilitating the provision of qual- sity Press; 2012. Physicians and Surgeons of BC library. ity spiritual care in palliative care. Omega 26. Lo C, Hales S, Jung J, et al. Managing Can- 2013;67:37-41. cer And Living Meaningfully (CALM): Competing interests 14. Maugans TA, Wadland WC. Religion and Phase 2 trial of a brief individual psycho- None declared. family medicine: A survey of physicians therapy for patients with advanced can- and patients. J Fam Pract 1991;32:210- cer. Palliat Med 2014;28:234-242. References 213. 27. Nissim R, Freeman E, Lo C, et al. Manag- 1. Swenson DF. Something about Kierke 15. Post SG, Puchalski CM, Larson DB. Physi- ing Cancer and Living Meaningfully gaard. Macon, GA: Mercer University cians and patient spirituality: Professional (CALM): A qualitative study of a brief indi- Press; 1983. p. 111-134. boundaries, competency, and ethics. Ann vidual psychotherapy for individuals with 2. Kierkegaard S. The essential Kierkegaard. Intern Med 2000;132:578-583. advanced cancer. Palliat Med 2012;26: Hong EH, Hong HV, editors and transla- 16. Breitbart W, Alici Y. Psychosocial palliative 713-721. tors. Princeton, NJ: Princeton University care. Oxford: Oxford University Press; 28. Kirk S, Pritchard E. An exploration of par- Press; 2000. p. 216-217. 2014. p. 118. ents’ and young people’s perspectives of 3. Heidegger M. History of the concept of 17. Puchalski C, Romer AL. Taking a spiritual hospice support. Child Care Health Dev time: Prolegomena. Kisiel T, translator. history allows clinicians to understand pa- 2012;38:32-40. Bloomington: Indiana University Press; tients more fully. J Palliat Med 2000;3: 1992. p. 313. 129-137. 4. Kierkegaard S. Søren Kierkegaard’s jour- 18. Puchalski CM. The FICA Spiritual History nals and papers. Hong HV, Hong EH, edi- Tool #274. J Palliat Med 2014;17:105-106. tors and translators. Bloomington: Indiana 19. Aase M, Nordrehaug JE, Malterud K. University Press; 1967. p. 22-26, 56. “If you cannot tolerate that risk, you 5. Gemes K, Richardson J. The Oxford hand- should never become a physician”: A book of Nietzsche. New York: Oxford Uni- qualitative study about existential experi- versity Press; 2013. p. 675-700. ences among physicians. J Med Ethics 6. Sartre J-P. Existentialism is a humanism. 2008;34:767-771. Macomber C, translator. New Haven, CT: 20. LeMay K, Wilson KG. Treatment of exis- Yale University Press; 2007. p. 55. tential distress in life threatening illness: A 7. Sartre J-P. Being and nothingness: An es- review of manualized interventions. Clin say on phenomenological ontology. Psychol Rev 2008;28:472-493. Barnes H, translator. New York: Washing- 21. Holland JC, Romano SJ, Heiligenstein JH, ton Square Press; 1992. p. 680-698. et al. A controlled trial of fluoxetine and 8. Frankl VE. Man’s search for meaning. Bos- desipramine in depressed women with ton: Beacon Press; 2006. advanced cancer. Psychooncology 1998; 9. Breitbart W, Poppito S. Individual mean- 7:291-300. ing-centered psychotherapy for patients 22. Breitbart W, Rosenfeld B, Pessin H, et al. with advanced cancer: A treatment man- Depression, hopelessness, and desire for ual. New York: Oxford University Press; hastened death in terminally ill patients 2014. with cancer. JAMA 2000;284:2907-2911. 10. Breitbart W, Poppito S. Meaning-cen- 23. Hoffmaster B. The rationality and morality tered group psychotherapy for patients of dying children. Hastings Cent Rep with advanced cancer: A treatment man- 2011;41:30-42.

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Changing epidemiology of Clostridium difficile–associated infections lostridium difficile infection ed across Europe and North America Although little is known of where continues to be a common and is occurring in patients who are and how C. difficile is acquired, it C cause of health care–associat younger, healthier, and with fewer is well known that alteration of the ed diarrhea in North America, contrib- risk factors. A recent report showed a normal enteric flora, especially from uting to patient morbidity and mor- shift in strain types in a region in BC unnecessary use of antibiotics, is an tality. C. difficile is a gram-positive, from a highly virulent strain associ- important risk factor. Two of the main spore-forming, anaerobic bacteria that ated with health care–associated C. challenges in C. difficile are relapse spreads via the fecal-oral route from difficile in 2008 to novel strain types and recurrence of disease. Predispos- person to person. Its pathogenicity is in 2013.3 These novel strain types ing factors for relapse include insuf- based on the production of toxins and, ficient length of treatment, inadequate in some strains (e.g., NAP-1 strain), an doses of oral agents (commonly met- C. difficileis a overproduction of toxins. Manifesta- ronidazole), or both. It is important tion of C. difficile is characterized by gram-positive, spore- to note that almost 30% of cases diarrhea, fever, nausea, and abdominal forming, anaerobic bacteria were reported as recurrent in 2012.1 pain, and in severe cases progresses to that spreads via the fecal- In many of these cases, conventional toxic megacolon, sepsis, and death. As oral route from person to antibiotic treatments have had limited well, reduced susceptibility to metro- person. Manifestation of success and patients suffer repeated nidazole is emerging, and this compli- episodes. Proper choice and dosing of C. difficile is characterized cates treatment. Those who are immu- antibiotics according to recommend- nosuppressed and those over 65 years by diarrhea, fever, nausea, ed guidelines are important steward- of age have increased risk of compli- and abdominal pain, and in ship practices. Patients should be cations and death. Children were tra- severe cases progresses to counseled to adhere to treatment regi- ditionally thought to be asymptomatic toxic megacolon, sepsis, mens and to complete the prescribed carriers of the organism; however, and death. course. Recently, stool transplanta- children between the ages of 1 and 18 tion has provided a safe and effective years are affected by C. difficile.1 alternative to antibiotic treatment for It is important to understand the identified in the health care setting in patients with recurrent CDI. A guide changing epidemiology of C. difficile 2013 were seen in the community set- for best practice management is avail- to understand diagnosis and guide ting within this region in 2008, sug- able at www.picnet.ca/wp-content/ infection prevention and control gesting that C. difficile strains from uploads/Toolkit-for-Management practices. According to the Provincial the community setting were likely -of-CDI-in-Acute-Care-Settings Infection Control Network of British introduced into health care facilities -2013.pdf. Columbia (PICNet), the provincial where they contributed to circulating —Linda Hoang, MD, MSc, FRCPC rate of C. difficile has decreased by health care–associated strains. Using Medical Microbiologist, BCCDC more than 50%, from 8.6 per 10 000 whole genome sequencing, a group Public Health Laboratory inpatient days in 2009–10 to 4.2 per in the UK demonstrated that there BC PICNet Medical Co-Lead 10 000 inpatient days in 2014–15. are numerous sources for C. difficile —Elizabeth Bryce, MD, FRCPC Among the 2014–15 cases, howev- acquisition, including colonization in Medical Microbiologist, VGH er, close to 30% were community- the community prior to admission to Microbiology Laboratory associated, which is double the num- hospital. BC PICNet Medical Co-Lead ber of those cases in 2009–10.2 This Currently, there is very limited in- —Bonnie Henry, MD, MPH, FRCPC increase in incidence of community- formation on potential environmental Deputy Provincial Health Officer, associated C. difficile has been report- sources of C. difficile. However, C. Ministry of Health difficile can be recovered from retail This article is the opinion of the BC Centre meats and vegetables. Colonization References for Disease Control and has not been peer by household pets has also been re- Available at bcmj.org. reviewed by the BCMJ Editorial Board. ported.4

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New inorganic lead-monitoring guidelines

ead (Pb) is the quintessential the dose and duration of exposure. heavy metal with toxic proper- They are typically nonspecific and Adverse health effects ties that have been recognized can include fatigue, myalgia, arthral- L associated with elevated for centuries. It’s a naturally occur- gia, irritability, lethargy, abdominal ring, nonessential element with well- discomfort or pain, tremors, head- lead exposure include defined dose-toxic effect relationships. aches, constipation, and difficulty hypertension and anemia, Adverse health effects may start with concentrating. More extreme expo- as well as renal, blood lead levels (BLL) as low as sures can result in encephalopathy gastrointestinal, 0.48 μmol/L (10 μg/dL)* in adults. with seizures, altered consciousness, reproductive, and central The 95th percentile for BLL for Ca- coma, and death. Enquiring about and peripheral nervous nadian adults is approximately 0.2 to workplace activity and exposure can 0.3 μmol/L. Adverse health effects identify lead exposure as a possible system dysfunction. associated with elevated lead expo- contributing factor. For additional sure include hypertension and ane- information on lead toxicity and man- mia, as well as renal, gastrointestinal, agement, see the suggested reading. ment officers doing target practice, reproductive, and central and periph- to workers at battery recycling facili- eral nervous system dysfunction. The Lead exposure in ties or radiator repair shops, weld- International Agency for Research on the workplace ers dismantling lead painted bridges, Cancer has deemed lead a probable Lead exposure still occurs in many metal refinery workers, grinders of carcinogen. workplaces in BC, and every year fishing lead lures, and others. Work- Inorganic lead is absorbed by WorkSafeBC adjudicates claims SafeBC requires that employers have inhalation or ingestion. Signs and for exposure and toxicity. Exposure an exposure control program for lead- symptoms of lead exposure vary with situations vary from law enforce- exposed workers. Exposure control programs typically include biological monitoring Table. Recommended actions for measured BLL. for lead by measuring BLL. Work- Retest Blood lead level Recommended action SafeBC guidelines for BLL moni- recommendation toring were summarized in a prior < 0.48 μmol/L None to annually. No specific actions necessary. article in the BCMJ (2009;51:388). (< 10 μg/dL) The guidelines were based on the 0.48–0.96 μmol/L Every 6 months. ALERT American Occupational Safety and (10–19 μg/dL) Minimize exposure by reviewing all sources of exposure and improving protective measures. Health Administration standards first enacted into law in 1978 for gen- 0.97–1.44 μmol/L Every 1 month. REMOVAL (20–29 μg/dL) 1. Remove worker from further lead exposure if a repeat eral industry. Many clinicians and test is greater than 0.97 μmol/L (20 μg/dL). researchers in the field of occupa- 2. Return worker to previous duties when: tional medicine have advocated for a - Blood lead level is acceptable to a physician, and - Exposure is minimized by reviewing all sources of review of the older standards of prac- exposure and improving protective measures. tice because they are not considered ≥ 1.45 μmol/L Monthly until the REMOVAL to be sufficiently protective for work- (≥ 30 μg/dL) level is 1. Remove worker from further lead exposure. ers with occupational lead exposure. acceptable to a 2. Return worker to previous duties when: physician. - Blood lead level is acceptable to a physician, and Newer recommendations have been - Exposure is minimized by reviewing all sources of proposed to rectify this situation and exposure and improving protective measures. better protect the health of workers. Note: Pregnant or breastfeeding women should be reassigned to tasks that do not involve lead exposure. In response to these changes, Work- SafeBC is also updating its guide- *In the past, BLL was reported in μg/ This article is the opinion of WorkSafeBC lines. These newer guidelines are dL, but now it is reported in μmol/L (1 and has not been peer reviewed by the summarized in the Table . μmol/L is approximately 20 μg/dL). BCMJ Editorial Board. Continued on page 287

