- Another look into children who have been diagnosed with cancer. It's heartbreaking to hear what children and their parents are going through. A situation that none of us can ever imagine.
Wednesday, May 25, 2011
Patient Voices: Childhood Cancer - Interactive Feature - NYTimes.com
Patient Voices: Childhood Cancer - Interactive Feature - NYTimes.com
The Student Biotechnology Network
Alzheimer's disease: a look at a inside perspective.
An excerpt from the novel: Still Alice, written by Lisa Genova.
Upon reading this, I felt a sense of guilt of how we tend to avoid how people with certain diseases feel. The best information is to gain from those who are or have actually experienced a disease. How someone can spend their life time being educated, respected and have a high status among a community and then have their world come apart due to a illness. Learn from those who can tell us.
I would definitely recommend this novel to anyone who would be interested in a internal perspective of someone with Alzheimer's. It has been voted as New York Times best sellers, amongst many other.
Saturday, May 14, 2011
Injectable gel could spell relief for arthritis sufferers
Injectable gel could spell relief for arthritis sufferers
While helping out in arthritis research and working personally with patients who have been diagnosed with arthritis, I have come to really understand the complications it can have not only physically but mentally as well. No matter what the medication is, arthritis is a inflammatory autoimmune disease that cannot be cured till this date. There are temporary reliefs available as well as clinical trials that take place on a constant bases. I hope to see many significant discoveries in this area. This is in fact a great start!
Euthanasia: Does Canada discriminate against people like Nancy Johnson and Sue Rodriquez?
Quite frankly, I do not think that Canada discriminates on terms of who should practice Euthanasia but instead, the Canadian law is against the act of Euthanasia or physician assisted suicides itself. In the following paragraphs, I will discuss the basis on which I am against the act of euthanasia and bring into perspective of the moral theories that oppose assisted suicide. In Canada, suicide is not illegal but physician assisted suicide is as the criminal code states that “Everyone who counsels a person to commit suicide or aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years (241). I agree with Canada’s law because it prevents people who are not mentally capable of making their own decisions from being assisted in suicide as well as the value of a human being would decrease if active euthanasia were to be decriminalized. Many cases of active euthanasia have been reopened for debate on what Canada should consider morally acceptable in the terms of euthanasia. In terms of Kantianism, one should act according to a maxim that will become a universal law and one should always do the right thing regardless of the consequence (Fisher, 2009). The Canadian government in my point of view is following Kant’s perspective as they have made it illegal because it is the right thing to do no matter what the consequence may be. Utilitarianism takes the opposite approach that actions are based on the consequences (Fisher, 2009). With the aspect of euthanasia though, the consequences are different in everyone’s eyes. The person who wants to take part in active euthanasia perceives it to be positive because they will die with dignity, free of pain and not be a burden on the family. The physician performing the suicide could also be thinking that the consequences be positive because they are helping the patient end their misery as well as bringing their own moral ethics into the situation (Latimer, & McGregor, 1994) In certain provinces, as in Quebec’s physician code of ethics states “A physician must, when the death of a patient appears to him to be inevitable, act so that the death occurs with dignity. He must also ensure that the patient obtains the appropriate support and relief.”(58); although in the eyes of society as a whole, the act of killing yourself is immoral and the consequence of death due to suicide is seen as negative (Latimer, & McGregor, 1994).
Many people also look at the situation of legalized assisted suicide in Canada through a care ethics approach (Fisher, 2009). No matter how serious the illness, life is a gift and one must cherish it. The health care industry of Canada has also implemented other means where pain relief can be offered while being able to pass away in dignity. The concept that life is a gift is also understood in terms of disability ethics. Within the spectrum there is a division of people who are born with disabilities or develop them over time. Those who are born with disabilities haven’t experienced a life without it so they appreciate life for what they have but for those individuals who become disabled later on in their life, it is sometimes hard for them to live as they did before. I personally agree with Susan Wendell’s approach that “Healthy people with disabilities express gratitude for being healthy, people with chronic illnesses express gratitude for not having gotten sicker, and people with fluctuating chronic illnesses express gratitude for coming out of a relapse.” The law of Canada also abides through the eyes of multicultural ethics. Every community or religion has their own definition of what is considered moral or immoral (Latimer, & McGregor, 1994). Many belief systems would say that God has given you your soul and only God can take it away. If you have a illness, it is in your fate and you should be able to abide to it patiently. Euthanasia can be perceived differently within each scenario; either it be completely wrong to take one’s life or it is one’s autonomy to decide what they want to do with their own body and soul (Latimer, & McGregor, 1994).
There are many courage stories of people who live with ALS and have accepted the illness. One patient, Durwin Cadeau is 26 years old and has been diagnosed with ALS (Cadeau, 2010). Cadeau was known to be free spirited, had a passion for cars, has a baby boy, and an amazing family. He mentions that his pain is unbearable and he knows his disease is getting worse (Cadeau, 2010). Cadeau has his entire life to look forward to but won’t be able to see his son grow up or his sister get married, yet he still is holding on (Cadeau, 2010). He feels that God has another plan for him and he will see the rest of his family in heaven because that is the eternal life (Cadeau, 2010). In my perspective, the most difficult of illnesses are to those who are diagnosed at a young age, and if someone like him has the ability to pull through it then we should all have the strength to carry on.
