Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.
Abstract
With the rapidly increasing numbers of elders in North American Society, the prevalence of those living with dementia is clearly on the increase. According to the most recent document provided by the Alzheimer Society of Canada, The Rising Tide the growth in the numbers of those living with dementia will increase from 480,600 in 2008 (1.5% of Canada's population) to in the year 2038—1,125,200 people with dementia (2.8% of Canada's population).1 All the challenges that Canadian society faces with this growing population merely mirror the enormous complexities that those living with dementia, their families and health care professional providers must increasingly contend with. Government policy makers must find ways to address this increasing population in which Dementia plays a prominent role. The result of the Supreme Court ruling on the Rasouli case has major potential implication for those facing the later stages of dementia and those under whose care members of this population will be entrusted.
Key Words: dementia, aging population, substitute decision makers.
Introduction
The natural progression of Alzheimer's disease and other causes of dementia is fairly predictable even within individual variations. The condition is progressive with a varying time-line. The medications that exist for the treatment of the dementia conditions are at best symptomatic even though for some individuals the impact may be very positive and confer some substantial improvement in cognition, but more often inter-connectedness and quality of life. Whether there might also be some decrease in the rate of decline is not clear, but for many patients and families, taking the medications appear to be worthwhile.2
The major challenge in the condition is when there are behavioral issues that may require interventions that often include medications whose side effects may be poorly tolerated and significantly dull the individuals personality and creative spirit as well as physical and emotional energy—the price paid for the medications' calming effect.
The usual model of care for which most family members participate is for increased levels of care to be required with either full-time help in a community setting or admission to a long-term care facility where all the Activities of Daily Living (ADL) can be provided. The biggest challenge that is seen increasingly in long-term care facilities is the difficulty that family members have knowing when to discontinue inter-current acute treatments for conditions such as pneumonia and urinary tract or other infections and decisions related to artificial nutrition and hydration and ultimately whether or not resuscitative attempts will be undertaken at the very end.2
Every once in a while an individual with later stage dementia develops an illness that results in a decision for acute hospitalization and for one reason or another the result is an admission to an intensive care unit with life-support. If there are sufficient complicating factors it may become clear that withdrawal of the life-support will in all likelihood result in the death of the person, if not immediately on discontinuation of the life-support then soon afterward. This, not unlike the Rasouli case that was recently decided upon by the Supreme Court of Canada,4,5 a Substitute Decision Maker (SDM) might decide that withdrawal of life-support or other life-sustaining treatment such as artificial nutrition and hydration is not acceptable to them.
Case of Friedberg et al. v. Korn, 2013 ONSC 960, Court
