Facing Death, Embracing Life: Understanding what dying people want by David Kuhl, MD. Doubleday Canada, 2006. ISBN-10: 0385660669. Paperback, 336 pp. $25.
This book builds upon the author’s previous, highly successful book What Dying People Want. In this volume Dr Kuhl expands upon the various themes of time, death anxiety, the legacy we each will leave, and the experience of spirituality at the end of life. Other topics include the interpersonal gap experienced in communications, family meetings, the role of touch, and practicalities such as pain control and advanced directives. He brings these seemingly disparate topics together by posing questions, providing exercises, and integrating the work of well-known psychologists and philosophers. In addition, Dr Kuhl also reflects further on his personal experiences with death and lessons learned. Topics here include grief, anger, and forgiveness. This book is both an excellent stand-alone volume as well as a companion to the earlier work.
Who should read this book? I would argue that everyone should read this book. All of us will die. All those we care for will die. While the focus of this book appears to be for and about those facing the end of life, it really is about ensuring that we all live our lives to the fullest and continue to connect with those we care about most.
Am I biased? Probably. I have long admired the work of my Providence Health Care colleague. I have had the privilege of watching his journey through family medicine, palliative care, and now as the director of the Centre for Practitioner Renewal. The latter is jointly funded by Providence Health Care and the University of British Columbia and seeks to better understand how to support healthcare providers in their work.
The additional good news is that each of the book’s chapters can be read on its own. Those not facing a terminal illness may wish to focus on the introduction as well as the sections concerned with death anxiety, the interpersonal gap, and the lifeline and life review exercises. However, I would encourage all health care providers to read the entire book. Not only will we be better informed of the issues our patients might face, but we will be challenged to face our own fears. Dr Kuhl has argued that unless we do so, we can unconsciously visit our anxieties on our patients—creating what he calls “iatrogenic suffering.”
Written in a respectful, compassionate style, this book is provocative. This leads me to a caution: I expect that some health care providers might find themselves becoming defensive when reading certain passages. I would encourage readers who might wish to throw the book across the room to persevere. Who was it that pointed out that it is in facing these challenges we learn the most about ourselves?
I hope I have convinced you to read this book—no matter your age, stage, or circumstance in life. I suspect in doing so you will come to even better understand yourself and those you care for and about.
—Eva Knell, MD
The Vancouver Home Hospice Palliative Care Service, VCH, is available 24/7 to support family physicians caring for their palliative patients living at home in Vancouver. Please call our new number, 604 742-4010, for help with symptom management, psychosocial issues, and difficult end-of-life or ethical decision-making.
—Bev Spring, MD, Medical Leader
Vancouver Home Hospice Palliative Care Service
Early childhood mental health service
To expand on the table of provincial infant mental health resources printed in the May issue (BCMJ 2007;49:181), Richmond now has an early childhood mental health service, with contact information as follows:
Richmond Early Childhood Mental Health Program
Richmond Hospital, Dept. of Psychiatry
7000 Westminster Highway
Richmond BC, V6X 1A2
Phone 604 278-9711, ext. 4055
This service has been running since September 2006 and has a multidisciplinary staff serving these children and their families and liaising with community providers.
—Carolyn Steinberg, MD
The dire lack of health care workers in southern Africa is threatening efforts to expand access to HIV/AIDS treatment, warned Médecins Sans Frontières (MSF) in a report issued in May. The report covers four southern African countries—Lesotho, Malawi, Mozambique, and South Africa—where more than 1 million people still need life-saving antiretroviral treatment but do not have access to it.
Severe shortages of health staff are compromising the quality and availability of HIV/AIDS care across southern Africa. MSF workers in the Thyolo district of Malawi are treating 7000 people with HIV/AIDS. However, they need to increase this number to 10 000 by the end of the year, but cannot do so because there are not enough nurses, doctors, or medical assistants. There, a medical assistant can see up to 200 patients per day.
In the Mavalane district of Mozambique, patients are forced to wait for up to 2 months to start treatment because of the lack of doctors and nurses, and many have died during the wait.
In Lesotho there are only 89 doctors in the whole country. Providing HIV care in rural clinics depends on nurses, but they are overwhelmed by the number of patients. Consultation times are too short, and sick patients suffer needlessly.
MSF is urging governments to develop and implement emergency plans to retain and recruit health care workers that include measures to raise pay and improve working conditions. In most countries this will only happen if donors change their policies and start providing financial support for recurrent costs such as salaries. Ministries of finance and the International Monetary Fund (IMF) will need to find solutions to overcome caps on the number of health workers and level of salaries. Otherwise, governments will not be able to respond adequately to the unmet need for treatment.
Even in South Africa, which has more health care workers who are better paid compared to other southern African countries, unequal distribution and inadequate numbers of staff are causing delays to expanding treatment.