As mentioned above, I do not think that the Canadian law has discriminated against women but it has set laws to make physician assisted suicide illegal as a whole. Majority of the cases in the courts are debated by women but there are also cases that are also reopened by men but not mentioned as much as it should be (Daigle, & Côté, 2006). Let’s take the case of Robert Latimer, he was charged with the death of his daughter Tracy Latimer because he could not stand her pain and allow her to undergo mutilation and torture (Fisher, 2009). Even though his intentions were motivated by his love for his daughter, he was still taken to court and given prison time. Through this we can see that it may not have been a plea for a physician assisted, but it is a case of active euthanasia. The difference in Latimer’s case was that as a father, he decided to take the life of his daughter which was a act of kindness on his part. Although we can question whether or not Tracy Latimer wanted to live but she did not have a say because she was deemed as incapable of making her own decisions. In my point of view, this is going against the child’s autonomy and her own rights. This is also why I agree with Canada’s law of active euthanasia or physician assisted suicide being illegal because not everyone is able to make proper decisions for themselves in times of grievance. Women are not the only gender that has experienced a negative response in the areas of euthanasia. I agree with Susan Wolf’s statement that over that years women have been seen as vulnerable, the primary caregivers and would be able to sacrifice their life for their family because they do not want to be a burden to them. I also agree that women are more likely to get diagnosed with a chronic disease than men are but I do not think that it makes it easier for women to have the duty to die (Kluge, 2000). Men are also the caregivers of the family but at the external level; they work hard to make money and provide for their families (Daigle, & Côté, 2006). They also have an emotional attachment to their wife and children so they are also capable of sacrificing their lives in terms of not becoming a burden (Daigle, & Côté, 2006). Wolf objects to the terms at which men and women ask for active euthanasia by mentioning that the problems are correlated with gender health issues. She explains that women have difficulty in receiving good medical care, have poor pain relief, higher incidence of depression as well as higher rate of poverty. Among those reasons, Wolf also argues that women attempt suicide in an effort to change an oppressive situation more than men do but women are considered “attempters” whereas men would be considered “completers” of suicide (Wolf, 2009). There are some areas where her claims of women wanting to take part in euthanasia more than men are not supported though. For example in Oregon USA, there is evidence that half the people who seek euthanasia are men, the other half are women and most of them tend to be Caucasian from the middle class sector (Wolf, 2009) .
I disagree with aspect that women are not given as good as medical care as men are. I believe that women are usually treated better than men especially in the Canadian health care system (Kluge, 2000). If a man and a woman were to enter the hospital with the same illness, the women would be looked after first because she is considered fragile whereas the man can find the strength to carry on longer. The concept of euthanasia can also be compared to the ethical and moral theories. A women may appeal to physician assisted suicide because she feels that she has the “right” to do what ever she pleases with her body. If she feels that by ending her life, she would be able to die with dignity then it is in her own autonomy to make that decision. Autonomy goes hand in hand with self determination as it entitles the patient to refuse unwanted life sustaining treatments (Callahan, 2009). Dr. Fraser, states “"I believe if someone wants to commit suicide [she has] a right to do it, but [she does] not have a right to expect me to perform it," (Kluge, 2000). Through this we can understand that it is in the patient’s full autonomy to reject a certain treatment but she does not have the right to ask a physician to assist her with suicide because it is not in the physician’s autonomy to do so (Kluge, 2000). Besides self autonomy, women tend to have the responsibility to care for their families and relationships. Most of the time, their decision to end life is based on the fact that she does not want to be a burden on her family and loved ones. This brings into perspective the ethics of care where the individual makes decisions based on selfless reasons and only to benefit the people around them. Even though the act of physician assisted suicide may be based on a completely selfless reason, the justice and law of Canada does not allow it. As earlier explained, the Canadian law takes the Kant approach and abides by the concept of “act only on that maxim that will become a universal law”. Another perspective that could tie in with a women's decision to take part in euthanasia is due to the social model of disability (Morris, 2001). The social environment seems to define what “disability” really means which is one of the factors to why individuals believe that there is no point of living if they cannot do anything (Morris, 2001). For instances if someone is in a wheelchair, it means they have limited accessibility compared to a person who is able to walk. Society has also come to define that any impairments of the body is a form of disability even if it’s for a short time being (Morris, 2001); as in, wearing a cast for a few weeks. When one has a disability or impairment of any sort, they start to be a burden on not only their loved ones but as well as the general public (Morris, 2001). If active euthanasia was to become legal it will send a message to those with disabilities, the vulnerable and the rest of the community that it is better to die instead of live with impairments. If this was to happen then the value of life would decrease. The test of patience and strength would be diminished as everyone would give up on the hope of getting better and decide that they are better to pass away then to live on.
The concept of Euthanasia and physician assisted suicide does not discriminate on the basis of women but it denies the right to everyone who resides in Canada. I think that it is immoral to take away a person’s life because it devalues the significance placed on life disregarding gender. If active euthanasia was to be made legal then the consideration of suicide would be increased and therefore decrease the value that has been placed on life and patients. Instead the focus should be placed on improving care no matter what the situation be. Government should invest in building a atmosphere to aid those who are disabled just like the families would need to change the environment in their homes as well. This would then change the perspective of the social model of disability to accept all impairments and disabilities as well as promote well being.
Now let's put ourselves in a situation of those who resort to any type of Euthanasia ( from a inside perspective):
How short is life
How long are we going to live?
I once was healthy, worked hard and cared for my children
But as my illness progresses, I feel helpless and weak,
They say I will not die soon,
But soon is an understatement,
I see my life passing me by,
And I do not understand why,
I beg for mercy and pray for a miracle,
There will come a day when I won’t be able to walk,
Won’t be able to properly talk,
My hands won’t be able to work
An intolerable burden to my loved ones,
That I cannot bear
And I ask for you to care,
My wish for when things get worse,
Is the choice to end my own source,
To pass away with peace and dignity,
I do not want to die,
But I have to.
Regards:
Many people also look at the situation of legalized assisted suicide in Canada through a care ethics approach (Fisher, 2009). No matter how serious the illness, life is a gift and one must cherish it. The health care industry of Canada has also implemented other means where pain relief can be offered while being able to pass away in dignity. The concept that life is a gift is also understood in terms of disability ethics. Within the spectrum there is a division of people who are born with disabilities or develop them over time. Those who are born with disabilities haven’t experienced a life without it so they appreciate life for what they have but for those individuals who become disabled later on in their life, it is sometimes hard for them to live as they did before. I personally agree with Susan Wendell’s approach that “Healthy people with disabilities express gratitude for being healthy, people with chronic illnesses express gratitude for not having gotten sicker, and people with fluctuating chronic illnesses express gratitude for coming out of a relapse.” The law of Canada also abides through the eyes of multicultural ethics. Every community or religion has their own definition of what is considered moral or immoral (Latimer, & McGregor, 1994). Many belief systems would say that God has given you your soul and only God can take it away. If you have a illness, it is in your fate and you should be able to abide to it patiently. Euthanasia can be perceived differently within each scenario; either it be completely wrong to take one’s life or it is one’s autonomy to decide what they want to do with their own body and soul (Latimer, & McGregor, 1994).
