Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
Not all families work in harmony. Health care providers look to families for direction and support for those we care for especially when the patient is no longer able to make decisions for themselves. This is usually the result of a medical condition that affects the brain such as dementia, a common occurrence in those who require long-term care. When there is conflict between family members, health care and social service professionals must use their best communalization skills and sensitivities to help families resolve their differences so that the best possible care can be provided to those they love.
Keywords: sibling rivalry, conflict, decision-making.

Christopher B. Overgaard, MSc, MD

Atrial Fibrillation and Elderly Patients
Atrial fibrillation (AF) is by far the most common cardiac arrhythmia, and is most prevalent among the elderly. One large study found that 70% of all patients with AF were between 65 and 85 years of age.¹ Many underlying conditions have been associated with the development of AF, including diabetes, hypertension, pulmonary disease, thyrotoxicosis, cardiomyopathy, and nonspecific conduction defects; the AF patient population is, therefore, a heterogeneous one.² Regardless of underlying cardiac pathology, this arrhythmia is associated with a doubling of mortality and is a very significant health issue for elderly patients.

AF occurs through the propagation of random waves of intra-atrial reentry, with many macroreentrant circuits moving throughout the atrial muscle.³ This chaotic pattern results in a random irregular rhythm, a significant decrease in stroke volume and cardiac output, and the risk of thrombus formation due to atrial stasis. Systemic embolization from an atrial clot is considered to be the most devastating, albeit potentially preventable, consequence of this disease process.²

Atrial Fibrillation, Stroke, and Bleeding Risk
Elderly patients with atrial fibrillation are at a fourfold higher risk of suffering a stroke than the age-matched general population.

Dr. Michael J. Taylor

With the rapid progress in medical knowledge and technology over the past several decades, caring for patients with terminal illness has become increasingly challenging to both individual physicians and to the profession of medicine as a whole. In addition to keeping abreast of an ever-growing body of palliative care literature, physicians caring for terminally ill patients must often make management decisions that are difficult because outcomes, such as the impact on quality of life and the potential to increase patient survival, are hard to predict. The resulting uncertainty combined with the fear and anxiety experienced by physicians, patients and families facing terminal disease, often presents obstacles to effective communication among all parties. Furthermore, in busy inpatient and outpatient settings, the palliative needs of terminally ill patients may be overlooked by physicians who are trained to focus on the prevention and cure of disease, but are ill-equipped to meet the challenges of attending to a patient's spiritual and psychosocial 'end-of-life' needs. The following article examines some of the current deficiencies characterising the care of the terminally ill, and highlights a number of the obstacles to overcoming these deficiencies through a brief survey of some of the literature that addresses this complex issue.

Michel Silberfeld, MD, MSc, CRCP(C)

Coordinator, Competency Clinic, Department of Psychiatry
Baycrest Centre for Geriatric Care. North York, Ontario

In Ontario, as in some other provinces, there was a push to modernize guardianship and consent legislation, which culminated in new statutes in 1992. The motivations for new legislation came from several directions. The Ontario Mental Incompetency Act was felt to be outdated because it only permitted plenary guardianship. Plenary guardianship gives a person authority over all decision-making, much like a parent has over a small child. Furthermore, incapacity was poorly defined, based primarily on evidence as to the severity of an illness, and a person deemed incapable had to be incapable in all respects. There were no provisions for Powers of Attorney for personal care.

Several policy initiatives came from patient rights advocates. There was a desire to promote patient autonomy. This was accomplished by clarifying the definitions of capacity in statutes. The new definitions permitted the recognition of partial competence whereby a person could be incapable in one respect and yet retain the right of discretion in all others.