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Book review: The Reservoir In Paris they are joined by a virologist primary care setting. The guideline By Douglas Has- from the Pasteur Institute. After an ar- is available to physicians across Brit- san, MD. New duous journey down the Congo River ish Columbia at www.BCGuidelines York, NY: Page the group encounters the new species .ca and includes new action plans and Publishing, 2015. of ape and obtains blood samples for flow sheets. ISBN 978-1-68139- further study, but unknown to them a 655-2. Paperback. Pakistani doctor turned terrorist hop- Key recommendations Dr Hassan was ing to create a biological weapon is • Send children aged 6 years and in several of my also on his way to find a sample of the older for spirometry when they are classes while work- same virus. When the CIA becomes symptomatic to improve accuracy. ing toward his medical degree at UBC aware of the potential bioterrorism • Send patients for spirometry regu- in 1987, and then went on to study threat, agents joint the race to inter- larly as part of the assessment of orthopaedics and hand surgery. He cept the plan. asthma control. currently works with Puget Sound Or- It would be unfair to readers to re- • Prescribe controller medication dai- thopaedics. I have also known his fa- veal the dangers and conflicts that the ly and not intermittently. ther, Dr Leslie Hassan, a retired North group runs into, and the CIA’s wild • Controller medication does not Vancouver physician for many years, pursuit of the terrorist across several need to be increased with an acute so it was a very pleasant surprise to continents. As for more about the vi- loss of asthma control in children. read Dr Hassan’s thriller, The Res- ral sample held in the Pasteur Insti- • At each visit, assess for proper use ervoir, the first volume of a planned tute in Paris, you’ll have to wait for of asthma medication devices and trilogy. the second installment of this trilogy. medication compliance as these are Several stories are intertwined in I am looking forward to it. common reasons for poor asthma this fiction with bioterrorism as the —George Szasz, CM, MD control. underlying theme. A report of an Eb- West Vancouver • Prescribe an age-appropriate spacer ola-like virus that is devastating the device for patients using metred populations of small villages in the GPAC guideline: Asthma dose inhalers (MDI). Virunga area of the Congo, and the in Children—Diagnosis • Send all patients and families to an suspicion that an unidentified species and Management asthma education centre to learn of highly evolved apes might be the A new BC Guideline developed by self-management (where available). reservoir of the virus, prompts a sci- Child Health BC in collaboration • Given that many children less than entific expedition. A small team sets with the Guidelines and Protocols 6 years of age outgrow their asthma out from Seattle—an anthropologist Advisory Committee provides rec- symptoms, reassess the persistence expert in apes, his friend, an orthopae- ommendations for diagnosis and of symptoms every 6 months in this dic surgeon, an adventurer familiar management of asthma in patients age group. with the area, and a security person. aged 1 to 18 years presenting in a • There is insufficient evidence to recommend one inhaled corticoste- roids molecule over another with respect to efficacy or safety. • Ensure children have normal activity levels and do not limit physical ac- The services we provide are: tivity to control asthma symptoms. • Filing Corporate Tax Return • Annual WCB Return • Filing Individual • Payroll Return for owners • Complete a written asthma action (Shareholders) return and issue of T4 slips plan with each patient and reassess • Notice to reader and • Dividend Return and this plan with the patient on a regu- financial statements issue of T5 slips lar basis. • Year-end Book-keeping for • Tax Planning

the fiscal year • Estate and Financial Planning 2540 Nanaimo Street, Cell: (604) 440-6195 Vancouver, BC V5N 5X1 Fax: (604) 628-0399 www.ashishaccounting.com [email protected] bcmj.org

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Resident Doctors of BC: the internal medicine residency pro- ways to help residents learn. Addi- 2015 award winners gram with the full support of program tionally, he is timely and effective in The annual Awards of Excellence administration. his feedback, offering residents semi- recognize members of the health annual “fireside chats” to highlight care community for their contribu- Dr Patricia Clugston Memorial their strengths and suggest improve- tions to creating an optimal train- Award for Excellence in ments. ing environment for residents in Teaching: Dr Jagdeep Ubhi BC. Congratulations to this year’s The Dr Patricia Clugston Memo- Residents’ Advocate Award: Dr winners. rial Award for Excellence in Teach- Andrew Campbell ing recognizes a physician clinical The Residents’ Advocate Award rec- Award of Merit: Dr Meghan Ho educator for his or her contributions ognizes an individual who advocates The Award of Merit recognizes a to residents’ medical education. The for the personal, professional, or edu- resident who has shown outstand- recipient will have created a safe cational advancement of residents. ing initiative in resident health and learning environment that encourages Dr Andrew Campbell is the pro- well-being, promotion of the role of self-inquiry, supports adult learning, gram director of cardiac surgery and residents in the health care system, or and fosters within learners a desire to a staff congenital cardiac surgeon at advocacy and representation of resi- achieve their highest potential. BC Childen’s Hospital and St. Paul’s dents that leads to improved work or Dr Jagdeep Ubhi is program Hospital. He has advocated for sim- learning environments. director of the UBC Obstetrics and ulation training for residents since Dr Meghan Ho, an internal Gynaecology Residency Program becoming program director 5 years medicine resident, advocated for and the resident site director at Royal ago, and the simulations he developed a program to improve the training Columbian Hospital. His nominators have provided residents with invalu- that junior residents receive so that noted that he is an excellent teacher able experience to practise emergen- the transition to senior resident is who is calm and encouraging when cy scenarios and complex situations smoother. The resulting transition teaching integral skills, and is always in a low-risk environment. He is a program has become a formal part of looking for innovative and effective Continued on page 278

When medication Now we’re is not enough... here for you 24 hours a day, seven days a Evidence supports adding psychotherapy to the treatment plan week. can help your patients find the emotional well-being and balance they are looking for. The Physician Health Program of British Columbia The Summit Counselling Group is a collection of highly skilled now offers help 24/7 to B.C. doctors and Registered Clinical Counsellors with the experience and qualifications their families for a wide range of personal and to address a full spectrum of emotional or psychological concerns. We professional problems: physical, psychological and provide exceptional care to children, adolescents, adults, couples, and social. If something is on your mind, give us a call families, seven days a week. at 1-800-663-6729. Or for more information about our new services, visit www.physicianhealth.com. Easily accessible location. Sliding scale available. CVAP, ICBC and AFU accepted. Self-referrals welcome. 604-558-4898 summitcounselling.ca

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Continued from page 277 $1000 to donate to a charity of their rected an error that appeared on pages staunch ally of resident well-being choice and a personalized memento to 331, 332, and 334. The sentence that and provides support on a personal recognize the achievement. read “… the leading cause of traumat- level by sharing meals with residents, ic death in children under 2 years of accommodating illness and family Correction: Abusive age …” should have read “… a lead- needs, and adding physical health into head trauma ing cause. …” The corrected article is academic sessions to promoting per- The author of the article “Abusive available at www.bcmj.org/articles/ sonal well-being. head trauma: Evolution of a diagnosis” abusive-head-trauma-evolution Each award winner receives (BCMJ 2015;57:331-335) has cor- -diagnosis.

either needed blood or know some- being said, don’t wait to donate. The one who has. In 2015 we collected need is constant. 1326 units of blood, surpassing our The CFMS sincerely thanks the goal of 1225 units. Therefore, our junior and senior blood champions 2016 goal is to reach 1350 units. at each medical school across Can- ada for their volunteered time and Annual Phlebotomy Bowl dedication to this important cause. To encourage blood donations and Blood champions are medical stu- to raise awareness, the CFMS runs dents who work hand in hand with a friendly 6-month-long (Septem- their local territory managers to ber through February) competi- plan blood drives at their schools tion between medical schools to year round. They go above and track which school accumulates the beyond in encouraging their peers most donations and first-time blood to donate blood, while helping at donors. This competition, appropri- blood-typing events (called What’s ately named the Phlebotomy Bowl, Your Type?) and stem-cell cheek pits medical schools against one swabbing events held on campus. another. Students register as donors CFMS is alsoContinued looking on pageinto 278 through their school’s Partners for actively participating in stem-cell Life number, and donations are registration events. The national CFMS national blood drive: tracked by Canadian Blood Servic- stem-cell network matches donors The need is constant es at local blood clinics. Results are to patients who need stem-cell trans- One in ten Canadian patients admit- then converted from absolute num- plants. Stem cells are used to treat ted to hospital receives blood prod- bers into a per capita rate, and the more than 80 blood-related diseases ucts and, in most cases, from more winning schools receive engraved and disorders, and less than 25% of than one donor. That’s one reason plaques from Canadian Blood Ser- patients who need transplants will why the Canadian Federation of vices at the end of the competition. find a match in their family. If you Medical Students (CFMS) entered Our 2015–16 Phlebotomy Bowl are between 17 and 35 years old, into a partnership with the Canadian was a great success, resulting in 754 you can contribute to the Give Life Blood Services 39 years ago. lifesaving donations and 98 new campaign by donating stem cells. The CFMS represents over 8400 blood donors. McMaster Univer- Please register today at www.blood medical students across Canada who sity placed first in the Most Dona- .ca/stem-cells. are committed to helping others in tions Per Capita category, followed To find out how you can help every way possible. The CFMS is a by Queen’s University and the Uni- your medical school win the cov- Canadian Blood Services Partners versity of Saskatchewan. McMaster eted Phlebotomy Bowl while Giv- for Life organization and pledges University took first again in Most ing Life, contact me at salima. an annual goal for blood donations New Donors, followed by the Uni- [email protected]. because the need is ongoing. Less versity of Ottawa and Queen’s Uni- —Salima Abdulla, BSc than 4% of eligible Canadians give versity. The next Phlebotomy Bowl CFMS National Blood Drive Officer blood, yet half of Canadians have will start in September 2016. That UBC Medicine, Class of 2017