There are many courage stories of people who live with ALS and have accepted the illness. One patient, Durwin Cadeau is 26 years old and has been diagnosed with ALS (Cadeau, 2010). Cadeau was known to be free spirited, had a passion for cars, has a baby boy, and an amazing family. He mentions that his pain is unbearable and he knows his disease is getting worse (Cadeau, 2010). Cadeau has his entire life to look forward to but won’t be able to see his son grow up or his sister get married, yet he still is holding on (Cadeau, 2010). He feels that God has another plan for him and he will see the rest of his family in heaven because that is the eternal life (Cadeau, 2010). In my perspective, the most difficult of illnesses are to those who are diagnosed at a young age, and if someone like him has the ability to pull through it then we should all have the strength to carry on.
As mentioned above, I do not think that the Canadian law has discriminated against women but it has set laws to make physician assisted suicide illegal as a whole. Majority of the cases in the courts are debated by women but there are also cases that are also reopened by men but not mentioned as much as it should be (Daigle, & Côté, 2006). Let’s take the case of Robert Latimer, he was charged with the death of his daughter Tracy Latimer because he could not stand her pain and allow her to undergo mutilation and torture (Fisher, 2009). Even though his intentions were motivated by his love for his daughter, he was still taken to court and given prison time. Through this we can see that it may not have been a plea for a physician assisted, but it is a case of active euthanasia. The difference in Latimer’s case was that as a father, he decided to take the life of his daughter which was a act of kindness on his part. Although we can question whether or not Tracy Latimer wanted to live but she did not have a say because she was deemed as incapable of making her own decisions. In my point of view, this is going against the child’s autonomy and her own rights. This is also why I agree with Canada’s law of active euthanasia or physician assisted suicide being illegal because not everyone is able to make proper decisions for themselves in times of grievance. Women are not the only gender that has experienced a negative response in the areas of euthanasia. I agree with Susan Wolf’s statement that over that years women have been seen as vulnerable, the primary caregivers and would be able to sacrifice their life for their family because they do not want to be a burden to them. I also agree that women are more likely to get diagnosed with a chronic disease than men are but I do not think that it makes it easier for women to have the duty to die (Kluge, 2000). Men are also the caregivers of the family but at the external level; they work hard to make money and provide for their families (Daigle, & Côté, 2006). They also have an emotional attachment to their wife and children so they are also capable of sacrificing their lives in terms of not becoming a burden (Daigle, & Côté, 2006). Wolf objects to the terms at which men and women ask for active euthanasia by mentioning that the problems are correlated with gender health issues. She explains that women have difficulty in receiving good medical care, have poor pain relief, higher incidence of depression as well as higher rate of poverty. Among those reasons, Wolf also argues that women attempt suicide in an effort to change an oppressive situation more than men do but women are considered “attempters” whereas men would be considered “completers” of suicide (Wolf, 2009). There are some areas where her claims of women wanting to take part in euthanasia more than men are not supported though. For example in Oregon USA, there is evidence that half the people who seek euthanasia are men, the other half are women and most of them tend to be Caucasian from the middle class sector (Wolf, 2009) .
I disagree with aspect that women are not given as good as medical care as men are. I believe that women are usually treated better than men especially in the Canadian health care system (Kluge, 2000). If a man and a woman were to enter the hospital with the same illness, the women would be looked after first because she is considered fragile whereas the man can find the strength to carry on longer. The concept of euthanasia can also be compared to the ethical and moral theories. A women may appeal to physician assisted suicide because she feels that she has the “right” to do what ever she pleases with her body. If she feels that by ending her life, she would be able to die with dignity then it is in her own autonomy to make that decision. Autonomy goes hand in hand with self determination as it entitles the patient to refuse unwanted life sustaining treatments (Callahan, 2009). Dr. Fraser, states “"I believe if someone wants to commit suicide [she has] a right to do it, but [she does] not have a right to expect me to perform it," (Kluge, 2000). Through this we can understand that it is in the patient’s full autonomy to reject a certain treatment but she does not have the right to ask a physician to assist her with suicide because it is not in the physician’s autonomy to do so (Kluge, 2000). Besides self autonomy, women tend to have the responsibility to care for their families and relationships. Most of the time, their decision to end life is based on the fact that she does not want to be a burden on her family and loved ones. This brings into perspective the ethics of care where the individual makes decisions based on selfless reasons and only to benefit the people around them. Even though the act of physician assisted suicide may be based on a completely selfless reason, the justice and law of Canada does not allow it. As earlier explained, the Canadian law takes the Kant approach and abides by the concept of “act only on that maxim that will become a universal law”. Another perspective that could tie in with a women's decision to take part in euthanasia is due to the social model of disability (Morris, 2001). The social environment seems to define what “disability” really means which is one of the factors to why individuals believe that there is no point of living if they cannot do anything (Morris, 2001). For instances if someone is in a wheelchair, it means they have limited accessibility compared to a person who is able to walk. Society has also come to define that any impairments of the body is a form of disability even if it’s for a short time being (Morris, 2001); as in, wearing a cast for a few weeks. When one has a disability or impairment of any sort, they start to be a burden on not only their loved ones but as well as the general public (Morris, 2001). If active euthanasia was to become legal it will send a message to those with disabilities, the vulnerable and the rest of the community that it is better to die instead of live with impairments. If this was to happen then the value of life would decrease. The test of patience and strength would be diminished as everyone would give up on the hope of getting better and decide that they are better to pass away then to live on.
The concept of Euthanasia and physician assisted suicide does not discriminate on the basis of women but it denies the right to everyone who resides in Canada. I think that it is immoral to take away a person’s life because it devalues the significance placed on life disregarding gender. If active euthanasia was to be made legal then the consideration of suicide would be increased and therefore decrease the value that has been placed on life and patients. Instead the focus should be placed on improving care no matter what the situation be. Government should invest in building a atmosphere to aid those who are disabled just like the families would need to change the environment in their homes as well. This would then change the perspective of the social model of disability to accept all impairments and disabilities as well as promote well being.
Now let's put ourselves in a situation of those who resort to any type of Euthanasia ( from a inside perspective):
How short is life
How long are we going to live?
I once was healthy, worked hard and cared for my children
But as my illness progresses, I feel helpless and weak,
They say I will not die soon,
But soon is an understatement,
I see my life passing me by,
And I do not understand why,
I beg for mercy and pray for a miracle,
There will come a day when I won’t be able to walk,
Won’t be able to properly talk,
My hands won’t be able to work
An intolerable burden to my loved ones,
That I cannot bear
And I ask for you to care,
My wish for when things get worse,
Is the choice to end my own source,
To pass away with peace and dignity,
I do not want to die,
But I have to.
