2. Shortell SM, McNerney WJ: Criteria and guidelines for reforming the U.S. health care system. N Engl J Med 1990; 322: 463-467 3. Radovsky SS: U.S. medical practice before Medicare and now - differences and consequences. Ibid: 263-267
Replacing CFC aerosols with powders W r e agree with the conx cerns expressed by Drs. Bill Swales (Can Med Assoc J 1989; 141: 1224) and Robert A. Mclvor (Can Med Assoc J 1990; 142: 705) in their recent letters on the environment and the need for the medical profession to contribute toward reducing the amount of fluorocarbons released into the atmosphere. One small contribution, suggested by both writers, could be substituting powder aerosols for
chlorofluorocarbon (CFC)-pressurized metered-dose inhaler (MDI) aerosols. Powder inhalers, such as Rotahalers, Spinhalers and. Diskhalers, have many advantages: they are breath-actuated, portable and Freon-free. However, their use is limited to adults and children over 3 years of age, who are able to generate sufficiently high inspiratory flows to dispense the powder as a respirable aerosol from the device, thereby achieving deposition of the drug in the lower respiratory tract. This may be an issue during an acute exacerbation of asthma with severe airflow limitation, when at the time the patient most needs the medication he or she is unable to generate the necessary flow.' The increasing worldwide rate of death from asthma illustrates the need for effective treatment. In addition, because of the requirement for high peak inspiratory flow, oropharyngeal deposition is high with the powder aerosols and comparable to that with CEC MDI delivery, so that there 1036
CAN MED ASSOC J
1990:
142 (10)
is the potential for side effects when steroids are used. Other problems may be encountered: the hygroscopicity of the powders causes clumping in the device; exhalation into the device before inhalation results in loss of the dose; and loading or assembly may be difficult for some patients, particularly at times of distress. The aerosol propellants referred to as dangerous by Swales may be detrimental to the environment but have not been shown to be harmful to patients unless the standard (two-puff) dose is increased by a factor of 1 5.2 Replacing CFC aerosols with powder aerosols may be a good alternative and acceptable to many patients, but powder inhalers are not foolproof. Maintaining control of the asthma is critical, and this may necessitate the use of CFC aerosols, at least in some cases, especially during severe airflow limitation. Myrna B. Dolovich, PEng E. Helen Ramsdale, MB, FRCPC Department of Medicine St. Joseph's Hospital Hamilton, Ont.
References 1. Pederson S: How to use a Rotahaler.
.4rch Dis Child 1986; 61: 11-14 2. Draffan GH, Dollery CT, Williams FM et al: Alveolar gas concentrations of fluorocarbons -11 and -12 in man after use of pressurized aerosols. Thorax 1974: 24: 95-98
Resuscitation of the terminally ill T Nhe articles and letters on this topic that have recently appeared in CMAJ have underlined the inadequacy of the current CMA guidelines on resuscitative intervention for the terminally ill. ' Baylis2 emphasized the need to recognize and respect patients' autonomy. Few physicians would
disagree with this position, but the process is more complicated than she implied. To function autonomously patients must be competent and fully informed. The competence of severely ill patients to understand the significance of their illness and the nature of cardiopulmonary resuscitation (CPR) and to make rational decisions is often highly questionable. Accurate and complete information about CPR, the poor survival rate and the potential complications is rarely provided, and to provide it would be inappropriate and inhumane in many clinical situations, as Buckman and Senn3 stated. Seeking guidance from distressed family members is also often unsatisfactory, because they will frequently request all possible measures when what they are really seeking is appropriate and compassionate care of their loved one. The CMA guidelines are directed primarily at the concerns of nursing and hospital administration and emphasize the legal aspects rather than how to provide compassionate care for the dying patient. Unfortunately, CPR is now mandated in most Canadian hospitals unless the attending physician has written a "Do not resuscitate" (DNR) order. I believe hospitals that have such policies also have an ethical obligation to inform patients at the time of admission that they will be resuscitated unless they request otherwise and to advise them to discuss the matter with their attending physician. However, a significant number of patients do not wish to discuss resuscitation, and many doctors are reluctant to raise the issue. It is important to recognize that the attitudes of patients and physicians may be greatly influenced by the underlying diagnosis, the clinical setting and religious and cultural factors. For instance, patients with cancer may be more receptive to palliative approaches
than those with equally fatal but less dreaded illnesses. Hospice patients may be more inclined to a DNR policy than those in an acute care setting, and an orthodox Jew will emphasize the importance of preserving life. It is unfortunate that current policies dictate that a traumatic, invasive and usually ineffective procedure be imposed automatically on all patients unless they request otherwise. In allowing this situation to develop we have permitted legal considerations to override humanitarian responsibilities and our respect for the principle of autonomy to outweigh the respect due to beneficence. It would be far better to define appropriate levels of health care for individual patients, as Walker- implied and Emanuel' suggested, than to isolate CPR from other life-sustaining therapies, such as ventilation, intravenous feeding and dialysis. Peter A.F. Morrin, MB, FRCPC Renal Unit
Kingston General Hospital Kingston, Ont.