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THIS IS LEADERSHIP 2015/2016 ANNUAL REPORT

Doctors of BC annual • Dr Davidicus Wong: Inspiring pa- ing care for youth growing up with report: This is leadership tients to embrace health education, complex health conditions. The 2015–16 annual report celebrates and bringing evidence-based health The core elements, which scan a few of your colleagues who are pio- information to the public. the association’s work in support- neers in their respective fields—BC • Dr Ahmer Karimuddin: Fostering ing members, are also represented: physicians offering forward-thinking a collaborative, comprehensive ap- the message from the CEO, reports innovation and medical leadership in proach to Enhanced Recovery pro- from the president and the chair of a diversity of practice areas. grams for patients undergoing sur- the Board, financial highlights, and • Dr Arun Jagdeo: Shaping and im- gery. reports from all Doctors of BC com- proving residents’ experiences and • Dr Fiona Duncan: Supporting local, mittees in the White Report. residency education, and expanding regional, and provincial initiatives Explore this year’s report at www the scope of Resident Doctors of to lead primary care. .doctorsofbc.ca/who-we-are/annual BC. • Dr Sandy Whitehouse: Transform- -report.

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Disability insurance: patient with one of these conditions must apply and provide proof of good Your financial safety net take time away from work, as needed, health. The PDI plan provides a max- In the pursuit of practising medicine, to further their recovery and increase imum $6100 monthly benefit, based you have made many sacrifices. Fol- their quality of life. If you were to find on your income. Additional disability lowing your perseverance throughout yourself with a limitation, would you insurance is also available to increase medical school and residency, your have the freedom to follow your own your benefit amount and fill any gaps most valuable asset is the ability to advice? in coverage. work. If your circumstances changed due to a disability and you found your- Residents’ Disability Insurance self unable to practise medicine, would The provincial BC’s medical residents are provided your family be financially secure? government funds the with health coverage through Resi- Data from Statistics Canada indi- Physician’s Disability dent Doctors of BC. Due to recent cate that 18.3% of working Canadi- Insurance (PDI), but collective bargaining outcomes, Resi- ans in the 45 to 64 age bracket iden- dent Doctors of BC is no longer able coverage is not automatic: tify as having a physical, mental, or to provide disability insurance for other health-related limitation to their you must apply and provide residents, and has, instead, instated a daily activities. The top five reasons proof of good health. requirement for residents to hold dis- for claims among phyisicians are ability insurance independently. accidents, musculoskeletal disorders, In order to fill this need in the psychological disorders, cancer, and Your health circumstances may resident community, Doctors of BC circulatory disorders. change when you least expect it. has enhanced the Resident Disability These categories span a broad While you decrease your workload Insurance plan. Residents transition- range of potential disabilities. A phy- due to illness or injury, you may find ing into practice have 90 days from sician would likely recommend that a your savings diminishing or your line the end of residency to convert their of credit ballooning as you care for resident coverage to the Member Dis- personal and professional expenses ability Insurance plan without having out of pocket. to provide proof of good health. The KEY to SUCCESS with Many assume that there are Newly practising physicians are SPEECH RECOGNITION government-funded programs in also eligible to enroll in the provin- place to assist you in the event that cially funded Physicians Disability you become disabled. The Canada Insurance plan without proof of good ® Certifi ed Dragon Pension Plan Disability Benefits may health provided that, as residents, Medical Software be available to you if you have paid they held a minimum $2000 monthly Sales & Training into CPP for 4 of the last 6 years. benefit in the Doctors of BC Resident However, the maximum monthly Disability plan for at least 12 months. disability benefit is $1264.59. This One-on-one training sessions amounts to only $15 175.08 annually, Planning for the unplannable Customized to your workfl ow well below both the minimum wage If you were faced with a disability, and specifi c needs and the living wage in British Colum- with an appropriate disability insur- Complete initial, basic, and bia. To ensure your financial well- ance plan in place, you would be advanced instruction available being, supplemental disability insur- able to take time off work and focus Exclusive and professionally ance is a necessity. on your health and well-being while written training materials ensuring that your hard-earned sav- Follow up assistance and support Physicians’ Disability Insurance ings and your family were protected. and Disability Income Insurance Doctors of BC has noncommis- Disability insurance helps you plan sioned insurance advisors available Solutions for your family’s needs in the event to help you find the best plan for your CONTACT US TODAY! that you are no longer able to work career stage and financial situation. or your workload is significantly To arrange a complimentary insur- decreased due to a disability. The pro- ance review, contact insurance@doc speakeasysolutions.com vincial government funds the Physi- torsofbc.ca or 604 638-7914. 1-888-964-9109 cian’s Disability Insurance (PDI), —Caleb Bernabe but coverage is not automatic: you Insurance Administrator

280 bc medical journal vol. 58 no. 5, june 2016 bcmj.org council on health promotion

Water recycling: A step to better water stewardship and public health

y children were angry at me. Though there are many facets to allow water utility providers to dis- It was another scorching to prudent water management, one tribute nonpotable water and to allow summer day and the “water- option is to recycle greywater and nonpotable distribution systems to be M 3 park” Dad built in the backyard was rainwater. Greywater is the household installed in buildings. Currently, the not operational due to water restric- wastewater from bathtubs, showers, BC Ministry of Health is drafting a tions. Incredibly, in rainy Vancouver, sinks, dishwashers, and washing manual for greywater use in compost- a poor winter snowfall combined with machines. Water from toilets and ing toilets.5 the record sunny summer we experi- urinals is considered blackwater and Using recycled water to flush our enced last year resulted in a mora- is not suitable to be recycled. Water toilets and to water our lawns and torium on running the hose over the from kitchen sinks and dishwashers, gardens can benefit the environment playhouse slide. The kids were dying by reducing the draw on drinking to cool off, which is better than how water, improving plant growth and the garden tomatoes felt; they were soil maintenance, recharging local just dying. groundwater, and decreasing the load As my children and tomatoes on sewage and treatment infrastruc- continued to wilt I chatted with my ture. To go a step further, some sys- neighbor and learned that Vancouver At home, my tems can even extract the heat from restricts the outdoor use of only treat- rainwater barrel is washing machine and bath effluent ed drinking water.1 My neighbor has standing ready and for use elsewhere in the home. a rainwater tank. Now I do too, and I my garden is On the other hand, the use of re- am ready for another summer. looking good. claimed water may carry human Water restrictions are not always health risks, although the danger is headline news, but they do point to thought to be low.6 For example, wa- a growing issue in BC and through- ter from bathing may carry potentially out the world. To be sure, drought has pathogenic microorganisms, and wa- been part of the earth’s climate rep- ter from kitchen sinks or dishwashers ertoire for millennia, but current pro- may contain food waste and chemi- jections call for increased frequency which contains food waste, may be cals.7 Moreover, some chemicals of and more widespread occurrence considered grey or black depending contained in greywater can adversely of water shortages as global temper- on the jurisdiction.3 Rainwater can be affect plants.7 To mitigate risks to hu- atures rise.2 harvested from roofs or through other man health and agriculture, systems The human health implications of collection methods.3 are typically used to prevent direct water scarcity are already upon us and It is estimated that reusing grey- human exposure or to divert unwant- are likely to be further exacerbated as water can save up to 60% of house- ed waste and chemicals. water supplies become more precar- hold water,4 and there are many ways In BC there are still opportunities ious. Water scarcity directly threatens to reuse water (e.g., watering gardens to enhance existing regulations to agricultural production, food secur- and lawns, or flushing toilets and urin- balance water stewardship with pub- ity, and the effectiveness of sanita- als), but regulations around reusing lic health, including more compre- tion systems. Also troubling are the water vary across jurisdictions. hensive Ministry of Health policies geopolitical implications of diminish- In BC regulations have included and regulations for reusing different ing access to water. The World Bank provisions for the use of reclaimed types of water, and municipal bylaws warns of the prospects for economic water since 1999. Wastewater in BC on plumbing code reuse provisions.3 decline, increased poverty, and inter- is already being reused in toilet/urinal More broadly, greater alignment national conflict.3 flushing, landscape watering, play- between environmental, health, and ground use, green-roof irrigation, municipal policies and regulations This article is the opinion of the Council on golf course irrigation, and forage can minimize human health risks Health Promotion and has not been peer crop irrigation. The BC government associated with reusing water. reviewed by the BCMJ Editorial Board. has also updated the Building Code Continued on page 283

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The person first

This essay is based on the winning entry from the UBC Faculty of Medicine Book Club’s 2016 writing competition.

