4. Recognize and Respond [videotape], American College of Radiology and Canadian Association of Radiologists, 1990

[Dr. Chafe responds.] Dr. Hammond's letter describes one of the many dilemmas in applying the legal doctrine of informed consent in clinical practice. The Supreme Court of Canada in Hopp v. Lepp' stated that physicians have a duty to disclose material risks, probable risks, possible risks and special or unusual risks of procedures to patients; these are not exclusive of each other. The court did not elaborate on the exact meaning of the terms. A material risk is any risk that a reasonable patient would want to know about that might influence his or her decision whether to continue with a certain procedure; it depends on the circumstances of the case. The court realizes that physicians need not disclose every conceivable risk of a procedure. Probable risks must be disclosed. Risks that are remote possibilities do not necessarily require disclosure, but this depends on their gravity. Even if a risk is a mere possibility it should be regarded as a material risk requiring disclosure if its occurrence carries serious consequences.2 The courts single out death and paralysis as examples. The term "special or unusual" risks may mean probable risks or may refer to possible risks with serious consequences. It may refer to risks of particular concern to those outside the scope of the ordinary, reasonable patient. In addition to disclosing all material risks physicians must answer all questions posed by a patient, even if it causes the disclosure of remote risks that do not have serious consequences. In answer to the specific concern about the use of intravenous contrast agents the interpretation of the Supreme Court's decision would make this a material risk JUNE 15, 1991

requiring disclosure. The court recognized the possibility that patients would become more apprehensive with increased disclosure but felt that disclosure, coupled with an explanation of why the procedure is necessary, contributes to the informed consent that allows a patient to make a choice to proceed or not. With regard to the use of the new, safer contrast agents the principles from the Supreme Court can only serve as a guide. If it is felt that information about contrast agents may influence a patient's decision whether to have the procedure or not, then disclosure is required. But the courts emphasize that it depends on the circumstances of each case. Unfortunately, we have the legal rules in place but not always the guidance to implement them in clinical practice. Susan Chafe, BSc, BMedSci, MD, LLB Resident in radiation oncology University of Alberta Edmonton, Alta.

References 1. Hopp v. Lepp, 2 SCR 192 (1980) 2. Reibl v. Hughes, 2 SCR 880 (1980)

Screening for cognitive impairment in the elderly I read with great anticipation the "Periodic health examination, 1991 update: 1. Screening for cognitive impairment in the elderly" (Can Med Assoc J 1991; 144: 425-431), from the Canadian Task Force on the Periodic Health Examination. I cannot find fault with the recommendations made or the research priorities identified. However, I do not feel the article does justice to this important and growing health care problem. In particular, the sections on the potential benefits

and harm of early identification do not fully address the issues. As a clinician and researcher working with caregivers of elderly people with dementia I see far too many patients who have not been identified and labelled early enough in the course of their disease. Patients may have considerable difficulty functioning safely in their own homes even in the early stages of their illness. Moreover, families are left wondering why their relative is behaving differently and what can be done about it. Despite the fact that Alzheimer's disease and many other dementias are not reversible there still are many modes of treatment available. These include family education and planning and the introduction of a variety of community services aimed specifically at such patients: respite care, either in the home or in long-term care facilities, and specialized day care. My colleagues and I have found that physicians do not use these services adequately and need to be educated about their availability and potential benefits (unpublished data). Little is known about the effects of labelling a person as demented. Much is made in the article of the barriers to care encountered by elderly people with psychiatric illness. This is indeed a grave problem, but it is by no means specific to patients with dementia. In fact, the authors have not made a good case for the potential harm of early identification. This is an area begging for further research, as identified in the research priorities section. Understandably, early labelling will have no benefit if physicians and health care professionals are not educated as to the types of treatment and services available to this patient population and their caregivers. In the interim, it seems premature to suggest that it is not advisable to screen for cognitive impairment if to do so would at CAN MED ASSOC J 1991; 144 (12)