References 1. Resuscitation of the terminally ill. Can Med Assoc J 1987; 136: 424A 2. Baylis FE: Resuscitation of the terminally ill: a response to Buckman and Senn. Can Med Assoc J 1989; 141: 1043- 1044 3. Buckman R, Senn J: Eligibility for CPR: Is every death a cardiac arrest? Can Med Assoc J 1989; 140: 1068-1069 4. Walker I: Resuscitation of the terminally ill. Can Med Assoc J 1990; 142: 531532 5. Emanuel LL: Does the DNR order need life-sustaining intervention? Time for comprehensive advance directives. Am J Med 1989; 86: 87-90
letter (Can Med Assoc J 1990; 142: 281-282) that "we have become a global village" and that "fear of a virus" is wrong. From the latter I can only infer that Somerville believes AIDS to be simply a virus that we should be able to shrug off. For those of us who live in the real world and not a utopia AIDS is a killer. With the frustrations of an aging population, shrinking number of hospital beds and difficulty in obtaining home care for our locals, can we really afford to shrug our shoulders and import an incurable infection? We cannot even look after our own seniors, who have worked to build this country and now have some very real problems in retirement. We can certainly not afford to open the doors to just anybody suffering from any disease and offer to look after him or her. AIDS is a tragedy, but charity still begins at home. Let's clean up our own corner of the global village before we open the doors to the problems of another. Grazina M. Girdauskas, MD 419-2425 Bloor St. W Toronto, Ont.
All of Dr. Somerville's arguments in her Platform article (Can Med Assoc J 1989; 141: 889-894) and all arguments along the lines that she follows see this whole problem from the aspect of the person infected with the human immunodeficiency virus (HIV) and seem to fail to recognize the tragedy of the unwitting victims of this condition. I do not mean for a minute to be cruel or judgemental or inhumane to people who have the deep misfortune of becoming HIV positive, but I do think that The case against should know that they have HIV antibody testing of they this condition so that they can refugees and immigrants take suitable precautions to protect others. I see no advantage I' t is interesting to read Dr. whatsoever in concealing the Margaret A. Somerville's ide- truth. Of couse, HIV positivity ,,alistic statements in her recent must be treated in absolute confi-
dence, and it is in this area that I feel that great care must be taken. I feel that not to test for HIV is just as discriminatory and unpleasant as to test for it. I can see that the arguments on either side, whether they be protection of the immigrant or protection of the society that has welcomed the immigrant, can be more or less persuasive. The central question is whether we wish to suppress facts that have unsavoury connotations. I feel that the suppression of truth for any reason is inappropriate and that in this day and age the knowledge of whether someone is HIV positive or not is very important in many aspects of our society. Euan M.S. Frew, MB 340 Campbell St. Nanaimo, BC
[Dr. Somerville replies.] Dr. Girdauskas raises some very important issues. First, paradoxically, and contrary to what Girdauskas implies, we may only be able to protect ourselves and our lifestyles by recognizing rather than denying the reality that we are now a "global village". The spread of HIV is a tragic example of this reality. It is not a matter of opening our doors. In many respects they are open, and in some cases they are unable to be shut; in other cases - for instance, with respect to travel it is not acceptable to try to shut them. Second, there is a difference between fearing a virus, which is justified in the case of HIV, and. fearing the people infected with the virus, which is not. We can all protect ourselves from being infected with HIV; the steps necessary are clear. Third, allocation of medical resources is an important and difficult issue, but it should not be focused upon only in relation to CAN MED ASSOC J 1990; 142 (10)
1037
Replacing CFC aerosols with powders W r e agree with the conx cerns expressed by Drs. Bill Swales (Can Med Assoc J 1989; 141: 1224) and Robert A. Mclvor (Can Med Assoc J 1990; 142: 705) in their recent letters on the environment and the need for the medical profession to contribute toward reducing the amount of fluorocarbons released into the atmosphere. One small contribution, suggested by both writers, could be substituting powder aerosols for