Regards:
Fisher, J. (2009). Morality and Ethics. Biomedical Ethics, ch. 1(4-20). Retrieved on March 25, 2011.
Wolf, S (2009). Gender, Feminism and Death: Physician Assisted Suicide and Euthanasia. Biomedical Ethics, ch. 4(181-193). Retrieved on march 25, 2011.
Callahan, D (2009). When Self Determination Runs Amok. Biomedical Ethics, ch. 4(177-181). Retrieved on march 25, 2011.
Kluge, Eike-Henner W. (2000), "“Assisted Suicide, Ethics and the Law: The Implication of Autonomy and Respect for Persons, Equality and Justice, and Beneficence.”", in Prado, C.G., Assisted Suicide: Canadian Perspectives, Ottawa, Canada: University of Ottawa Press, pp. 83.
Daigle, M., & Côté, G. (2006). Nonfatal suicide-related behavior among inmates: testing for gender and type differences. Suicide & Life-Threatening Behavior, 36(6), 670-681. Retrieved from EBSCOhost.
Latimer, E., & McGregor, J. (1994). Euthanasia, physician-assisted suicide and the ethical care of dying patients. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 151(8), 1133-1136. Retrieved from EBSCOhost.
Morris, J. (2001). Impairment and Disability: Constructing an Ethics of Care that Promotes Human Rights. Hypatia, Volume 16(4). Retrieved from Webct.
Cadeau, D. (2010). 15 Minutes of Fame. The ALS Society of Ontario. Retrieved from http://www.alsont.ca/stories/durwincadeau/
Criminal Code of Canada. (2009). C-46, 241. Retrieved from http://www.efc.ca/pages/law/cc/cc.html
Code of Ethics of Physicians. (2004). #58. Retrieved from http://www.cmq.org/~/media/132E0C657730482DBEE837D7473D439D.ashx
Canada Medical association (1996), Code of Ethics. Retrieved from http://www.cma.ca/
ADHD: Disorder or not?
The American Psychiatric Association has defined ADHD as a “developmental neurobiological condition defined by the presence of severe and pervasive symptoms of inattention, hyperactivity and impulsivity”. A child must show a variety of inattentive, impulsive and hyperactive behaviour over a period of six months which should be present in school and at home (Daley, D et al). In my opinion, the definition of ADHD laid out by the APA has been taken out of context. How do you know when a child is portraying a behaviour that defines ADHD? Society has come to define what they consider ADHD may look like. If a child is not paying attention in their homework and would rather be playing video games, it is considered a sign of ADHD (Daley, D et al). Or if a child does not like or understand math but has more of an artistic and creative mind, that also means the child has ADHD (Daley, D et al). It seems as if children are not allowed to be children anymore. I also think that society needs to adapt to our technological era since children are exposed to a fast paced environment of television, video games, and computer games. When a child is removed from that environment and forced to do work, they tend to lose focus because they are not accustomed to a slower paced atmosphere. For example, in Sean’s case, he is more artistically minded and does better in music than he does in math. This doesn’t necessarily mean that he has ADHD but that he might simply find those courses tedious compared to his other interests.
Many children that show the symptoms of ADHD also show performance deficiencies when engaging in social interactions as well as aggressive behaviour with other peers (King, S et al). The individual with ADHD has difficulties when taking turns, talks excessively, doesn’t listen when spoken to, interrupting others during conversation and classroom discussions (Daley, D et al). I think that the basis in which testing occurs for ADHD needs to be altered. At the moment, the diagnosis of ADHD is subjective and based on a list of behaviours. A teacher is given a list of nine categories and if a child demonstrates six of the nine categories, they are labelled as ADHD (Null. G et al). The most “powerful” symptom of ADHD as mentioned in the documentary is when a child fidgets with their hands, feet or squirms in their seat (Null. G et al). If a child is misdiagnosed as ADHD, it can lead to unnecessary use of health and education services as well as exposure to psychoactive medications (Null. G et al). In the documentary “The drugging of our children”, a child who has been misdiagnosed as ADHD took a higher dose of Ritalin as he grew older; he became addicted to the medication and went into relapse when he did not have access to it. Within the power points of health ethics, ADHD is also defined as a “made up disease”, in which the intake of mind altering drugs with children can increase blood pressure as well as heart rate. Through situations like these, we can tell how dangerous it can be to misdiagnose someone as ADHD. I think the diagnose of ADHD should be on the basis of exclusion and narrowing down the symptoms while comparing it to other illnesses and situations, instead of basing it on a list of behaviours that almost all children exhibit these days.
I think that parents, physicians as well as teacher’s are all responsible in the misdiagnosis of ADHD. As mentioned above, teachers decide whether or not a child needs medical attention while comparing to a list of behaviours that define ADHD. Elementary school teachers often have a class of twenty five to thirty students and it becomes difficult when some students are not cooperating like the rest of the class (Dang, M et al). At this point the teacher will speak to the parents and the school board will ask them to either place them on methylphenidates or transfer the child to a special needs school (Dang, M et al). This places pressure on the parents because they don’t want their child to go to a special needs school. Many parents are also in the working force so they want to be able to come home to a stress free environment hence they will take their children to the physician to test for ADHD. Many parents have long term dreams for their child and are willing to take any steps in order to achieve them.
. Even though parents make decisions based on what they think will benefit the child’s future, that doesn’t necessarily mean that the parent is always making the right decision (Ross. F.L). Decision making in health care must be based on good morals and practical reasoning. I agree that parental autonomy is extremely important when it comes to making decisions about children but parents also need to think of what benefits the child’s long term autonomy as well as present day autonomy (Ross. F.L). The American Academy of Paediatrics recommended that children should be able to have a say in decision making and be given a greater voice as they mature (Ross. F.L). A third party, such as physicians are told to resist the decision making process unless the decisions made are negligent and abusive (Ross. F.L). When children are able to make proper decisions about their life , then a physician is able to approve of it with the permission of the parents taking into account the child’s assent (Ross. F.L). Not only does this allow the physician to withhold their professional roles as medical practitioners but also respect the decisions of the child and the opinions of the parents. If we are to refer back to Sean’s case, he does not want to take Ritalin because he does not like the way it makes him feel but the parent’s insist on him continuing the medication because they don’t want any trouble from his school and want to keep a stress free home environment. In my opinion, the parents should ask Sean how he is feeling and if he is having any side effects. More priority should be given to the child since they are the ones taking part in the treatment and would be able to explain how they are feeling.
