New legislation will allow control of medical treatment

By David South

Today’s Seniors (Canada), December 1993

It isn’t the nicest thing to think about, but if accident or illness strikes, you could end up receiving unwanted treatment. 

But in 1994 things will change. The living will or advance directive - a document clearly stating a patient’s wishes about how they want to be treated - will become part of the doctor-patient relationship. 

A trio of acts passed last December - the Advocacy Act, the Substitute Decisions Act and the Consent to Treatment Act - allow, albeit in rather vague language, for Ontarians to set out in advance which medical procedures they would or wouldn’t accept and let’s them name a proxy in case they are incapable of expressing their wishes. 

This vague language - intended to allow patients to customize their wishes - means that writing a living will can prove to be a troubling and confusing experience. 

To aid decision-making, the University of Toronto Centre for Bioethics is offering advice through a “model” living will. 

The centre’s Dr. Peter Singer has geared the “model” to meet Ontario legislation and to offer a guide for anybody who doesn’t know where to begin. 

“We put a lot of detail in the advance directive about states of incompetence people get into, and also the sorts of procedures providers might recommend in those health states.”

Singer sees living wills as an effective tool aiding patients to control their own health care.

“Unless the doctor is a longstanding friend it’s hard to know what patients want. As a practicing doctor, I have run into an incompetent person where their family member has no idea what sort of wishes the person would have wanted. The goal of a living will is to provide the personal care the patient would want.”

But there is a danger. Dr. Singer urges the need for informed and detailed language in a living will. 

“If I have a couple minutes to make a decision I need a document that gives me a lot of confidence that this person wouldn’t want this treatment.”

In an emergency, the doctor might not even know of the living will’s existence. Dr. Singer advises giving a copy to your family doctor, lawyer, or proxy, and keep one with you at all times. When so-called “smart” health cards come along, Dr. Singer would like to see the living will recorded on the magnetic strip along with other health information. 

Private firms thrive as NDP ‘reinvents’ medicare

By David South

Today’s Seniors (Canada), August 1993

Many of today’s seniors fought for Canada’s internationally-admired public health system. But more and more people are becoming worried that the combination of health care reform, funding cutbacks and free trade is fuelling the growth of a second tier of private medical services serving the well off. 

The provincial government sees things differently, arguing Ontarians no longer expect government to pay for everything and rather than eroding medicare, the NDP is reinventing it. 

Whichever way one looks at it, private insurance companies, homecare providers, labs and other services designed to make money are becoming more and more involved in the health care business. 

Operating in the territory outside the guidelines of the 1984 Canada Health Act - which sets out the principles of medicare for the federal government to enforce - the private sector has room to expand, at the same time as OHIP coverage is scaled back from more and more services. 

Janet Maher, whose Ontario Health Coaltion (OHC) represents doctors, nurses and other health care workers, worries for the future of medicare. 

“A number of things like accomodation services - laundry, food services - are in the grey area of the Canada Health Act,” says Maher. “So with all these fees that are being introduced, by the strict letter of the law, there is no way to stop them. But as far as we are concerned the spirit of the Act isn’t being observed.”

In its current reforms, the government of Ontario is emphasizing paramedical professions like midwives who fall outside the CHA and aren’t covered by OHIP. The turn to community-based services means that people have to rely more on services and providers that aren’t covered under the CHA. 

Maher says privatizing accomodation services is a recent phenomenon, the result of hospitals finding creative ways to trim their budgets. 

“It’s a new area that hospitals are taking bids on,” she says. “The other thing around the accomodation services is that because they are not categorized, strictly speaking, as health care services, none of this is exempted in the Free Trade Agreement from U.S. competition.”

A recent report by two British Columbia researchers tries to put together this complex puzzle. Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia recently charged that a combination of free trade and budget-slashing governments is eroding the universality of medicare and ushering in a two-tier system. 

Fuller and Henwood identify the Free Trade Agreement as the culprit. While the health care industry created more jobs than any other sector of the Canadian economy between 1984 and 1991, they point out the job growth has been concentrated in the private sector since free trade was implemented in 1989. And they expect worse under the proposed North American Free Trade Agreement (NAFTA). 

“NAFTA will accelerate trends towards a privatized, non-union and corporate-dominated system of health care in Canada.”

One provision of the Free Trade Agreement has also made it possible for U.S. companies to compete against Canadian firms in health care. Chapter 14, “health-care facilities management services”, allows wide-open competition. 

Under NAFTA, provisions will bind all levels of government to consider for-profit health care companies on both sides of the border on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board they’ve been wronged. 

“That represents a substantial encroachment on the democratic right of local, provincial and federal governments to make decisions,” says Cathleen Connors, who chairs the national wing of OHC, the Canadian Health Coalition. 

It’s this plus health care cutbacks - federal and provincial - that’s resulting in service and job cuts and bed closures in the public sector and an increase in privatization, say Henwood and Fuller. These opportunities have not gone unnoticed by private companies south of the border. 

One such company is American Medical Security Inc. (AMS) of Green Bay Wisconsin. After hiring Canadian pollsters Angus Reid to do a survey, AMS saw a profitable market in offering American hospital insurance to frustrated Canadians awaiting surgery. Sixteen per cent of those polled said they wanted this service; that was enough for AMS. 