Trish Caddy, MD

“ he Family Room,” the triage Rooms that were beepless and halo- plunged into a nightmare. This person nurse said, nodding me in and gen-lit, trying to soften the blow of she had trusted threatened murder, Thanding me a crumpled scrap loss. I introduced myself, explained then assaulted her. Try as she might, of something. my role, and sat down. She looked at she found she couldn’t overpower A receipt. Weird. I yawned and the ground, at the door. him, or even shout for help. Faced stuffed the paper in my pocket as I I said, “I know you’ve told your with no alternatives, she prayed he stepped into the windowless space. story a hundred times tonight. It’s wouldn’t kill her, and waited. Stopping short, I saw her. Elise was okay. You don’t have to tell me.” Afterwards, he cried and said he young, deaf, and mute. She sat erect, She started to tell me. Slowly at didn’t know what to do; now it was clutching a cardboard tray in shaking first, but soon, the ideas tumbled out over. She swore she’d never tell. She hands. Waves of nausea were racking and over each other as fast as her even told him she loved him. It was her, and her smooth, dark skin had a hands could form them. Pausing only fine. She’d keep it quiet. He let her go, greenish cast. Her translator shook once or twice, she would lift the tray and she got herself to an Esso around my hand. I had met many women by to wretch uselessly at the cardboard the block. On the back of a receipt, that time in those rooms with their before setting it into her lap again. she wrote to the cashier: “Call me an faded couches, Kleenex boxes and “Nothing left,” she signed, and ambulance. Tell them no sirens.” As dusty plants on dated sideboards. sighed. She shifted her weight in her she waited for paramedics, she wrote seat, and I noticed something odd down the rest of her story for the Ms Caddy recently received her MD from about the way her movements trans- nurse at triage. the University of British Columbia and is lated themselves down her limbs. In that job I had heard many night- excited to start her residency training in Her insteps were slightly different mare stories, but hers hit me the hard- family medicine. Having forgone a creative shades, and I wondered at first if she est. Her courage was monolithic, butt- writing degree to pursue biology, she at- had a rash. ing up next to the giants of grief and tended Malaspina University-College (now Maybe a burn? Then, all at once, I fear, filling the room completely. Vancouver Island University) before earn- realized that Elise’s left leg was pros- I felt useless, tiny, foolish. I ing her BSc in biology at the University of thetic. thought, “Why am I here, in this Victoria. The translator’s voice became stranger’s nightmare, at 11:30 p.m. on hers. I was an on-call support work- a Friday? I shouldn’t know these ter- UBC Medicine’s writing competition aims er for survivors of sexualized vio- rible things. Who am I to her?” She to encourage writing as a way to reflect lence. I was also 20 years old, a med might have wondered all this, too. Her and communicate, just as adjuvants boost school hopeful, technically prepared, story told, I played my part, discuss- the immune system in vaccines. The and yet, not ready at all for what she ing prophylactic medication, hospital competition was open to all UBC medical would tell me. policy, police procedures. After all students. The winning submission was That very morning, same as me, that, we still had time to kill before selected by a panel of judges with literary she had gotten out of bed, changed her seeing the doctor. Maybe to lend the experience and an interest in fostering the clothes, and brushed her teeth. She encounter some semblance of nor- relationship between the written arts and stopped by a friend’s house for coffee. malcy, we began to chat. She asked medicine. Once inside, he barred the door. She me about myself, and I answered.

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Three older brothers, yes. Coffee whipped her head around to seek my Continued from page 281 with extra cream, no sugar. A job eyes. Nobody, before that moment, At home, my rainwater barrel teaching med students pelvic exams. had ever fixed me with that look. is standing ready and my garden is Surprised, she asked why anyone Years later, I’d see it again and again looking good. would ever sign up for a job like that. in the eyes of soon-to-be moth- But my kids are still angry at me. Smiling, I told her I loved to teach, ers in labor, close to the end. That They hate tomatoes. but what I really wanted was to be fear of death, the pain, and dread —Lloyd Oppel, MD a doctor, like my students would be. of pain, mingled with tears and a She frowned and wrinkled her nose. coarse resolve. Elise grit her teeth References “I hate doctors,” she signed. “I’ve and stared through me, inside of me, 1. City of Vancouver. About the watering dealt with them all my life, and I hate holding on in desperation, a drown- restrictions. Accessed 18 April 2016. them. I hate them.” ing woman adrift. Staring, clenching http://vancouver.ca/home-property “. . . But why?” her jaw, refusing to stop the exam, -development/about-the-watering She looked at me, incredulous. it was clear she was taking me with -restrictions.aspx. “Because they don’t care. They her. I followed her down as far as a 2. Alavian V, Qaddumi HM, Dickson E, et don’t look at you and see a person, person who had never lived her life, al. Water and climate change: Under- they see a problem. Especially me.” who would never truly understand, standing the risks and making climate- She consented to a special, could go. Her desperate grasp was smart investment decisions. The World extensive pelvic exam that collects counterpoint to everything her face Bank, 2009. Accessed 21 April 2016. evidence in cases like hers. It was beheld: gratitude, shades of dig- http://documents.worldbank.org/curat optional. I explained that pelvic nity and pride in the corners of her ed/en/2009/11/11717870/water exams don’t usually hurt, but that, in mouth, and a deep, enduring sorrow -climate-change-understanding-risks light of her injuries. . . . She nodded ringing the sockets of her bloodshot -making-climate-smart-investment in haste that she understood as she eyes. Looking back at her, I was -decisions. signed her consent, determined. But flooded with certainty. 3. UBC News. UBC expert calls for better she had turned from green to grey, This. This mattered. This was water recycling in BC. Accessed 21 April frightened, despite herself. why, at 3:00 a.m., I was not fast 2016. http://news.ubc.ca/2015/08/31/ Slamming down the pen, she asleep in my comfortable bed. This ubc-expert-calls-for-better-water-recycl turned briskly and asked if I would moment was why I wore that pag- ing-in-b-c/. hold her hand. I felt myself pale. I er, and later, this one. Without any 4. US Department of Energy: Energy Effi- had always waited down the hall as warning, a total stranger mattered ciency and Renewable Energy. Guide to women were examined. in a way that deeply affirmed some- home water efficiency (2010). Accessed “Of course,” I said. Inside, my thing shared, and resilient, between 21 April 2016. http://publications.usa heart hammered. The blood in my us. Its relation to bruises and blood- .gov/USAPubs.php?PubID=331. ears was torrentially loud. Down the work was only tangential. My eyes 5. Government of British Columbia. Draft hall where I usually sat, the story she pricked with tears as I held that provincial composting toilet manual. Ac- told me was safely sequestered by all hand, that stare, that moment of deep cessed 21 April 2016. www2.gov.bc.ca/ my professional boundaries. But in and honest human, humane connec- gov/content/environment/waste-man the exam room. . . . tion. This was the heart and soul that agement/sewage/onsite-sewage-sys The nurse was ready for us. The would drive the years of sleepless tems/draft-composting-toilets-manual. curtain swung around, sealing us in. nights, on-call disasters, and over- 6. Busgang A, Friedler E, Ovadia O, et al. The day-surgery wing abandoned, time hours. The live, electric bril- Epidemiological study for the assess- we helped Elise to lay supine on the liance of that unguarded, understood ment of health risks associated with table and guided her foot and pros- moment had lit the way through an graywater reuse for irrigation in arid re- thetic to the footrests. Stupidly, I told evening of hell. gions. Sci Total Environ 2015;538:230- her that I had two hands and could I looked at Elise, surrounded by 239. afford to have one broken. Her face people she barely knew, on the very 7. State Government of Victoria, Australia. blank and stony, she watched the worst day of her very young life. Her Greywater – recycling water at home translator as I spoke, but signed hand in my hand, I said nothing. But Accessed 15 April 2016. www.better nothing. A knot in me tightened, then, and forevermore, I would see health.vic.gov.au/health/healthyliving/ somewhere. the person. greywater-recycling-water-at-home. It was a difficult exam. Elise The person first, Elise. I promise. crushed my fingers together, and

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PEARLS FOR IMMUNIZATION fessional Education Working Group. CFPC’s CME Program Award and is PRACTICE For further information and to enroll, celebrating its 20th anniversary this Online courses available now please see www.bccdc.ca/health-pro- year. Lead faculty Greg Dubord, MD, Are you interested in refreshing your fessionals/education-development/ has given over 300 CBT workshops essential immunization knowledge? immunization-courses. and is a recent University of Toronto Ensuring you are up to date on immu- CME Teacher of the Year. For details nization resources? Being better pre- MEDICAL CBT and to register visit www.cbt.ca or pared to answer clinical-related vac- Various locations and dates call 1 877 466-8228. Look for early- cine questions? Learning tips that will When you learn medical cognitive bird deadlines. improve your vaccination technique behavior therapy’s ultra-brief tech- and efficiency? Learning about the niques, you’ll feel much more com- OCCUPATIONAL MEDICINE Immunization Infographic for Health fortable handling the many “supraten- COURSES Professionals, a centralized clini- torial issues” in your practice. Choose Self-learning course, Sep–May cal resource to make accessing vac- from the following workshops, each The Foundation Course in Occupa- cine information easier? Pearls for accredited for at least 12 Mainpro-C tional Medicine, developed at the Immunization Practice is an online credits: Banff—Banff Delta Royal University of Alberta, is now being self-learning course for all interested Canadian Lodge (11–13 Jul); Whis- presented across Canada in two parts. immunization providers that takes tler—Delta Whistler Suites (18–20 Our British Columbia Part A course is approximately 1 hour to complete. It Jul); British Isles cruise—Celebrity facilitated by three BC occupational is especially useful for physicians new Silhouette (6–20 Aug); Toronto— physicians and runs from September to to immunization practice in BC. This Sheraton Centre (26–27 Aug); Van- May by monthly teleconferences and course is also suitable as a refresher couver—Westin Vancouver Airport two full-day face-to-face Vancouver- for physicians who have a theoretical (16–17 Sep); Scottsdale—Fairmont based workshops (21 Jan and 27–28 and clinical understanding of immu- Scottsdale Princess (24–26 Nov); May). This practical, case-based, nization practice and would like to Caribbean cruise—Disney Fantasy group learning curriculum enhances update their knowledge. The course (10–17 Dec); Disney World—Grand the effectiveness of primary care and was developed by the British Colum- Floridian Resort (19–21 Dec); Baha- community-based physicians in deal- bia Immunization Committee Pro- mas—Atlantis Resort (9–12 Feb ing with occupational medicine cases 2017); Maui—Sheraton K’anapali including fitness-to-work determina- (27–29 Feb); Kauai—Grand Hyatt tions and disability prevention and BCMJ’s CME listings (10–12 Apr 2017); South Pacific management. Course enrollment is Rates: $75 for up to 150 words cruise—Paul Gauguin (15–29 Apr limited to 15 participants to enhance (maximum), plus GST per month; 2017); Mediterranean cruise—Celeb- the small-group experience. This there is no partial rate. If the rity Reflection (9–20 Oct 2017). CBT course (Part A) has been accredited by course or event is over before an Canada is a national winner of the the CFPC for up to 111 M1-MainPro issue of the BCMJ comes out, there is no discount. VISA and MasterCard accepted. Deadlines: COLLEGE OF PHYSICIANS AND SURGEONS OF BC Online: Every Thursday (listings are posted every Friday). Education Day + AGM Print: The first of the month 1 month prior to the issue in which you want your notice to appear, e.g., 1 February for the March When duty calls: legal and issue. The BCMJ is distributed professional obligations by second-class mail in the second week of each month except www.cpsbc.ca in medical practice January and August. E-mail: [email protected] Phone: 604 638-2815 SEPT , #DutyToAct REGISTER TODAY