Any decisions made either by parents, teachers or physicians, should always look into the beneficence of the child. I strongly believe that we need to respect the child’s autonomy because he or she will be the one to suffer the consequences or gain benefits from a treatment (Ross. F.L). I agree that children are vulnerable and that as adults, we have the responsibility to care for them but we need to think about the implications our decision can have on the children (Ross. F.L). If we are to diagnose all children that may show behaviors that link to ADHD, then how will we define how children behave in general? This can viewed through Kant’s theory in which actions are taken to make it a universal law (Fisher,J). If one child depicts behaviour of ADHD, then another child with similar behaviour will also be diagnosed as ADHD. Hence, more children are being misdiagnosed for the sake of “universal law” and not for their autonomy or beneficence (Fisher,J). Even though I am against the concept of diagnosing children as ADHD, I do believe that it exists but within a spectrum that should define exactly what ADHD is. I understand that if certain behaviours are a link towards ADHD and the child is not treated, it can also cause great complications in the future (Null. G et al). As mentioned in the documentary, one child who had been under diagnosed as ADHD ended up hurting himself because he did not understand why he was different from others and how he couldn’t live up to the expectations of his parents (Null. G et al). This approach is taken through the eyes of utilitarianism (Fisher,J); parents make decision about their children because they want to minimize their child’s pain within society and expand their opportunities for them to achieve the best they can.
Any decisions made either by parents, teachers or physicians, should always look into the beneficence of the child. I strongly believe that we need to respect the child’s autonomy because he or she will be the one to suffer the consequences or gain benefits from a treatment (Ross. F.L). I agree that children are vulnerable and that as adults, we have the responsibility to care for them but we need to think about the implications our decision can have on the children (Ross. F.L). If we are to diagnose all children that may show behaviors that link to ADHD, then how will we define how children behave in general? This can viewed through Kant’s theory in which actions are taken to make it a universal law (Fisher,J). If one child depicts behaviour of ADHD, then another child with similar behaviour will also be diagnosed as ADHD. Hence, more children are being misdiagnosed for the sake of “universal law” and not for their autonomy or beneficence (Fisher,J). Even though I am against the concept of diagnosing children as ADHD, I do believe that it exists but within a spectrum that should define exactly what ADHD is. I understand that if certain behaviours are a link towards ADHD and the child is not treated, it can also cause great complications in the future (Null. G et al). As mentioned in the documentary, one child who had been under diagnosed as ADHD ended up hurting himself because he did not understand why he was different from others and how he couldn’t live up to the expectations of his parents (Null. G et al). This approach is taken through the eyes of utilitarianism (Fisher,J); parents make decision about their children because they want to minimize their child’s pain within society and expand their opportunities for them to achieve the best they can.
To conclude, ADHD is a subjective disorder in which the diagnosis has to be carefully evaluated. It is not ethically correct to identify children as ADHD by associating it with a list of behaviours that all children may display at one point or another. We need to be able to evaluate the consequences and benefits of diagnosing children as ADHD as well as research more into how children actually behave in general before prescribing medications that may affect them in the long term.
Much Thank to the following for their research:
Castel, A., Lee, S., Humphreys, K., & Moore, A. (2011). Memory capacity, selective control, and value-directed remembering in children with and without attention-deficit/hyperactivity disorder (ADHD).Neuropsychology, 25(1),15-24. Retrieved from EBSCOhost.
King, S., Waschbusch, D., Pelham, W., Frankland, B., Andrade, B., Jacques, S., & Corkum, P. (2009). Social information processing in elementary-school aged children with ADHD: medication effects and comparisons with typical children. Journal Of Abnormal Child Psychology, 37(4), 579-589. Retrieved from EBSCOhost on March 3.
Daley, D., & Birchwood, J. (2010). ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom?. Child: Care, Health And Development, 36(4), 455-464. Retrieved from EBSCOhost on March 3.
Dang, M., Warrington, D., Tung, T., Baker, D., & Pan, R. (2007). A school-based approach to early identification and management of students with ADHD. The Journal Of School Nursing: The Official Publication Of The National Association Of School Nurses, 23(1), 2-12. Retrieved from EBSCOhost on March 3.
Rey, JM., Sawyer, MG. (2003). Are Psychostimulant drugs being used appropriately to treat child and adolescent disorders. Br. J Psychiatry Journal, 182: 284-286. Retrieved from EBSCOhost.
Null, G & Louden, M. (Directors). (2005). The Drugging of Our Children [http://topdocumentaryfilms.com/the-drugging-of-our-children/].Gary Null & Associates.
Ross, F.L. (1997). Health Care Decisionmaking by Children. Is it in their best Interest? The Hastings Center Report, 27(6), 41-45. Retrieved from Webct on February 27.
Fisher, J (2009). Morality and Ethics. Biomedical Ethics: A Canadian Focus, 1.3(12-17). Retrieved on March 3.
Nicki, A (2011). Power points on Mental Health Ethics. Slide 23. Retrieved on March 3.
Canadian Palliative Care: What can we do to improve it?
As the Canadian health care system expands to incorporate the demands of an increasing population, so do the expectations of Canadians. The shift from infectious to chronic illnesses over the past two decades has meant that more and more patients are being admitted into, and sometimes dying, in intensive care units or long term care at hospitals. A higher life expectancy and an aging population has also contributed to more care being provided in hospitals (CHPCA). Many people would rather spend their last few months at home or in a place that promotes a quality death as they spend time with loved ones and reflect on their past. In Canada every citizen has a right to quality end of life care that allows them to die free of pain and with dignity while surrounded by their loved ones in the setting of their choice (Health Canada). A way to achieve this is through palliative care, also known as end of life care or hospice care. There is an urgent need to advance hospice palliative care (HPC) services and planning. Even though Canadians have access to palliative care, many people choose not to take advantage of the service. This is due to some weaknesses that Canada’s health system has when it comes to end of life care. Some of the flaws that affect palliative care in Canada that should be given attention to are access to end of life care facilities and services, hospice home care, insurance coverage for medications, as well as eradicate gender differences within hospice palliative care. In this paper, I will explain the reasons why Canadians do not take advantage of hospice palliative care and how Canada can improve its palliative health care program.