Donors provide funds for life-long AIDS treatment and the building of new clinics, but support is also needed for health care worker salaries. People living with HIV/AIDS do not only need drugs and clinics; they need trained, motivated health care workers to diagnose, monitor, and treat them.
|Correction: Dr Derek Royle
Author and editors alike sincerely apologize for the misspelling of Dr Derek Royle’s name in Dr J.L. Benedet’s article saluting Dr Royle and colleagues in the June issue of the BCMJ.
Practice support program
The workshops held earlier this summer were extremely successful; in fact, many were filled to capacity with GPs and MOAs lining up at the door. Interest was high in the opportunities being made available to GPs.
At the workshops, physicians heard about ways to make their time with patients more effective and how to make their professional lives more manageable and, therefore, more satisfying.
Some ways in which physicians will be making changes to their offices in the months and years to come include:
• Allowing patients same-day access for faster service and less stress on the physician.
• Creating a patient registry to more efficiently manage their practice and provide better care for patients.
• Using the CDM toolkit—a web-based clinical-quality improvement application used to provide better and more consistent care for chronic disease patients.
• Starting group visits so they and other providers can offer care, education, and advice in a group setting that is efficient for their practice and provide patients with the support needed to manage their chronic conditions.
Physicians attending the workshops throughout the province repeatedly stated that this program provided the type of support they needed and made them feel more committed to continuing to be a GP rather than moving on to something else.
One physician mentioned that given the seemingly neverending negative commentary about health care, this program offered a sense of hope that physicians can actually do something positive for their patients and for themselves.
One presenter recalled how physicians would talk to her after the workshops and spoke of how impressed she was by their enthusiasm about what they had heard and how they were going to start adapting some of the practices discussed.
Regional teams: next phase
Workshops were only the first phase of this program. The next phase will see hundreds of GPs having signed up with their health authority and starting to implement the practice changes learned about at the workshops. Acting as technical and collegial support are teams of physicians, MOAs, and information technology specialists, collectively known as the Regional Practice Support Teams. Each health authority has its own team, and some have already started working with physicians to make the practice changes.
Also, the physicians and MOAs will be encouraged to form their own groups to provide a forum for exchanging ideas and experiences and to learn from each other. There will be financial compensation for GPs and MOAs as they integrate these changes into their practices.
Contact information about the Regional Practice Support Teams can be found on the members’ web site at www.bcma.org—click on the “Practice Support Program” button.
Attracting and keeping family physicians in areas of need is always a challenge. A new program designed to encourage new doctors and residents to these urban and rural areas has just started.
Called the FPs4BC (Family Physicians for BC) Program, it provides eligible physicians with access to as much as $100 000 in a mix of options, such as up to $40 000 for student debt repayment, up to $40 000 to set up or join a group practice, and a New Practice Supplement of $2000 per week for the first 26 weeks of practice.
Eligible physicians will be required to commit to a three-year Return of Service Agreement to provide full-service family practice in a designated community.
The application deadline is 31 March 2010 or until all available funding has been allocated—whichever comes first.
For more information and an application form, please go to www.bcma.org and click on the “FPs4BC” button.
It has been a busy time for the vendor evaluation team. It received three times the number of applications than was originally expected. Despite the tripling of the workload, the team has remained on schedule for completing the evaluation and testing the software by the end of June. A list of the successful vendors will be announced in July 2007.
The launch of the pilot project is still planned for August 2007. Although the criteria for selecting the pilot physician groups have not yet been finalized, the BCMA is maintaining a list of interested practices.
Specialist Services Committee
$30 million income disparity fund
The Specialist Services Committee (SSC) reached a decision on the allocation of the $30 million specialist income disparity fund that was provided in the 2006 Letter of Agreement. The BCMA Board approved the allocation on 13 April 2007.
The first $10 million was distributed based on the 2005 Recruitment and Retention proposal that was developed by the BCMA and Society of Specialist Physicians and Surgeons (SSPS). Some of these funds apply to existing fee items and, therefore, will be implemented right away by the Medical Services Plan (MSP). The details of the remaining Recruitment and Retention proposals are being worked on by the MSP and the sections involved. It is anticipated that these funds will be implemented this fall.
The remaining $20 million was allocated using the Modified Adjusted Net Daily Income model that was developed by the SSPS. We anticipate that these funds will be implemented at the same time as the general fee increase.
The Joint Standing Committee on Rural Issues will conduct a review of its programs between July and December 2007. The review will evaluate the effectiveness of each program and make recommendations on future funding and additional programs.
If you would like to comment or make a submission on any or all of the programs or to suggest new ones, please send your information to the BCMA committee co-chair. For contact details and more information, please go to www.bcma.org, and click on “Joint Standing Committee on Rural Programs” under Agreement News.
BCMA Communications Department
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org