284 bc medical journal vol. 58 no. 5, june 2016 bcmj.org calendar credits. Those completing Part A can audience: Any physician providing ver-False Creek). Conference regis- progress to the Part B course. Partici- emergency care—from rural to urban, tration, information, program details, pants who pass written exams on both part-time to full-time, residents to sea- and online registration is available parts are eligible for accreditation soned veterans, and emergency nurs- at http://ubccpd.ca/course/sphemerg from the Canadian Board of Occupa- es and paramedics. Special guests, the -2016. Phone 604 875-5101, fax 604 tional Medicine. Further information Hair Farmers will be featured at our 875-5078, e-mail [email protected], visit the Foundation’s website at www Friday night reception at the newly web ubccpd.ca. .foundationcourse.ualberta.ca. renovated GLC. Keynote speakers: Dr Grant Innes (University of Alber- MINDFULNESS IN MEDICINE PRACTICE SURVIVAL SKILLS ta), Dr Stuart Swadron, (Keck School Tofino, 28 Sep–2 Oct (Wed–Sun) Vancouver, 11 Jun (Sat) of Medicine, USC), Dr Judith Tintin- Mindfulness in Medicine—Founda- This 9th annual conference will be alli, (UNC School of Medicine), and tions of Theory and Practice is a 4-day held at UBC Robson Square. PSS Sam Sullivan (CM, MLA, Vancou- Continued on page 286 2016 will emphasize practical, non- clinical knowledge crucial for your career, with topics such as billing, navigating through the medical orga- nizations, accreditation, practice audits, medicolegal advice and report writing, job finding, office skills and management, physician resources, practice management, and mindfulness. Target audience for “What I Wish I Knew in My First Years of Practice” conference are family phy- CMA General Council 2016 sicians, specialty physicians, locums, IMGs, physicians new to BC, family practice and specialty residents, and VANCOUVER physicians working in episodic care settings. Conference format: Inter- CMA 149th Annual Meeting active, didactic lectures, interactive small-group workshops, plenty of August 21-24, 2016 networking opportunities, practice- The Westin Bayshore Hotel based exhibits, end-of-day job fair, and reception. Meet with colleagues and make career connections! Con- cma.ca/gc2016 #cmagc ference registration and information at www.ubccpd.ca, call 604 875- 5101, fax 604 875-5078, or e-mail [email protected].

ST. PAUL’S EMERG MED UPDATE Whistler, 22–25 Sep (Thu–Sun) Join us at the Whistler Conference Centre for the 14th annual St. Paul’s conference—four exciting days of learning, networking, and of course, recreation! Last year more than 300 people attended this meeting, so don’t miss out this year. Preconfer- Change in Action. Be part of it. ence workshops: AIME, CASTED, EDE, EDE2, ACLS, CARE. Target

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Continued from page 285 elderly; Ambulatory glucose moni- details of current promotions. Phone experiential workshop approved for toring/CGMS; Combination therapy: 604 684-7327, or toll free 1 800 647- 16 Mainpro C credits. The work- Does 1 + 1 equal 3; Economics of 7327; e-mail cruises@seacourses shop’s focus will be mindfulness and diabetic foot complications: Impor- .com. Visit seacourses.com for a com- meditation as it relates to the unique tance of risk reduction; How to dis- plete list of CME cruises and tours. challenges and blessings of our work cuss obesity – A family physician’s as physicians. As chronic stress and perspective. A public health fair has HAWAIIAN CME: MAUI AND/OR its associated mental and physical been scheduled for Sunday, 6 Nov at KAUAI health challenges continue to rise in the same venue. Conference registra- Maui, 27–29 Mar 2017 (Mon– epidemic proportions, the application, information, program details, Wed), and Kauai, 10–12 Apr 2017 tion of mindfulness in clinical prac- and online registration are available at (Mon–Wed) tice settings has gained prominence www.ubccpd.ca. Tel 604 875-5101; Aloha! Please join us in the happi- both in terms of evidence-based fax 604 875-5078; e-mail cpd.info@ est American state next spring for research and in the popularity of its ubc.ca. award-winning CME in medical cog- use. Learn about the latest clinical nitive behavior therapy—Medical evidence and neuroscience on mind- SEA COURSES SUMMER/FALL CBT: Ultra-brief Techniques for Real fulness in medicine, find out about CME CRUISES Doctors. The Maui workshop (CBT programs offered throughout BC and Various destinations, Jul–Nov 2017 for Depression/Happiness) will be Canada, and explore practical medi- Travel with the CME cruise experts. held at the idyllic Sheraton Maui on tation tools for yourself and for your Discover new destinations. Return Ka’anapali Beach. With 23 acres of patients. Visit www.drmarksherman to favorite ports. Baltic and Russia lush Hawaiian grounds, you’ll never .ca for more information, or register at (Jun/Jul), Greece and Turkey (Jul), feel crowded! Maui has been voted [email protected]. Iceland and Norway (Jul), Alaska best island by the readers of Condé (Aug), Mediterranean (Aug and Sep), Nast Traveler for more than a dozen LIVE WELL WITH DIABETES Tahiti and Marquesas (Nov). Trips years. Attractions include 10 000 foot Richmond, 4–6 Nov (Thu–Sun) planned by physicians for physicians. Hale’akala (Hawaiian for house of the Come check out the conference for Sea Courses has provided almost 300 sun), 14 golf courses (including some health care professionals at the Radis- unique CME conferences onboard of the world’s top-rated), the scenic son Hotel, our new venue in Rich- cruise ships over the past 20 years. road to Hana, the Seven Sacred Pools mond, close to the Canada Line sta- Programs are accredited for special- of Oheo, and over 500 restaurants. The tion! Building on the success of our ists and family physicians, have no Kauai workshop—CBT Tools, will be new 3-day format, this year’s agen- pharma sponsorship, and include a held at the spectacular Grand Hyatt on da includes presentations designed complimentary enrichment program sunny Poipu Beach. The Grand Hyatt for family physicians, allied health for traveling companions. All Sea Kauai is ranked among the world’s professionals, podiatrists, and other Courses trips offer group pricing, top resorts by both the Condé Nast health care professionals who have an special airfares, and free cruising for Traveler and Travel+Leisure. Kauai interest in recent advances in diabe- companions. Contact Sea Courses is the most tranquil and pristine of the tes. Featured topics: Diabetes and the Cruises for more information and main Hawaiian Islands, with beaches fringing nearly 50% of its tropi- cal coastline. Attractions include the world-famous Kalaulua Trail on the Napali Coast, red-rocked Waimea Canyon, 17-mile Polihale Beach (Hawaii’s longest), crescent-shaped Hanalei Bay, and Hawaii’s only navi- gable river, the Wailua. See www.cbt. ca for details about both the Maui and Kauai workshops. Warning: Our significantly discounted guest rooms for these two workshops will sell out far in advance.

286 bc medical journal vol. 58 no. 5, june 2016 bcmj.org calendar worksafebc

GP IN ONCOLOGY TRAINING pearls, and tamure dancing suggest- Continued from page 275 Vancouver, 12–23 Sep (Mon–Fri), ive enough to make you blush. The Further information and 20 Feb–3 Mar 2017 (Mon–Fri) CME provides a rock-solid founda- If you are concerned about the evalu- The BC Cancer Agency’s Family tion in medical CBT for depression, ation of a worker’s exposure or BLL Practice Oncology Network offers reviewing a plethora of ultra-brief results, please contact a medical ad- an 8-week General Practitioner in office techniques to defeat depres- visor in your nearest WorkSafeBC Oncology training program begin- sion and be happy. CBT Canada is a office. ning with a 2-week introductory ses- national winner of the CFPC’s CME —Sami Youakim, MDCM, sion every spring and fall at the Van- Program Award, and is celebrating MSc, FRCP couver Centre. This program pro- its 20th anniversary this year. Lead WorkSafeBC Medical Advisor vides an opportunity for rural family instructor Greg Dubord, MD, is a physicians, with the support of their University of Toronto CME Teach- Suggested reading community, to strengthen their onc- er of the Year. Assistant faculty in- Agency for Toxic Substances and Disease ology skills so that they may provide cludes the inimitable Fijian psychia- Registry. Case studies in environmental enhanced care for local cancer pa- trist Benjamin Prasad, MD, FRCPC, medicine, lead toxicity. Accessed 19 tients and their families. Following from the University of Manitoba. April 2016. www.atsdr.cdc.gov/csem/ the introductory session, participants Super early bird rates for ocean-view lead/docs/lead.pdf. complete a further 6 weeks of cus- staterooms aboard the spectacular Friedman LS, Simmons LH, Goldman RH, et tomized clinic experience at the can- m/s Paul Gauguin start at $12 850 al. Case records of the Massachusetts cer centre where their patients are re- (which includes all beverages, all General Hospital. Case 12-2014. A ferred. These can be scheduled flex- taxes, all gratuities, return airfares, 59-year-old man with fatigue, abdominal ibly over 6 months. Participants who and companion cruises free). Book pain, anemia, and abnormal liver func- complete the program are eligible for with Canada’s largest cruise agency, tion. N Engl J Med 2014;370:1542-1550. credits from the College of Family CruiseShipCenters. See CBT Can- Warniment C, Tsang K, Galazka SS. Lead Physicians of Canada. Those who are ada at www.cbt.ca or call 888 739- poisoning in children. Am Fam Phys REAP-eligible receive a stipend and 3117. 2010;81:751-757. expense coverage through UBC’s Enhanced Skills Program. For more information or to apply, visit www. fpon.ca, or contact Jennifer Wolfe at 604 219-9579.

