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Primary care physicians rarely initiate time-consuming conversations about end-of-life planning for fear they might induce anxiety/depression in their vulnerable patients.

Moe Doiron/(Moe Doiron/The Globe and Mail)

End of life

Although your article, It's A Reality Conversation (Nov. 28) is comprehensive, it left out an important barrier to the success of advance care planning. Primary care physicians rarely initiate these time-consuming conversations for fear they might induce anxiety/depression in their vulnerable patients.

Research evidence shows that most patients want to be invited, but are too fearful to initiate the planning. Until this communication gap is bridged, families will have to suffer unnecessarily in deciding what is best for their dying, incompetent loved ones.

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Michael A. Dworkind, MD, Living Will Project, Jewish General Hospital, Montreal


As a metastasized cancer patient prepared to transition from oncological care to palliative care, the article about spending the last few days at home confirmed for me my clearly outlined wishes to spend that time in an institution with 24-hour access to health-care providers familiar with pain relief. It's my belief that in the majority of cases, placing that burden on a spouse and/or family members is a selfish way to spend one's final days.

Ed Shannon, Toronto


Re Drawing The Line (Nov. 26): The editorial is rightly concerned with the high cost of end-of-life care. However, without knowing the "correct" choice of treatments to be accepted or refused, merely completing an advance directive won't alleviate the economic problems caused by end-of-life care.

Second, urging provincial governments to create a fee code so that clinicians are reimbursed for their end-of-life discussions with patients will do nothing to avoid clinicians' having to make medical ethical judgments about the realistic prospects for a particular patient yet will encourage both provincial ministers of health and critical care clinicians to confuse therapeutic goals with economic ones.

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William R. C. Harvey PhD, LLB, professor emeritus, philosophy, University of Toronto


Criticizing Occupy

The Occupy movement is not a reflection of the majority of the population (A History Lesson For The Occupy Protesters And Those That Supported them – Nov. 28). It is instead, a reflection of overeducated, underemployed students who feel they deserve something after spending more years in school than they have being productive adults.

I spent five years in university, graduating with a master's degree and a pile of student loans. Very quickly I decided I go anywhere to work in my field. Family, friends, fellow students and even teachers thought I was crazy.

Months before I finished school I had taken a position as a curator's assistant in a small community in northwestern Ontario. Sure, it was tough to give up everything I had gotten used to in the city. However, out of all the people I went to school with I am one of the small handful actually working in my field.

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Brent Rosborough, Red Lake, Ont.


The unfortunate part about Gywn Morgan's column is not its mass of ugly distortions. The bigger danger of his ideological regurgitation is that it depoliticizes the political: demands for justice, for fairness, for the way our politics operates.

Through the use of the fantasy of capitalism (e.g. that "free enterprise has always delivered vastly superior results") to justify capitalist ideology, Mr. Morgan is doing nothing less than excising opposition to the status quo.

Criticize our movement – but don't depoliticize it under paternalistic get-back-to-work (and-be-the-next-Steve-Jobs) propaganda.

Byron Taylor-Conboy, 22, University of British Columbia, Vancouver


Cancer screening

Re Cures For Cancer At Any Cost (Nov. 26): Screening for cancer involves important trade-offs between quality and quantity of life. The question also involves analysis and interpretation of large and often conflicting sets of data.

The panel Margaret Wente quotes that advised against prostate-specific antigen screening did not take into account more recent analyses of the large screening trials which indicate that the number of patients needed to treat for each cancer death avoided is as little as five, a very acceptable number. It did not address the impact of conservative management for low-risk disease, which has become widely accepted in Canada, but much less so in the U.S. This reduces the overtreatment problem dramatically and makes PSA testing much more palatable.

Laurence Klotz, professor of surgery, University of Toronto


Recent coverage of breast screening guidelines requires clarification. Previous guidelines advised women aged 50-69 to have mammograms every one to two years, not necessarily annually.

The new guidelines recommend against routine screening for average risk women aged 40-49. This recommendation is considered weak, and a weak recommendation implies some degree of choice based on individual circumstances. Annual mammography for women over 40 has never been the norm in Canada.

The mortality rate for breast cancer has fallen by over 35 per cent since the late 1980s; the most significant drop occurred after 1996, which was six to eight years after the introduction of breast screening programs.

Breast screening programs in Canada recognize there are harms and benefits, and they have produced a decision tool for women aged 40 and older ( to assist them in making their choice.

Gregory Doyle, chair, national committee, Canadian Breast Cancer Screening Initiative, St. John's, Nfld.


Spousal assault

Re Amazing News About Rape (Nov. 22): Statistics Canada's 2006 data indicate that "following evidence of a decline in the incidence of spousal assault against women in the 1990s, the most recent surveys suggest no change [increase or decline]since 1999."

Ontario is home to over 30 sexual assault centres. In the most recent fiscal year, the Sexual Assault Centre in Halton region alone noted a total of 2,127 client contacts, involving calls to the sexual assault crisis line, counselling sessions, group support, and accompanying survivors of assault to hospital, court or police reporting.

Are these contacts from "the grievance industry" No. These are calls and visits from real women who continue to be beaten and raped.

Nicole Pietsch, co-ordinator, Ontario Coalition of Rape Crisis Centres


Poll questions

Re Who's Healthier: Women With Children Or Women Without? (Nov. 27): Intriguing? Definitely. But the basis of this article was a study described as "exploratory" by its own authors. While I appreciate that the Hot Button Blog is intended to provoke, more caution is needed before publishing research results for broad consumption.

Instead of answering a research question, this study was designed to generate questions. The authors studied just 50 childless women who all worked at a university. Additionally, they compared these women, ages 30-45, to all of the Australian female population aged 18 and over.

Why didn't the researchers compare this group of childless 30-45 year olds to similarly aged peers who do have children?

Victoria Arrandale, Toronto

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