chlorofluorocarbon (CFC)-pressurized metered-dose inhaler (MDI) aerosols. Powder inhalers, such as Rotahalers, Spinhalers and. Diskhalers, have many advantages: they are breath-actuated, portable and Freon-free. However, their use is limited to adults and children over 3 years of age, who are able to generate sufficiently high inspiratory flows to dispense the powder as a respirable aerosol from the device, thereby achieving deposition of the drug in the lower respiratory tract. This may be an issue during an acute exacerbation of asthma with severe airflow limitation, when at the time the patient most needs the medication he or she is unable to generate the necessary flow.' The increasing worldwide rate of death from asthma illustrates the need for effective treatment. In addition, because of the requirement for high peak inspiratory flow, oropharyngeal deposition is high with the powder aerosols and comparable to that with CEC MDI delivery, so that there 1036
CAN MED ASSOC J
1990:
142 (10)
is the potential for side effects when steroids are used. Other problems may be encountered: the hygroscopicity of the powders causes clumping in the device; exhalation into the device before inhalation results in loss of the dose; and loading or assembly may be difficult for some patients, particularly at times of distress. The aerosol propellants referred to as dangerous by Swales may be detrimental to the environment but have not been shown to be harmful to patients unless the standard (two-puff) dose is increased by a factor of 1 5.2 Replacing CFC aerosols with powder aerosols may be a good alternative and acceptable to many patients, but powder inhalers are not foolproof. Maintaining control of the asthma is critical, and this may necessitate the use of CFC aerosols, at least in some cases, especially during severe airflow limitation. Myrna B. Dolovich, PEng E. Helen Ramsdale, MB, FRCPC Department of Medicine St. Joseph's Hospital Hamilton, Ont.
References 1. Pederson S: How to use a Rotahaler.
.4rch Dis Child 1986; 61: 11-14 2. Draffan GH, Dollery CT, Williams FM et al: Alveolar gas concentrations of fluorocarbons -11 and -12 in man after use of pressurized aerosols. Thorax 1974: 24: 95-98
Resuscitation of the terminally ill T Nhe articles and letters on this topic that have recently appeared in CMAJ have underlined the inadequacy of the current CMA guidelines on resuscitative intervention for the terminally ill. ' Baylis2 emphasized the need to recognize and respect patients' autonomy. Few physicians would
disagree with this position, but the process is more complicated than she implied. To function autonomously patients must be competent and fully informed. The competence of severely ill patients to understand the significance of their illness and the nature of cardiopulmonary resuscitation (CPR) and to make rational decisions is often highly questionable. Accurate and complete information about CPR, the poor survival rate and the potential complications is rarely provided, and to provide it would be inappropriate and inhumane in many clinical situations, as Buckman and Senn3 stated. Seeking guidance from distressed family members is also often unsatisfactory, because they will frequently request all possible measures when what they are really seeking is appropriate and compassionate care of their loved one. The CMA guidelines are directed primarily at the concerns of nursing and hospital administration and emphasize the legal aspects rather than how to provide compassionate care for the dying patient. Unfortunately, CPR is now mandated in most Canadian hospitals unless the attending physician has written a "Do not resuscitate" (DNR) order. I believe hospitals that have such policies also have an ethical obligation to inform patients at the time of admission that they will be resuscitated unless they request otherwise and to advise them to discuss the matter with their attending physician. However, a significant number of patients do not wish to discuss resuscitation, and many doctors are reluctant to raise the issue. It is important to recognize that the attitudes of patients and physicians may be greatly influenced by the underlying diagnosis, the clinical setting and religious and cultural factors. For instance, patients with cancer may be more receptive to palliative approaches
than those with equally fatal but less dreaded illnesses. Hospice patients may be more inclined to a DNR policy than those in an acute care setting, and an orthodox Jew will emphasize the importance of preserving life. It is unfortunate that current policies dictate that a traumatic, invasive and usually ineffective procedure be imposed automatically on all patients unless they request otherwise. In allowing this situation to develop we have permitted legal considerations to override humanitarian responsibilities and our respect for the principle of autonomy to outweigh the respect due to beneficence. It would be far better to define appropriate levels of health care for individual patients, as Walker- implied and Emanuel' suggested, than to isolate CPR from other life-sustaining therapies, such as ventilation, intravenous feeding and dialysis. Peter A.F. Morrin, MB, FRCPC Renal Unit
Kingston General Hospital Kingston, Ont.