SOUTH PACIFIC CRUISE 15–29 Apr 2017 (Sat–Sat) The world’s most romantic destinations, from French Polynesia to Fiji. Join us for a 13-night cruise exploring exotic Tahiti (where Captain Bligh’s men mutinied to stay put), Mo’orea (Arthur Frommer’s vote for “the most beautiful island on earth”), Taha’a (French Polynesia’s vanilla- scented isle), Bora Bora (the celebri- ties’ exclusive hideaway), the Cook Islands (New Zealand’s private para- dise), the Kingdom of Tonga (proud- ly never colonized), and three idyllic islands of Fiji (Viti Levu, Vanua Levu, and postcard-perfect Beqa). You’ll be enchanted by the South Pacific’s craggy volcanic peaks, sugary beaches, warm lagoons teaming with fish, glistening black

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The Laboratory Services Act: Recovery of lab-test costs

n the May issue of the BCMJ we Preamble C.1 of the Doctors of • Mr Smith, age 35, goes to see his described how physicians may be BC Guide to Fees states: physician for an annual physical Iaffected by the Laboratory Ser- “Benefits” under the Act are with no medical indication. The vices Act (LSA). The Act reinforces limited to services which are physician bills MSP for the com- the provision of recovering lab-test medically required for the di- plete exam and orders a CBC, BUN, costs from the referring practitioner agnosis and/or treatment of creatinine, TSH, calcium, and liver (Section 54). This means that the a patient, which are not ex- function tests. In this case, the costs Ministry of Health is able to recover cluded by legislation or regu- of both the visit and the lab tests funds from doctors who order tests lation, and which are rendered could be recovered from the order- that are not associated with a benefit personally by medical practi- ing physician. but are billed to the Medical Services tioners or by others delegated • A physician in a wellness clinic (i.e., Plan. The ministry can recover these to perform them in accordance a facility devoted to the promotion funds by withholding amounts from with the Commission’s poli- of healthy living and the prevention future remittances. This month we’re cies on delegated services. of illness and disease) faxes a lab providing examples of circumstances Services requested or re- requisition to the lab prior to seeing under which recovery for lab-test quired by a “third party” for a patient. The following tests are or- costs may be sought by the ministry. other than medical require- dered: While most physicians will not be ments are not insured under • Male patient: CBC, ferritin, impacted, those practising wellness MSP. Services such as consul- Macro +/- micro urine, fbs, A1C, or lifestyle medicine may want to be tations, laboratory investiga- lipid profile, TSH +/- T4, Na, sure that they are ordering and billing tions, anesthesiology, surgi- K, ALT, GGT, eGFR, PSA (the lab tests in keeping with the Act. cal assistance, etc., rendered PSA is patient pay), LH, FSH, solely in association with oth- estradiol, total testosterone, This article is the opinion of the Patterns of er services which are not ben- DHEAS, hs-CRP, anti-TPO, Practice Committee and has not been peer efits also are not considered homocysteine, IGF-1. reviewed by the BCMJ Editorial Board. For benefits under MSP, except in • Female patient: CBC, ferritin, further information contact Juanita Grant, special circumstances as ap- Macro +/- micro urine, fbs, A1C, audit and billing advisor, Physician and Ex- proved by the Medical Servic- lipid profile, TSH +/- T4, Na, ternal Affairs, at 604 638-2829 or jgrant@ es Commission (e.g. Dental K, ALT, GGT, eGFR, LH, FSH, doctorsofbc.ca. Anaesthesia Policy). prolactin, estrogen, progester- The following examples describe one, testosterone, DHEAS, hs- situations in which the laboratory ser- CRP, anti-TPO, homocysteine, vice would not be considered a benefit: IGF-1. • A physician performs a pre- Previously, in order to recover employment examination for a new funds from the ordering physician, the BC Medical Journal recruit from the local fire depart- Medical Services Commission would ment. A CBC, lipid profile, and liv- have to prove that the tests ordered CME Cruise er function tests are required as part were not medically necessary. Under 12-Night Quintessential Mexican of the employer’s pre-employment the LSA, it may be up to the physician package. to prove the tests ordered were medi- Family Practice Refresher • Ms Jones brings a list of tests that cally necessary. February 09–21, 2017 her naturopath requested of her —Keith J. White, MD San Diego, CA, USA • Roundtrip physician and asks the physician to Chair, Patterns of order the tests. For more information: Practice Committee 1-888-647-7327 • A physician is performing a cos- [email protected] metic procedure on a patient who is www.seacourses.com on anticoagulants and orders a CBC and INR.

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Classified advertising (limited to 700 characters) Rates: Deadlines: Ads must be submitted or can- Doctors of BC members $50 + GST per celled by the first of the month preceding month for each insertion of up to 350 the month of publication, e.g., by 1 Novem- characters. $75 + GST for insertions of ber for December publication. Please call if 351 to 700 characters. We will invoice on you have questions. Tel: 604 638-2858. publication. Submit requests at www.bcmj.org/classi Non-members $60 + GST per month for fied-advertising-submission-form. each insertion of up to 350 characters. Provincial legislation prohibits ads that dis- $90 + GST for insertions of 351 to 700 criminate on the basis of sex. The BCMJ characters. We will invoice on publication. may change wording of ads to comply.

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We provide all the anesthesia, general internal medicine, general and lifestyle. Easy access to Lower Mainland, administrative and operational support. Con- surgery, orthopedics, psychiatry, radiology, Whistler, and Interior of the province. Call is tact Monam Ravaghi for more information at and urology. Opportunity to teach. Income of currently 1 in 5. Regular schedule includes 1 [email protected] or 604 724-6208. $244 200 supported through a service contract week off every fifth week. Full rural physician with on-call stipend and no overhead. For more recruitment and retention benefit eligibility, VICTORIA—FAMILY PRACTICE information e-mail physicianrecruitment@ including 38 days of rural locum coverage for Retired GP giving away busy, varied general interiorhealth.ca or visit www.betterhere.ca. holidays. World-class wilderness at your door- practice immediately in prime professional step for skiing, hiking, fishing, white-water kayaking, and mountain biking. Full-service building with lab, X-ray, pharmacy. Seven KELOWNA—FP/WALK-IN great colleagues. Efficient, paperless group rural hospital with GP surgeon and anesthe- Busy family practice/walk-in clinic. Looking clinic using Profile EMR; 4+ days per week; tist on staff. For more information e-mail for PT or FT doctors. Open 7 days per week. shared call. No obstetrics. No hospital MRP. [email protected] or Great staff. Shared weekend work. No call, no Teaching opportunities available. E-mail visit www.betterhere.ca. [email protected] or call 250 388-9846. OB, hospital privileges optional. Possibility of future partnership. Contact Dr Alden Lange at [email protected]. MERRITT—FP Rolling hills, sparkling lakes, and over 2030 employment hours of sunshine every year make Merritt a KELOWNA—HOSPITALISTS haven for four-season outdoor recreation. We ABBOTSFORD—LOCUMS Kelowna General Hospital, a tertiary hospital have a need for family physicians in their choice Full-service East Abbotsford walk-in clinic re- and referral centre with 400 beds, is seeking of clinic. Nicola Valley Hospital and Health quires locum physicians for a variety of shifts permanent full-time and part-time physicians Centre is a 24-hour level-1 community hospital including weekends and evenings. Generous to join our progressive hospitalist service. You with a 24-hour emergency room. Royal Inland split; pleasant office staff and patient popula- will provide general medical care of hospital- Hospital in Kamloops is a tertiary-level hospi- tion. Please contact Cindy at 604 504-7145 if ized adult patients, and co-management of sur- tal located only 86 km away. Remuneration is you are interested in obtaining more info. gical and psychiatric patients. The hospitalist fee-for-service ($250 000 to $450 000-plus per service is supported by a complement of spe- year), rural retention incentives and on-call CHILLIWACK—MEDI-SPA cialty services including anesthesia, general availability payment. For more information We are a medi-spa in Chilliwack that is cur- internal medicine, general surgery, orthope- e-mail [email protected] rently expanding and looking to hire a GP or dics, psychiatry, radiology, urology, and oncol- or view online at www.betterhere.ca. naturopath. The position involves administer- ogy. Income of $244 200 supported through a ing Botox Cosmetic and dermal fillers. Ide- service contract with on-call stipend and no NANAIMO—GP ally, the candidate would have experience in overhead costs. For more information e-mail General practitioner required for locum or the field but we are also willing to train and [email protected] or permanent positions. The Caledonian Clinic help with the costs of education. The position visit www.betterhere.ca. Continued on page 290