In order to deal with the problem of palliative care in Canada, we must understand what palliative care is and what it offers. The Canadian hospice palliative care society defines palliative care as “whole person health care that aims to relieve suffering and improve the quality of living and dying”. Hospice palliative care is for any individual that has or is at risk of developing a life threatening illness without the prognosis of getting better regardless of age (CHPCA). The care services range from treating the patient’s physical suffering and if the illness has progressed further, then the aim is to focus on care (CHPCA). In order for a person to be admitted into hospice palliative care, they need to be suffering from a life threatening illness and have about six months to live (Shadd, et al. 2008). The main focus of palliative care is to achieve comfort, increase the quality of life, and ensure that the patient is able to fulfill as many hopes and dreams they may have in a short amount of time (Shadd, et al. 2008). Palliative care focuses on providing emotional, spiritual, and social support for the patient and his/her family. It also provides counseling for the family after the patient has deceased (Holtslander, 2008). These issues that palliative care addresses are very important for the health and happiness of the patient in his/her last days as well as the health and well being of the family. Many people who are admitted into palliative care are undergoing different emotions when they realize that they might not be around for a very long time (Maida, 2008). Many family members are aware that the patient will pass away eventually but it is sometimes hard to accept that they have actually left the world (Holtslander, 2008). This can then affect the family in emotional and psychological ways. In order to help the family out during rough times, nurses and palliative professionals work together with grief counsellors to ensure that they have a better understanding of life (Holtslander, 2008). Research has shown that patients and families who have had access to palliative facilities got the opportunity to share quality time and allow for quality death of their loved ones (Maida, 2008). Many patients have referred to palliative care as “an experience that allowed them to fulfill their expectation of life before passing away” (Maida, 2008 ). In the eyes of the dying patient, palliative care allows them to optimize the quality of life and promote death with dignity (Maida, 2008 ).
Palliative care is a necessity and should be a right to all Canadians. Every resident in Canada should be entitled to a peaceful passing no matter what the situation may be. Even though there is a growing need are more elderly people in need of end of life care, Canada does not seem to have the establishments to care for the dying patients and their families.
One of the major problems of palliative care in Canada is the limited number of facilities and services available for those who need it. There is a turn in the era as infectious diseases decrease and the advances in the medical field increase (Bruera, 2002 ). Today’s population is living longer and therefore diagnosed with a chronic disease at a later age (Bruera, 2002 ). As there are more people with heart diseases, cancer, and other life threatening illnesses, the need for palliative care is increasing dramatically. The Canadian hospice palliative care association (CHPCA) estimates that over the next forty years the demand for hospice palliative care services will continue to increase (CHPCA). The awareness of the “right of every Canadian to die with dignity, and free of pain” is rising and the health care of Canada is required to implement methods within palliative care to match the needs of society (Collier, 2011). To meet the demands of the population, palliative services should incorporate levels of end of life care amongst the facilities that are specific to patient’s health status (Collier, 2011). For example, Canada should include inpatient palliative units as well as hospice homecare; hospitals should offer consultation services, expand outpatient clinics and provide bereavement support (Collier, 2011). As stated in the article by Schroder and Van, there should be three levels of palliative care to make sure the right to end of life care to every Canadian is ensured. The primary level would consist of general health professionals who can treat patients with chronic diseases without being referred to a specialist (Schroder, 2010). The secondary level would consist of specialist who has experience in palliative care as well as other health professionals such as psychologists and counselors to enhance the management of psychosocial or spiritual needs for patients in hospitals (Schroder, 2010). The tertiary level would consist of specialist health care professionals who take part in maintaining palliative medicine (Schroder, 2010). These physicians and nurses would have more complex training to keep up with the demands of end of life care needs (Schroder, 2010).
Another way to increase the number of facilities and services is by educating more people to become palliative physicians and nurses (Schroder, 2010). Hospice palliative care is delivered by an interdisciplinary team of health care providers regardless of status (Gibson, 1995). Currently Canada has over two hundred palliative care physicians working either full time or part time and about ten of fourteen medical schools have optional undergraduate elective rotation in palliative care (Schroder, 2010). If palliative rotations were to become mandatory, and then we would have more people interested in pursuing a career in palliative medicine (Schroder, 2010). The quality end of life care coalition of Canada mentions that over the next ten years, education will be more important in hospice palliative since Canadian will want to receive quality care in the hospital setting where they will die (Schroder, 2010). Since palliative care consists of more than just physicians; nurses, psychologists and counselors should also receive more education and designations as palliative care health professionals (Gibson, 1995). The more health professionals there are the more facilities and services we’ll have and hence increased access of every Canadian to a quality death.
The Canadian health care industry should also look into improving palliative home care services. Many people in their last days wish to spend it with their family and friends at the comfort of their own home however, very few people are able to afford home care services. When Canadians are limited with the financial resources and cannot afford to pay for medications, and equipment such as pain pumps, oxygen and other services, they are forced to seek admission in the hospitals. The delivery of home care funding is relied on the public; as the population increases, the demands of palliative home care increases as well but the funding for programs do not (Guerriere, et al. 2010). One of the reasons of the shortage in home care services is because of the shortage of home care workers (Oudshoorn, et. al. 2007). There isn’t much of a demand of physicians and nurses offering home care services (Oudshoorn, et. al. 2007). Through Canadian health trends, it is indicated that an effective home care plan can eventually contribute to decreased costs of the health care system hence the health care of Canada should take some initiatives to cover home care services (Guerriere, et al. 2010). Some provinces have organized reforms which have started to take place to improve home care for elderly people and those with chronic condition. For example, in Quebec, a new reform strategy called PRISMA has started to be put in place (MacAdam, et. al, 2008). PRISMA’s goals are to improve the health, empower and satisfy people with chronic diseases as well as modify their health and social service utilization without increasing the burden on their caregivers (MacAdam, et. al, 2008). The following shows how the needs of populations are met through a screening process that would distinguish the fate of the individual.