“One thing that comes across loud and clear is that Canadians for the most part are happy,” says spokesperson Carrie Galbraith. “They know they are taken care of during an emergency. But they are willing to pay a little extra if they need care.”

So far, AMS offers its plan to Ontario, B.C. and Manitoba, with Toronto its best market. Galbraith says plans are in the works to expand to all of Canada except the territories. 

Unfortunately, like most private health plans, AMS cuts its losses by avoiding what Galbraith calls “adverse selection” - anybody with a known serious health problem need not apply. 

Here in Ontario, private for-profit home care services take in close to half of all OHIP billings. Many clients pay out of their own pockets for additional services. 

The Ontario health ministry doesn’t keep statistics on the extent of the private home health care sector, says spokesperson Layne Verbeek. But the Ontario Home Health Care Providers’ Association, a trade group, estimates private homecare companies now employ 20,000 and serve more than 100,000. 

“It’s a market situation,” says Henwood. “If the services aren’t available to people within the public sector, they will go outside of it. We’ve seen this in other countries like England, where they had a public system and now have a parallel private system. If you erode a system enough that people get angry, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”

But in a recent interview, health minister Ruth Grier was adament this scenario wouldn’t be allowed to take place in Ontario. She strongly disagreed that medicare is being weakened due to recent changes, and said the government has actually “reaffirmed its commitment to medicare.”  

Health Care in Danger

Worrying breakdown in Ontario reforms

By David South

This Magazine (Canada), October-November, 1992

The Senior Citizens’ Consumer Alliance for Long-Term Care’s report on the Ontario New Democratic government’s health care reforms, released in July, documents what many people suspected: the much-needed reforms are mismanaged and dangerously close to chaos.

The report compares the present crisis to the failed attempt in the seventies to move psychiatric care out of institutions and into communities by closing 1,000 beds. Patients were left with inadequate community services, resulting in many homeless and jailed former patients. The alliance fears seniors – the biggest users of health services – could fall victim to reforms in the same way.

According to many health care reformers, Bob Rae’s government seems to have lost control of the issue, resulting in massive job losses and a worrying breakdown in services.

The NDP’s health care document “Goals and Strategic Priorities” reads like a wish list for progressive health care reformers, ranging from disease prevention programmes to improved access to health care for minorities, natives and women. To many, the debate isn’t over these goals but how they are achieved and what the government’s true motives are. Under pressure from big business and its lobby groups, the NDP is desperate to save money where it can, and as Ontario Health Minister Francis Lankin says, “not disrupt or destroy business confidence.”

Emily Phillips, president of the Registered Nurses’ Association of Ontario, is blunt: “The NDP’s plans sound good on paper, but they can’t give a budget or direct plan on how they hope to carry out reforms. They are going about things backward. They cut hospital beds and lay off staff without having community health care services ready.”

The national trend in health care is to deinstitutionalize and bring services to homes and communities. It is hoped that emphasizing prevention and healthy living will significantly reduce the need for hospitals, expensive drugs, surgery and high-tech equipment. The NDP has pledged to spend $647 million to reform long-term care services by 1997 – creating services that will allow seniors to stay in their own homes.

Problem is, the NDP has embarked on radical down-sizing of hospitals – closing beds and laying off thousands of health care workers – right now. Lankin claims that in the worst-case scenario, layoffs this year wouldn’t exceed 2,000, but the Ontario Hospital Association claims 14,000 jobs are in jeopardy. Phillips believes it will be hard to estimate job loss: “It is hard to even record the number of nursing jobs lost, because for every full-time job cut many part-time and relief positions go with it.”

Chaos will result when people who depend on hospitals have nowhere to turn but the inadequate community health care services, which are uneven and narrowly focussed. To make things worse, the same funding restrictions placed on hospitals have also hit the services that are supposed to save the day.

“I haven’t heard of any change in the quality of care. It is just too early,” says Phillips about the effect of layoffs on hospitals. “Right now the nurses are picking up the slack, but soon they will burn out. I don’t feel confident this government has the management skills to do this. I’d like to see a plan in place before moving people into the community.”

Training for laid-off hospital workers will have to come from the $160-million allocated for retraining workers laid off by cities, universities and school boards – all of whom are coping with record-low budget increases.

In February, Lankin appealed to hospitals to do everything in their power to make layoffs painless and to trim doctors and administrators first. But the NDP has yet to pass legislation that would bind hospital boards to make the right cuts. The boards operate at arm’s length from government and continue to make unnecessary decisions, ignoring the NDP’s moral pleas.

Rosanna Pellizzari, a member of the Medical Reform Group and chair of the Ontario Association of Health Centres, wants better community accountability for hospitals before they lay off staff and cut services: “Sometimes it makes sense to bring people to hospitals. Planning must be at the community level and open and democratic. Health care workers, who are mostly women, should not be scapegoated for financial problems. Doctors and management should go first. Physicians experience very little unemployment.”