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 289 classifieds

Continued from page 289 administrative support. Paul Foster, 604 572- is located in Nanaimo on beautiful Vancou- RICHMOND—FP 4558 or [email protected]. Opportunity to practise in a busy family prac- ver Island. Well-established, very busy clinic tice in Richmond, BC. Great location. Excel- with 26 general practitioners and 2 specialists. SURREY—LOCUM/ASSOC lent staff. Please call Lesily at 604 270-1998 or Two locations in Nanaimo; after-hours walk-in Full- or part-time locum or associate needed. e-mail [email protected]. clinic in the evening and on weekends. Com- Clinic well staffed; busy, diverse patient panel. puterized medical records, lab, and pharmacy Hours flexible from Monday to Saturday. Split on site. Contact Ammy Pitt at 250 390-5228 or RICHMOND—FP & LOCUMS is 25/75. Locum needed from 4–15 Mar, 8–19 e-mail [email protected]. Visit Opportunities for physicians looking to do Aug, 21 Nov–7 Dec. Staff friendly and experi- our website at www.caledonianclinic.ca. walk-in shifts, build a practice, or relocate in enced. Wolf EMR in office (training available). our busy modern clinic. EMR OSCAR. Great Please call Dr Pawan K. Ram at 778 998-9445 location next to a 24 hr Shoppers Drug Mart. or e-mail [email protected]. NEW WEST—FAMILY PHYSICIAN No hospital work, no call, 70/30 split—walk-in New Westminster: Columbia Square Medical shifts at $100 per hour minimum—and bonus THROUGHOUT BC—CORRECTIONS Clinic is looking for a family physician for a available. Contact us at healthvuemedical@ MED full- or part-time position. Partnership and gmail.com, 604 270-9833/604 285-9888. options to buy are available. Flexible hours, Curious about prison medicine? Interested in competitive split. The clinic is newly renovat- a blend of general medicine, psychiatry, ad- RICHMOND—FT/PT FP/WALK-IN ed with bright rooms, Oscar EMR, excellent dictions, infectious diseases, HCV, and HIV? Busy, modern clinic looking for more physi- friendly and efficient staff, 20 minutes from Opportunities exist in centres throughout cians to join Dr Tse’s practice! Oval Village downtown Vancouver. We have 800 families BC—Prince George, Interior, Lower Main- Clinic is fully furnished and spacious: seven waiting for a family doctor who wants to es- land, Vancouver Island. Mostly part-time. Fee- exam rooms, staff lounge, large waiting area, tablish a permanent practice or work part-time. for-service. No overhead. EMR. No call. Full MedAccess EMR. Perfect for physicians to es- nursing support. [email protected]. Considering a change of location or practice tablish a practice or work part-time. Located style? Call Irina at 778 886-6511 or e-mail in Oval Village with 6000 residential units in VAN/RICHMOND—FP/SPECIALIST [email protected]. need of family doctors. Already a long patient Walk-in or full-service family medicine posi- wait list. Flexible hours, 30/70 to 25/75 split, tions available. Split or fixed-cost options for POWELL RIVER—PERMANENT FPs & hourly minimum negotiable. All administrative specialists as well, especially a pediatrician, work will be taken care of. Training and billing LOCUMs at the South Vancouver and Richmond Super- support provided. A platform for you to build Powell River is a rural community of 20 000 store medical clinics. Modern and clean facili- people on the Sunshine Coast of British Co- your own patient-centred career. Join our pas- ties with many unassigned patients. Efficient lumbia, a 25-minute flight from Vancouver. sionate team by contacting us at 604 285-2555 and customizable EMR. Please contact Lisa at It’s known for its waterfront location, outdoor or e-mail [email protected]. [email protected]. beauty, urban culture, and international music festivals. Supported by a 33-bed general hospi- SURREY/DELTA/ABBOTSFORD—GPs/ VANCOUVER—FP tal, the close-knit medical community consists SPECIALISTS Mainland Medical Clinic is seeking a fam- of 26 general practitioners, 4 ER and anesthe- Considering a change of practice style or loca- ily doctor for our modern, multidisciplinary sia physicians, 2 NPs, and 7 specialists. We are tion? Or selling your practice? Group of seven street-level clinic in Yaletown, downtown looking for permanent general practitioners locations has opportunities for family, walk-in, Vancouver. We have been operating for over and locums. Please visit divisionsbc.ca/powell or specialists. Full-time, part-time, or locum 13 years in a comfortable setting shared with river/opportunities for details. doctors guaranteed to be busy. We provide a chiropractor, massage therapists, and a nutri- tionist to complement our three family doctors. Ideally seeking someone with an existing practice—perhaps relocating or cutting back. We serve a broad spectrum of patients, both walk- ins and appointments. Excellent revenue split. The clinic offers a pleasant work environment in an upbeat, fun neighborhood. Contact Dr BCMJ ADVERTISING Brian Montgomery at brian@mainlandclinic. com or 604 240-1462, or just drop by.

Want to reach BC doctors? VANCOUVER—FT/PT DERM Dermatologist wanted to join busy Aesthetic We’ve got you covered—in print and online. Medical Clinic in Vancouver. Full- or part- time. Please reply by e-mail to kt.crawford03@ gmail.com. For all your display advertising requirements, please contact: Kashmira Suraliwalla VANCOUVER—LOCUM 115-1665 West Broadway, Vancouver, BC V6J 5A4 Busy walk-in shifts in Kitsilano at Khatsahlano 604 638-2815 • [email protected] • www.bcmj.org Medical Clinic, three-time winner of Georgia Straight reader’s poll for Best Independent Medical Clinic in Vancouver. Split is 65%; VALUE = PROVEN READERSHIP + AUDIENCE INVOLVEMENT 70% on evenings/weekends. Contact Dr Chris Watt at [email protected]. “The BCMJ reaches physicians in the province with locally relevant topics and evidence-based practical medical advice. It has great graphics, and stimulating editorial content. The journal is an integral part of our medical community.” VANCOUVER—PRIVATE BILLING —Marshall Dahl, MD Associate/locum wanted for lucrative non- MSP practice. Initially 1 to 2 days per week

290 bc medical journal vol. 58 no. 5, june 2016 bcmj.org

BCMJ CHANGE IN ADVERTISING REPRESENTATION

Want to reach BC doctors? BCMJ CHANGE IN ADVERTISING REPRESENTAT We’ve got you covered—in print and online. Want to reach BC doctors? For all your display advertising requirements, please contact: We’ve got you covered—in print and onlin Kashmira Suraliwalla 115-1665 West Broadway, Vancouver, BC V6J 5A4 For all your display advertising requirements, please 604 638-2815 • [email protected] • www.bcmj.org Kashmira Suraliwalla 115-1665 West Broadway, Vancouver, BC V6J 5 VALUE = PROVEN READERSHIP + AUDIENCE INVOLVEMENT 604 638-2815 • [email protected] • www.bcmj.org

“The BCMJ reaches physicians in the province with locally relevant topics and VALUE = PROVEN READERSHIP + AUDIENCE INVO evidence-based practical medical advice. It has great graphics, and stimulating “The BCMJ reaches physicians in the editorial content. The journal is an integral province with locally relevant topics and part of our medical community.” evidence-based practical medical advice. It has great graphics, and stimulating —Marshall Dahl, MD editorial content. The journal is an integral part of our medical community.” —Marshall Dahl, MD classifieds with a view to taking over eventually. Recent hospital privileges are necessary. Please send a dental clinic, a chiropractic clinic, and a phar- graduate with a business inclination and strong inquiries to [email protected]. macy. Phone Alfred Marchi at 604 576-3868 computer skills would be ideal. Reply by e- (www.paragonrealty.ca). mail to [email protected]. No VICTORIA—WALK-IN phone calls please. Walk-in clinic shifts available in the heart of KELOWNA—PRIME AREA, GROUND lovely Cook St. Village in Victoria, steps from FLR VANCOUVER—PT/FT PHYSICIAN the ocean, Beacon Hill Park, and Starbucks. 3295 Lakeshore Rd. Professional bldg. Bright, South Granville Medical Centre, conveniently For more information contact Dr Chris Watt at well-lit with large windows; 710 sq. ft.; four located on the west side of Vancouver (3195 [email protected]. treatment rooms, two plumbed. Ground floor Granville St.), is seeking a physician (FP or in lovely part of Kelowna just off the lake. specialty) to join full-time or part-time. OS- WEST VAN—FAMILY PHYSICIANS Private entrance to outdoors. Bathroom. Small CAR EMR. Attractive split. Collegial group West Vancouver, FP/walk-in. Continuum waiting area. Wheelchair access. Option to and experienced staff. Please contact Dr Paula Medical Care is a large multidisciplinary clinic share reception. Modern finish with tile, hard- Iriarte at [email protected]. located in the heart of West Vancouver. We are wood, and rounded walls. E-mail duane@vein again expanding and are looking for primary skin.com or call 250 469-1416. VERNON—AESTHETICS/VEIN/LASER care physicians to join our team of 12 FPs, 7 Outstanding opportunity to join a well-estab- specialists, and a variety of allied health pro- N DELTA & SURREY—1700 SQ. FT. lished and thriving GP derm/aesthetics/vein/ fessionals. With over 17 000 patients, we are (7 ROOMS) laser practice in one of the best places to live in seeking primary care physicians to work in Located at 84th Ave and 120th Street. Reno- Canada. We are looking for an associate/equity our recently opened walk-in clinic and in our vated space available from recently departed, partner(s). The office has all the latest technol- newly renovated main clinic, offering full- high-volume walk-in clinic (1700 sq. ft., seven ogy and an excellent, congenial staff. Training service family practice care. Specialty training rooms). Six examination rooms, one treatment provided but a special interest in dermatology or diploma in sport medicine, geriatrics, life- room, office, kitchen, three bathrooms, two a definite asset. The Okanagan has some of the style medicine, concierge medicine, or execu- large reception areas (one could be converted best weather, lakes, wineries, golf courses, ski tive health would be an asset. Please contact to make two more rooms), and large waiting hills, and overall lifestyle anywhere in Canada, Dr Bryce Kelpin at 604 928-8187, or e-mail area. Ample parking. Compensation for break- if not the world. Contact Dr William Sanders: [email protected]. ing your lease available. Contact harjsamra@ 250 558-9606, [email protected]. rghs.ca. WILLIAMS LAKE—FP EMERGENCY VERNON—HOSPITALISTS, Seeking CCFP-EM or CCFP with ER expe- PRINCE GEORGE—BUILD-TO-SUIT PERMANENT rience. Cariboo Memorial Hospital services OPPORTUNITY Vernon Jubilee Hospital is a 180-bed regional a population of approximately 26 000 with Office space for lease: Up to 3500 sq. ft. Build- referral hospital in the Okanagan Valley. Clini- 20 000 visits to the ER annually. ER is staffed to-suit opportunity at 6760 Madill Rd, Prince cal and communication skills and ability to by six full-time ER physicians and a variety George. Location has easy access on/off the work with the health care team is required. of part-time ER physicians (staffed 24/7). We Hart Highway and is also tenanted by Shop- Admission, MRP, and discharge of unattached have a 28-bed hospital with 3-bed ICU. Ex- pers Drug Mart. Great opportunity to open a medical and surgical patients are primary re- cellent collegial specialist support including clinic in a new space with convenient access sponsibilities. Daily census of 60 to 70 inpa- general surgery, OB/GYN, pediatrics, internal to amenities. Contact Michael Spaull at mike@ tients and 6 to 10 admissions is managed by med, radiology, anesthesia, and psychiatry. hallpacific.com or 778 960-4878. a team of 3 to 4 hospitalists supported by a Further specialist support available at our re- nurse practitioner. Hours are 7:00 a.m. to 5:00 ferral centre in Kamloops. Williams Lake is RICHMOND—MED OFFICE SPACE p.m. Average 20 inpatients/physician; mean known for its outdoor opportunities and full New modern EMR clinic in Steveston Village length of stay is 3 to 5 days. Estimated salary range of amenities (including local college and looking for physicians to join our team. Oppor- $245 299 plus MOCAP Level 2. Contact In- airport). Contact 1 877 522-9722 or physician tunities to start a practice or relocate existing terior Health Physician Recruitment at 1 877 [email protected]. practice without worrying about administra- 522-9722 for further information. tive headaches. We offer base 70/30 split and higher for complex care and forms. Visit www. VICTORIA—GP/WALK-IN medical office space HealthVue.ca or contact healthvuemedical@ Shifts available at three beautiful, busy clinics: gmail.com, 604 285-9888. Burnside (www.burnsideclinic.ca), Tillicum ABBOTSFORD—OFFICE SPACE (www.tillicummedicalclinic.ca), and Uptown Fully furnished, ready-to-go medical office SURREY HLTH & TECH DISTRICT— (www.uptownmedicalclinic.ca). Regular and available for lease in heart of Abbotsford. SPACE occasional walk-in shifts available. FT/PT GP Rent-free for 6 months! Clinic includes four Locate your practice within the growing post also available. Contact drianbridger@ large exam rooms, reception area, large wait- Health & Technology District of Innovation gmail.com. ing room with TV, two washrooms, large pri- Boulevard in Surrey’s Central City. A LEED vate office, on-site free parking. Located in Gold–certified building with over 600 parking VICTORIA—LOCUM OPPORTUNITY a professional building at a busy intersection stalls and an on-site gym and spa boasts sig- Curious about practising in beautiful Victoria, with lots of walk-in traffic. Great opportunity nificant space for health professionals, clinical BC? If you are wondering if practising family for someone looking for an existing space with spaces, professional technology companies, as medicine in Victoria could be your future, here the flexibility to design their own practice and well as multiple restaurants and retail outlets. is an ideal opportunity to try it out. Busy fam- hours of operation. Please contact Frank Dyks- Currently provides space for over 90 medical ily practice/walk-in clinic looking for someone tra at 604 835-6300 or [email protected]. professionals. Immediately adjacent to Sur- to provide locum coverage for a 3- to 6-month rey Memorial Hospital and Health Sciences period starting March 2017. Ideal for husband- DELTA—PRIME SPACE, MED BLDG Campus, City Centre 2 (of the rapidly growing wife team. The clinic currently runs Monday to High-profile, professionally designed building Health & Technology District) is set to be com- Friday, fully functions using EMR, and is sup- with ample natural light from large windows. pleted in early 2017. Sales and leasing options ported by superb long-time staff. This oppor- Well situated in one of Surrey’s fastest grow- available in this strata build. Visit us at www. tunity could develop into a long-term position ing areas close to Hwy 91 and Scottsdale Mall. larkgroup.com. should there be an interest. No obstetrics or Other tenants include family medical practices, Continued on page 292