The Canadian health care industry should also look into improving palliative home care services. Many people in their last days wish to spend it with their family and friends at the comfort of their own home however, very few people are able to afford home care services. When Canadians are limited with the financial resources and cannot afford to pay for medications, and equipment such as pain pumps, oxygen and other services, they are forced to seek admission in the hospitals. The delivery of home care funding is relied on the public; as the population increases, the demands of palliative home care increases as well but the funding for programs do not (Guerriere, et al. 2010). One of the reasons of the shortage in home care services is because of the shortage of home care workers (Oudshoorn, et. al. 2007). There isn’t much of a demand of physicians and nurses offering home care services (Oudshoorn, et. al. 2007). Through Canadian health trends, it is indicated that an effective home care plan can eventually contribute to decreased costs of the health care system hence the health care of Canada should take some initiatives to cover home care services (Guerriere, et al. 2010). Some provinces have organized reforms which have started to take place to improve home care for elderly people and those with chronic condition. For example, in Quebec, a new reform strategy called PRISMA has started to be put in place (MacAdam, et. al, 2008). PRISMA’s goals are to improve the health, empower and satisfy people with chronic diseases as well as modify their health and social service utilization without increasing the burden on their caregivers (MacAdam, et. al, 2008). The following shows how the needs of populations are met through a screening process that would distinguish the fate of the individual.
PRISMA reform strategy above (MacAdam, et. al, 2008): The person will be screened for the chronic disease and illness. Once the illness has been confirmed, the patient will then be referred to a case manager who will do a series of diagnostic tests and examinations to refer them to the appropriate sector for maintenance of their health as presented above (MacAdam, et. al. 2008).
Research has also proven that patients who do end up taking part in palliative home care tend to live longer than actually anticipated because they are spending time with their loved one (Oudshoorn, et. al. 2007). Just because medical reasons have failed to cure the illness doesn’t mean that the person’s happiness should be taken away. Many patients come to accept their illness and realize that there is no reason to why they should not value the last few months of their life. If Canada is to implement a better home care program, then more people would be able to pass away with no regrets. This would also give the family an opportunity to bond and spend time with the patient which can then also delay the death (Oudshoorn, et. al. 2007). If home care coverage is enabled, more patients would benefit from Canada’s palliative policy as well as decrease health care costs in the long run (Guerriere, et al. 2010). .
Another issue of palliative care in Canada is the concern of insurance and coverage for services and medication that are offered. The cost of end of life care varies from the services that the patient may use to the amount of medications they may take (Johnson, et. al. 2009). These costs are covered by the provincial government and each province has its own jurisdictions of what and how much is covered (Johnson,. et. al, 2009). At the moment, the cost of palliative care that is offered in a hospital is covered by individuals provincial health care plans but the cost of home care is not covered (Heyland, et. al. 2010) Since funding into palliative care is low, hospices rely on volunteers to help run the care facilities (Heyland, et. al. 2010) Some costs are often taken up by patients, families, charities or donations as well as visiting nurses and doctors (Heyland, et. al. 2010). Similar to the services offered at hospitals, Medicare covers the same services in hospice care and will pay for any health problems that are not related to the illness (Heyland, et. al. 2010). Among the hospice benefits, the services included are similar to those offered in hospital services (Heyland,et. al. 2010). The patients have access to physician services, nursing care, medical equipment and supplies, medication for symptom control, social worker services, and counselling to help the patient and the family with grief and loss (Heyland, et. al. 2010) Another situation to consider is if a family cannot afford a private room, the patient will not want to be admitted to a hospice and rather spend their last days at home with their families (Johnson, et. al, 2009). Unfortunately, home care as mentioned above is not covered unless the patient has private insurance (Heyland, et. al. 2010).
Even though Medicare covers many services offered for palliative care, there are a few areas where it lacks insurance (Dumont, et. al. 2010). Once you switch from hospital care to palliative care, it will not pay for treatment of your disease or illness (Dumont, et. al. 2010). The entire purpose of palliative treatment is to get the patient comfort care to help them cope with the illness but not cure it (CHPCA). This is the one aspect that many patients and families are not ready to consider (Siden, et. al. 2008). Many people have the hope that their loved ones will get better and they feel that with proper treatment that is possible. In a society perspective, the Canadian government should be doing everything in its power to save people’s lives and support a death with dignity if treatment fails to help out (Siden, et. al. 2008). Many provinces have taken the initiative to implement programs to improve palliative care (Siden, et. al. 2008). In British Columbia for example, the government has proposed a “framework for End of Life care” to improve benefits, decrease costs, improve the services and the environment and offer the best kind of comfort so patients can pass away with dignity (Siden, et. al. 2008). This framework also includes the goal to improve home care services so people can have a respected death at home without being stressed out about medical bills (Siden, et. al. 2008).
Even though Medicare covers many services offered for palliative care, there are a few areas where it lacks insurance (Dumont, et. al. 2010). Once you switch from hospital care to palliative care, it will not pay for treatment of your disease or illness (Dumont, et. al. 2010). The entire purpose of palliative treatment is to get the patient comfort care to help them cope with the illness but not cure it (CHPCA). This is the one aspect that many patients and families are not ready to consider (Siden, et. al. 2008). Many people have the hope that their loved ones will get better and they feel that with proper treatment that is possible. In a society perspective, the Canadian government should be doing everything in its power to save people’s lives and support a death with dignity if treatment fails to help out (Siden, et. al. 2008). Many provinces have taken the initiative to implement programs to improve palliative care (Siden, et. al. 2008). In British Columbia for example, the government has proposed a “framework for End of Life care” to improve benefits, decrease costs, improve the services and the environment and offer the best kind of comfort so patients can pass away with dignity (Siden, et. al. 2008). This framework also includes the goal to improve home care services so people can have a respected death at home without being stressed out about medical bills (Siden, et. al. 2008).