Carol Kushner, co-author of the book Second Opinion, which evaluates the country’s medical system, sees chaos resulting from the conflicting agendas of governments and health care reformers: “Will the tremendous contradictions of institutions be transferred to the community? The federal government is rapidly draining money from medicare while provincial governments are having a hard time. This hasn’t produced extra funds for re-allocating services to the community – which was recommended by reformers. You have to ask: who is going to fall through the cracks?”

This Magazine (Canada), October-November, 1992.

Psychiatric care lacking for institutionalised seniors

By David South

Today’s Seniors (Canada), November 1992

“Don Weitz wears a T-shirt bluntly saying, “Fry rice - not brains.”

Seniors who live in nursing homes and homes for the aged are receiving an inadequate amount of psychiatric care, according to a study conducted by Toronto’s Baycrest Centre for Geriatric Care.

Dr. David Conn, director of psychiatry at Baycrest and an author of the report, says action must be taken to remedy this situation, since at least 80 per cent of elderly long-term care residents suffer from some form of mental disorder.

The issue of psychiatric care for seniors is complex. There are many, often strongly-held, opinions about the nature of this care and what measures will genuinely improve the mental well-being of seniors in institutions.

According to The Senior Citizens’ Consumer Alliance for Long-Care Reform, Ontario has the highest rate of institutionalisation of seniors in the world, with 7.5 per cent of seniors over the age of 65 and 15 per cent over 75 in institutions. The Alliance demanded in its reforms in Ontario that seniors’ mental health problems be taken more seriously and be included in any assessment for care.

Baycrest’s report surveyed 1,148 medical directors and nursing directors in over 500 nursing homes and homes for the aged across Ontario. The 601 who responded reported that 37 per cent of their residents received no psychiatric care, while only 12 per cent received more than five hours per month. The most common psychiatric problems under treatment were depression, agitation, wandering and physical aggression.

“Recognition of significant mental disorders in nursing homes is a recent phenomenon because geriatric psychiatry is a relatively new field,” says Dr. Conn. “The usual approach has been to reach for the prescription pad. We know now that antidepressants have been underused and tranquillizers overused.

“To deliver effective psychiatric care requires more than just psychiatrists - teams of psychiatric nurses can also be involved. Hopefully the staff of these institutions will become better educated as a result of this report.”

Dr. Kenneth Shulman, head of psychiatry at the Sunnybrook Health Sciences Centre, feels the worst neglect occurs in private rest homes.

“There is general lack of accountability when it comes to geriatric psychiatric services.” Schulman advocates a coordinated, comprehensive regional network of services.

Dr. Conn is sensitive to reports of sexual, physical and mental abuse of residents in some institutions. He says staff as well as residents of institutions can benefit from psychiatric consultations. “If more psychiatric consultants were available, the staff could also receive help in working out their problems,” he says. “Unfortunately the fee-for-service system doesn’t include paying for visiting staff.

“Being in an institution is not easy for anyone. It often means being apart from family, living with strangers, loss of freedom and having to live by the institution’s timetable.”

One of the most controversial of psychiatric treatments is electroconvulsive therapy (ECT). ECT involves placing electrodes on the sedated patient’s head and passing 100 to 175 volts of electricity into one of the lobes of the brain to induce grand mal seizure and coma.

Opponents of ECT say the procedure can cause memory loss and confusion, and in some cases proves fatal. A 1985 Ontario government task force report recommended against using ECT in certain cases: “For patients whose work requires a clear and precise memory, ECT is probably contraindicated.”

But many other sources say that while ECT has been abused in the past and, like many other medical procedures, may not be a pretty sight, it is sometimes effective in combating depression.

Dr. Conn confirms that the controversial procedure is still being used on seniors. “ECT is used on very depressed people,” he says. “It is a hospital-based service. The patient is admitted to a psychiatric unit of the hospital. We do it at Baycrest. It is only a last resort and has often been life-saving.”

Don Weitz, a senior citizen and spokesperson for Resistance Against Psychiatry, doesn’t mince words about what he says is the adverse effects of electroshock therapy and psychiatric practice in general. He wears a T-shirt bluntly saying, “Fry rice - not brains.”

“We have known about the adverse effects of shock for years,” says Weitz. “Research from the ‘40s and ‘50s was very clear that there was brain damage.

“What doctors mean by improvement is in fact post-injury euphoria - the brain will overcompensate with giddiness, and this only lasts for two to four weeks. Doctors seldom test people for more than two or three months afterwards.”

“What we know for sure is that within the institutions, they would rather give drugs or shock than talk to seniors. I think this should be called elder abuse - what else could it be? Is it such a mystery why people are depressed in institutions where they are abused? Psychiatrists have a vested interest in billing OHIP for pushing the button.”

But Dr. Shulman disagrees with blaming the atmosphere of institutions. “It is simplistic to think that the environment is responsible for aggressiveness or other problems,” he says. “These people are cognitively impaired - it could be medication-related or something else. These are complicated issues.”

For any nursing home workers who want further advice about psychiatry, Baycrest has produced a “Jargon-free” guide called Practical Psychiatry in the Nursing Home.

"Psychiatric care lacking for institutionalized seniors": Today's Seniors, November 1992

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