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 291 advertiser classifieds

index Continued from page 291 All specialties, family practice, and IME reports. Telephone or digital recorder. Fully SURREY/DELTA—MED OFFICE SPACE confidential, PIPEDA compliant. Dictation Thanks to the following advertis- Newly renovated Specialist Medical Clinic: tips at www.2ascribe.com/tips. Contact us at ers for their support of this issue private offices with either one or two exam www.2ascribe.com, [email protected], or toll rooms. Full-time, part-time, or satellite of- free at 866 503-4003. of the BC Medical Journal. fice. Flexible terms. Ideal for specialists. New furniture and medical equipment. Fully EMR. Ashish Accounting Inc...... 276 FREE MEDICAL RECORD STORAGE Large waiting room. Near Scott Rd. and Nor- Retiring, moving, or closing your family prac- Cambie Surgery Centre/ del Way. Contact [email protected]. tice? RSRS is Canada’s #1 and only physician- Specialist Referral Clinic ..... 246 managed paper and EMR medical records VAN (VGH AREA)—MED OFFICE storage company. Since 1997. No hidden Canadian Medical SUBLEASE costs. Call for your free practice closure pack- Association ...... 285 Office space for psychiatrists, psychologists, or age: everything you need to plan your practice any other specialist MD. No secretary or other closure. Phone 1 888 563-3732 (ext. 2), e-mail College of Physicians and additional overhead expenses. Top floor. Great [email protected], or visit www.RSRS.com. Surgeons of British view. Two offices for sublease. One office is bigger and has a sink and space for an exami- Columbia ...... 284 PATIENT RECORD STORAGE—FREE nation table. E-mail [email protected]. Retiring, moving, or closing your family or Grace Fertility Centre ...... 244 general practice, physician’s estate? DOCU- VANCOUVER—CLINIC SPACE davit Medical Solutions provides free storage Mercedes-Benz ...... 248 AVAILABLE for your active paper or electronic patient re- MNP LLP ...... 253 Medical office space for rent on Main and 50th. cords with no hidden costs, including a patient The clinic has five exam rooms, ideal setup mailing and doctor’s web page. Contact Sid Olive Fertility ...... 249 for walk-in clinic, high-volume walk-through Soil at DOCUdavit Solutions today at 1 888 Pacific Centre for traffic area, attached to existing pharmacy, 781-9083, ext. 105 or e-mail ssoil@docudavit available 1 October 2016. Very attractive and .com. We also provide great rates for closing Reproductive Medicine ...... 279 negotiable terms. Contact vanmedicalclinic@ specialists. Pacific Northwest Division gmail.com. RICHMOND—MED OFFICE of Family Practice ...... 293 WHISTLER—VISITING SPECIALISTS EQUIPMENT FOR SALE Pollock Clinics ...... 251 New office space for rent for visiting special- Closing medical office 1 July. Two Ritter ex- ists in Whistler. Day rate, reception and book- amination tables, two wall units, autoclave, Record Storage and Retrieval ing, wheelchair accessible, free parking, avail- numerous small surgical instruments for mi- Service ...... 287 able now. For more information please call 604 nor procedures, large refillable liquid nitrogen 905-1500 or e-mail [email protected]. canister, large computer/office desk, office and Sea Courses Cruises ...... 286 waiting room chairs, storage unit, etc. Phone 604 220-9197 or e-mail docmgfrey@gmail Speakeasy Solutions ...... 280 vacation properties .com. Summit Counselling Group Inc ...... 277 PROVENCE, FRANCE—YOUR VILLA VANCOUVER—TAX & ACCOUNTING Les Geraniums, a luxury 3-bedroom, 2½ bath SVCS villa, is your home in the heart of Provence. Rod McNeil, CPA, CGA: Tax, accounting, and Expansive terrace with pool and panoramic business solutions for medical and health pro- views. New kitchen and bathrooms. Walk to fessionals (corporate and personal). Specializ- Recently deceased lovely market town. One hour to Aix and Nice. ing in health professionals for the past 11 years, physicians Can be rented with independent studio for and the tax and financial issues facing them at couple. Come and enjoy the sun of southern various career and professional stages. The tax If a BC physician you knew well France! 604 522-5196. [email protected]. area is complex and practitioners are often not aware of solutions available to them and which is recently deceased, consider avenues to take. My goal is to help you navigate submitting a piece for our “In miscellaneous and keep more of what you earn by minimiz- Memoriam” section in the ing overall tax burdens where possible, while at BCMJ. Include the deceased’s CANADA-WIDE—E TRANSCRIPTION the same time providing you with personalized SVCS service. Website: www.rwmcga.com, e-mail: dates of birth and death, full E Transcription Services allows hospitals, [email protected], phone: 778 552-0229. name and the name the deceased clinics, and specialists to outsource a critical was best known by, key hospital business process, reduce costs, and improve CURRENT ADS ONLINE the quality of medical documentation. By out- All classified ads are available online in an and professional affiliations, sourcing transcription work you will be able to easily searchable format at www.bcmj.org/ relevant biographical data, and increase the focus on core business activities classifieds. a high-resolution photo. Please and patient care. Our goal is to exceed your expectations. Call for free trial 1 877 887-3186. limit your submission to a www.etranscription.ca. The online home of BC physicians maximum of 500 words. Send the content and photo by e-mail CANADA-WIDE—MED to [email protected]. TRANSCRIPTION Medical transcription specialists since 2002, bcmj.org Canada wide. Excellent quality and turnaround.

292 bc medical journal vol. 58 no. 5, june 2016 bcmj.org Experience Northwest British Columbia

Locum Opportunities Northwest British Columbia is one of the most scenic places on earth. Rich in First Nations culture, the region boasts spectacular mountain views, clear rivers, lush forests and unspoiled coastlines. Year-round adventure awaits with Dease Lake fi shing, hunting, biking, hiking and backcountry, downhill or cross-country

skiing all in your backyard. Stewart New Aiyansh Th e Pacifi c Northwest has many amazing locum opportunities. Eleven diverse Hazelton communities are served by over 85 family physicians with regional specialist Prince Masset Rupert Smithers support available. Practice opportunities include: Terrace Houston Queen • Rural health centres Charlotte Kitimat • Solo or group family practices • Options with ER and obstetrics A choice of practice size, style and timing allows you to customize your experience and workload. Remuneration is competitive, with fee-for-service, alternate payment plan and rural locum funding options available. Vancouver

For more information on the locum opportunities available, check out Pacific Northwest https://www.divisionsbc.ca/pacifi cnorthwest/locumnetwork or contact Zach Davies, PNW Locum Network Coordinator [email protected] • (250) 877-9354

bc medical journal vol. 58 no. 5, june 2016 bcmj.org 293 bcmj.org HEAD INJURIES HEAD TRAUMA BRAIN INJURY SKULL FRACTURE BRAIN DAMAGE

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