- © 2008 Canadian Medical Association
Life-support guidelines
The College of Physicians and Surgeons of Manitoba stepped boldly into the fray of withholding life-sustaining treatments by becoming the first regulatory body in Canada to issue guidelines governing when, and how doctors should decide, to declare it clinically appropriate to discontinue their efforts.
The comprehensive guidelines, released Jan. 30, 2008, say it is acceptable to withhold treatment when patients cannot recover to a level of cerebral function that would allow them to “achieve awareness of self; and achieve awareness of environment; and experience his/her own existence. For pediatric patients, the potential for neurological development must be factored into the assessment.”
In cases where the minimum level of cerebral function can be achieved, lifesustaining treatment can nevertheless be withheld or withdrawn on the proviso that “there are likely to be significant negative effects on the patient, including, but not limited to pain and suffering.” But the physician must first “explore the patient's values, needs, goals and expectations of treatment with the patient/proxy/representative” before making that decision.
In instances where there is no consensus between the doctor and the patient/proxy, whether the minimum level can be achieved or not, the physician must consult with another physician. If that physician disagrees, he or she “must either provide the treatment or facilitate the transfer of care to another physician who will provide the treatment.” If that physician concurs, they must give the family a “reasonable” opportunity to find an alternative provider of treatment, and a minimum 96 hours of written and verbal notice before discontinuing treatment.
The wide-ranging guidelines also cover acceptable practice in communicating with patients and their families, as well as implementing and documenting decisions. Available at http://cpsm.mb.ca, they were released against the backdrop of a legal dispute involving the treatment of an 84-year-old man with minimal brain function. Doctors want to withdraw treatment but the man's family says that would be an offence to his religious views as an Orthodox Jew. The issue will go to trial.
Pack your bags and beat it
Informed that the position of National Science Advisor will be eliminated by the federal government, Arthur Carty will retire in “dismay” that Canadians will be losing a mechanism for generating credible, independent nonpartisan scientific advice when he leaves the post Mar. 31, 2008.
Carty was informed last October that the 4-year-old Office of the National Science Advisor would be phased out in favour of advice provided by the recently minted Science, Technology and Innovation Council. Established in June 2007, the Council is composed of 3 deputy ministers and representatives of industry and academe. It is chaired by University of Ottawa Professor of Chemistry and former president of the Royal Society of Canada Howard Alper.
“I'm obviously dismayed that the office is being shut down, dismayed because I had hoped this would become a permanent, independent voice embedded at the centre of government, as have many other advanced countries,” Carty says.
Carty declined comment on whether the new advisory board is capable of providing independent, non-partisan advice or whether abolition of the national science advisor's position was an indicator of government belief regarding the role of science in society or the impact of technological progress on economic growth.
Several scientists said privately that Carty made it easy for the government to abolish the position. “He had no profile,” said a Canada Research Chair recipient on condition of anonymity. “In 4 years, did you ever once hear him publicly speak out on an issue?”
“The public doesn't know him and won't care,” said another. “He never became the voice of Canadian science. Instead, he tried to work behind-the-scenes and look what that got him.” — Wayne Kondro, CMAJ
Agencies review plastic bottles
Health Canada is conducting a review of scientific literature to determine whether it should revise its threshold for the use of the chemical bisphenol A in food containers, particularly tin can lining and reusable water bottles.
Concern over bisphenol A levels prompted retailer Mountain Equipment Co-op to yank reusable polycarbonate plastic bottles off their shelves in December 2007. The European Union, meanwhile, has reported the chemical causes reproductive problems.
Bisphenol A is an estrogen imitator used in shatterproof polycarbonate plastics, ranging from bicycle helmets to dental sealants. Plastics break down and leach chemicals over time, which prompts concerns about bisphenol A's safety.
Health Canada's threshold for safe consumption is 25 micrograms per kilogram per day, half the 50 micrograms set by the US Environmental Protection Agency. Health Canada's preliminary report is expected this spring, says Karen Lloyd, director-general of the safe environments program. “Certainly people are aware that we're doing this assessment, and I think there has been a lot of attention given to this chemical.”
Industry and academic researchers have long been at odds over the findings of their respective reviews of bisphenol A safety, while a National Institutes of Health report on the issue has come under methodological fire. A US National Toxicology Program review of the potential health effects should be completed this spring, says Associate Director John Bucher. — Elizabeth Howell, CMAJ