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agement of a recognizable change wan for the past 41/2 years I do not think the reasons for this disparity in health status. are difficult to understand. To Christopher Patterson, MD, FRCPC Carole A. Cohen, MD, FRCPC many, rural medical practice is an Associate professor and head Sunnybrook Health Science Centre unknown entity, and fear of the Division of Geriatric Medicine Toronto, Ont. unknown drives the average cliniFaculty of Health Sciences cian from rural practice. away McMaster University [The principal author responds.] Hamilton, Ont. Furthermore, rural locations are more difficult to visit, and the Dr. Cohen raises a number of References problems encountered take a long excellent points. The title and purtime to investigate fully. Many pose of the article address screen- 1. Organizing Committee, Canadian Conto pracphysicians want naturally ing in primary care. Although we sensus Conference on the Assessment of in in environtise the an city do question the value of incorpoDementia: Assessing dementia: the Canadian experience. Can Med Assoc J ment in which they are comfortrating mental status question1991; 144: 851-853 able, have sufficient back-up facilnaires into the periodic health ex- 2. Mohide EA, Pringle DM, Streiner DL ities and, most important, have amination we did not intend to et al: A randomized trial of family access to easy opportunities in offer guidelines on the assessment caregiver support in the home management of Am Geriatr Soc dementia. J medical practice. of symptomatic patients. 1990; 38: 446-454 The current policies requiring When "patients may have medical students or family mediconsiderable difficulty functioning cine residents to spend some time ... [and] families are left wonderin rural practice are starting to ing why their relative is behaving show some positive effects and in differently" the situation is one of Why won't doctors go time should help to attract fullclinical deterioration for which an time physicians. investigation of cognitive perfor- where they are needed? I believe that a comprehenmance is clearly indicated. These deputy minister asks sive strategy is needed to address circumstances are addressed in s outlined in Patrick Sul- the shortage of rural physicians. the conclusions of the Canadian livan's article (Can Med Physicians and rural hospitals Consensus Conference on the AsAssoc J 1990; 143: 949- should be working together nasessment of Dementia.1 We entirely agree that many 950) the distribution of physicians tionally to improve the image of modes of treatment are available in Canada is one of the most rural practice and to provide the for the management of Alzheim- vexing problems facing the medi- right kind of information about it. er's disease and other dementias. cal system. Physicians are distrib- This could go a long way toward Except for the impact of an edu- uted not according to need but removing the fear of the unknown cational support program for according to individual lifestyle and making rural practice a desircaregivers2 most have not been preference. To be more specific, able challenge. Many Canadian graduates are subject to rigorous study, and the main disparity is between the we must therefore rely on expert scarcity of physicians in rural short-changing themselves by not opinions, which are not always practice and the abundance in taking the opportunity to exconsistent. urban practice. perience this rewarding lifestyle. We did not conclude that "it It is a mistake to view physis not advisable to screen for cog- icians as a commodity that should Alan J. Brookstone, MB, BCh nitive impairment." We stated be distributed according to mar- 211 Ist St. W PO Box 417 that "there is insufficient evidence ket models of economics. Phys- Nipawin, Sask. to include routine screening for icians have responded very negacognitive impairment in or ex- tively to governmental pressures clude it from the periodic health aimed at forcing them into rural examination of people over 65 areas. These incentive schemes or years of age." Thus the decision to forms of penalization have not Embolism during include or exclude must be made elicited the key ingredient that is intrauterine laser on grounds other than evidence. needed to attract physicians to surgery If daily activities are not rural communities or keep them T n he letter by Frances Weber being performed a reason must be there - a desire for rural medical found, but this is no longer the practice. and Bill Wallace (Can Med role of screening: it becomes the As a family physician who Assoc J 1990; 143: 709) appropriate diagnosis and man- has practised in rural Saskatche- recommends that gas or air should

least determine its impact on daily activities.

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Screening for cognitive impairment in the elderly.

4. Recognize and Respond [videotape], American College of Radiology and Canadian Association of Radiologists, 1990 [Dr. Chafe responds.] Dr. Hammond'...
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