References 1. Resuscitation of the terminally ill. Can Med Assoc J 1987; 136: 424A 2. Baylis FE: Resuscitation of the terminally ill: a response to Buckman and Senn. Can Med Assoc J 1989; 141: 1043- 1044 3. Buckman R, Senn J: Eligibility for CPR: Is every death a cardiac arrest? Can Med Assoc J 1989; 140: 1068-1069 4. Walker I: Resuscitation of the terminally ill. Can Med Assoc J 1990; 142: 531532 5. Emanuel LL: Does the DNR order need life-sustaining intervention? Time for comprehensive advance directives. Am J Med 1989; 86: 87-90
letter (Can Med Assoc J 1990; 142: 281-282) that "we have become a global village" and that "fear of a virus" is wrong. From the latter I can only infer that Somerville believes AIDS to be simply a virus that we should be able to shrug off. For those of us who live in the real world and not a utopia AIDS is a killer. With the frustrations of an aging population, shrinking number of hospital beds and difficulty in obtaining home care for our locals, can we really afford to shrug our shoulders and import an incurable infection? We cannot even look after our own seniors, who have worked to build this country and now have some very real problems in retirement. We can certainly not afford to open the doors to just anybody suffering from any disease and offer to look after him or her. AIDS is a tragedy, but charity still begins at home. Let's clean up our own corner of the global village before we open the doors to the problems of another. Grazina M. Girdauskas, MD 419-2425 Bloor St. W Toronto, Ont.
All of Dr. Somerville's arguments in her Platform article (Can Med Assoc J 1989; 141: 889-894) and all arguments along the lines that she follows see this whole problem from the aspect of the person infected with the human immunodeficiency virus (HIV) and seem to fail to recognize the tragedy of the unwitting victims of this condition. I do not mean for a minute to be cruel or judgemental or inhumane to people who have the deep misfortune of becoming HIV positive, but I do think that The case against should know that they have HIV antibody testing of they this condition so that they can refugees and immigrants take suitable precautions to protect others. I see no advantage I' t is interesting to read Dr. whatsoever in concealing the Margaret A. Somerville's ide- truth. Of couse, HIV positivity ,,alistic statements in her recent must be treated in absolute confi-
dence, and it is in this area that I feel that great care must be taken. I feel that not to test for HIV is just as discriminatory and unpleasant as to test for it. I can see that the arguments on either side, whether they be protection of the immigrant or protection of the society that has welcomed the immigrant, can be more or less persuasive. The central question is whether we wish to suppress facts that have unsavoury connotations. I feel that the suppression of truth for any reason is inappropriate and that in this day and age the knowledge of whether someone is HIV positive or not is very important in many aspects of our society. Euan M.S. Frew, MB 340 Campbell St. Nanaimo, BC
[Dr. Somerville replies.] Dr. Girdauskas raises some very important issues. First, paradoxically, and contrary to what Girdauskas implies, we may only be able to protect ourselves and our lifestyles by recognizing rather than denying the reality that we are now a "global village". The spread of HIV is a tragic example of this reality. It is not a matter of opening our doors. In many respects they are open, and in some cases they are unable to be shut; in other cases - for instance, with respect to travel it is not acceptable to try to shut them. Second, there is a difference between fearing a virus, which is justified in the case of HIV, and. fearing the people infected with the virus, which is not. We can all protect ourselves from being infected with HIV; the steps necessary are clear. Third, allocation of medical resources is an important and difficult issue, but it should not be focused upon only in relation to CAN MED ASSOC J 1990; 142 (10)
1037