Other means of improving palliative care is by promoting the program. Even though, Canadians have access to hospices and end of life care, very few people tend to take advantage of it because they may not be aware of the services offered or are are not able to pay for it (Chloe. E. et al). When people are approached with the term “end of life care”, many of them are not interested because they think that it would be dark and depressing (Chloe. E. et al). Canada should improve its way in promoting that palliative care is a place where people can pass away with dignity and peace (Chloe. E. et al). It is important for the public to be aware of the major difference in the number of males and females that are in the care facilities (Brazil, et. al. 2009). In general, more females tend to take advantage of hospice care facilities than males do (Brazil, et. al. 2009). Much of those differences accounts for the fact that more females are usually diagnosed with chronic disease than males are (Brazil, et. al. 2009). Additional reasons to why women are more likely to take advantage of palliative care is because females are known to be “vulnerable”, ”fragile” and need to be looked after (Brazil, et. al. 2009). Whereas males are superior and are supposed to be independent hence they should be able to look after themselves (Brazil, et. al. 2009). Since males have the tendency to choose not to get help from other strangers, they stay home and prefer palliative home care over a facility (Brazil, et. al. 2009). This lead to one of the major contributors to gender difference in end of life care either it be in a facility or at home (Holtslander, 2008). Older men are more likely to be cared by their wives hence die at home than compared to older women who choose not to burden their loved ones and be admitted to a palliative centre (Holtslander, 2008). Over all, women represent the majority of care recipients at palliative care facilities as well as the majority of caregivers in home care (Brazil, et. al. 2009). Palliative care should be promoted so both males and females have a positive outlook upon palliative care as well as decrease home care which often becomes a burden to the loved ones (Holtslander, 2008).
In conclusion, the generations of the “baby boomers” have aged and therefore there is an increase in the elderly population. Among that, the era of infectious diseases has decreased and hence, chronic illnesses have made a prevalent entrance. As the trend of health care continues to expand, Canada has to adapt to a new setting of care for the elderly and the sick. A way to do this is by reforming palliative and hospice end of life care. Many people with cardiovascular and chronic diseases tend to die in dark settings such as hospitals. This is due to Canadians not having proper access to palliative facilities, do not have the luxury to be able to afford home care, are not aware of the facilities and services that palliative care has to offer as well as not being informed about the insurance cover Canada offers with end of life situations. The provincial governments should organize strategies to reform palliative care within women and men like Quebec has implemented. Once the health care industry tackles those problems, we can then expand the network of palliative medicine by promotion and awareness within society. The more people who are aware of palliative care, the higher the value of life will be. It should be targeted towards both males and females so they have an equal opportunity to reflect on their past in a peaceful setting.
With regards to:
In conclusion, the generations of the “baby boomers” have aged and therefore there is an increase in the elderly population. Among that, the era of infectious diseases has decreased and hence, chronic illnesses have made a prevalent entrance. As the trend of health care continues to expand, Canada has to adapt to a new setting of care for the elderly and the sick. A way to do this is by reforming palliative and hospice end of life care. Many people with cardiovascular and chronic diseases tend to die in dark settings such as hospitals. This is due to Canadians not having proper access to palliative facilities, do not have the luxury to be able to afford home care, are not aware of the facilities and services that palliative care has to offer as well as not being informed about the insurance cover Canada offers with end of life situations. The provincial governments should organize strategies to reform palliative care within women and men like Quebec has implemented. Once the health care industry tackles those problems, we can then expand the network of palliative medicine by promotion and awareness within society. The more people who are aware of palliative care, the higher the value of life will be. It should be targeted towards both males and females so they have an equal opportunity to reflect on their past in a peaceful setting.
With regards to:
Guerriere, D., Zagorski, B., Fassbender, K., Masucci, L., Librach, L., & Coyte, P. (2010). Cost variations in ambulatory and home-based palliative care. Palliative Medicine, 24(5), 523-532. Retrieved from EBSCOhost.
Shadd, J. (2008). Should palliative care be a specialty?: yes. Canadian Family Physician Médecin De Famille Canadien, 54(6), 840. Retrieved from EBSCOhost.
Bruera, E., & Sweeney, C. (2002). Palliative care models: international perspective. Journal Of Palliative Medicine, 5(2), 319-327. Retrieved from EBSCOhost.
Johnson, A., Abernathy, T., Howell, D., Brazil, K., & Scott, S. (2009). Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model. Palliative Medicine, 23(5), 448-459. Retrieved from EBSCOhost
Holtslander, L. (2008). Caring for bereaved family caregivers: analyzing the context of care. Clinical Journal Of Oncology Nursing, 12(3), 501-506. Retrieved from EBSCOhost
MacAdam, M. & MacKenzie, S. (2008). Canada: Improving care for the frail elderly – the PRISMA project. Health policy Moniter. Retrieved from www.hpm.org
Heyland, D., Cook, D., Rocker, G., Dodek, P., Kutsogiannis, D., Skrobik, Y., & ... Cohen, S. (2010). Defining priorities for improving end-of-life care in Canada. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 182(16), E747-E752. Retrieved from EBSCOhost.
Dumont, S., Jacobs, P., Turcotte, V., Anderson, D., & Harel, F. (2010). The trajectory of palliative care costs over the last 5 months of life: a Canadian longitudinal study. Palliative Medicine, 24(6), 630-640. Retrieved from EBSCOhost.
Brazil, K., Thabane, L., Foster, G., & Bédard, M. (2009). Gender differences among Canadian spousal caregivers at the end of life. Health & Social Care In The Community, 17(2), 159-166. Retrieved from EBSCOhost.
Gibson, B. (1995). Volunteers, doctors take palliative care into the community. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 153(3), 331-333. Retrieved from EBSCOhost.
Oudshoorn, A., Ward-Griffin, C., & McWilliam, C. (2007). Client-nurse relationships in home-based palliative care: a critical analysis of power relations. Journal Of Clinical Nursing, 16(8), 1435-1443. Retrieved from EBSCOhost.
Maida, V., Lau, F., Downing, M., & Yang, J. (2008). Correlation between Braden Scale and Palliative Performance Scale in advanced illness. International Wound Journal, 5(4), 585-590. Retrieved from EBSCOhost.
Collier, R. (2011). Access to palliative care varies widely across Canada. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 183(2), E87-E88. Retrieved from EBSCOhost.
Schroder, C. & Van, J.P (2010). Postgraduate Education for Palliative Medicine Physicians. http://www.cspcp.ca/english/documents/Overview_PalliativeMedicine_Education_April26_2010_FINALsm.pdf. Retrieved from Google scholar.
Siden, H., Miller, M., Straatman, L., Omesi, L., Tucker, T., & Collins, J. (2008). A report on location of death in paediatric palliative care between home, hospice and hospital. Palliative Medicine, 22(7), 831-834. Retrieved from EBSCOhost.
United States Department of Housing and Urban Development. (2008).Indiana income limits [Data file]. Retrieved from http://www.huduser.org/Datasets/IL/IL08/in_fy2008.pdf
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