Point-of-care genetic counselling : should family physicians counsel patients on genetic testing and screening?

Family medicine has come of age, with family doctors/general practitioners taking on greater roles and responsibilities and health care systems recognizing the important role of primary care. It is in this scenario that the question of pre- and post- testing counselling of genetic tests which are or would be offered directly to the general public through advertising and over-the-counter testing is being raised. This type of counselling would require enough personnel to deal with a large number of people; people who may not have genetic disorders in their families but who are curious about testing such as that for Breast Cancer (BRCA). It is argued that family doctors, albeit needing continuing professional development in this area, already have a solid foundation in genetics and are strategically placed in the community and numerous enough to impart such counselling. This would also liberate the responsibility from specialised geneticists who need to deal with families and individuals who have more serious genetic disorders to be managed.peer-reviewe

"May you live in interesting times"

It is an honour for me to be invited to write this guest editorial on the field of family practice as the new president of the Malta College of Family Doctors, which was established audaciously and courageously some fourteen years ago, those involved having toiled to found this institution. Change can distress those who contributed towards the process of building and establishing the College. Regrettably, political rifts often detract from important issues. The main objective for the College will, of course, remain as it was in the past. Meanwhile the arrival of vocational training (VT) and the Specialist Accreditation Committee (SAC) sent shock waves amongst family doctors and maybe even caused undue anxiety for those already established in practice.peer-reviewe

Maltese doctors : views and experiences on end of life decisions and care

Background: End of life (EoL) decisions are important and challenging for doctors. Aim: To better understand, describe and quantify this aspect of care. Methodology: A national cross-sectional validated survey was mailed to all doctors of the country. Results: The response rate was 39.3%. The respondents had been practicing for 19.72 years (95% CI: 18.3 – 21.0). 86% of respondents declared that their religion was important in EoL care. 42.9% (25.6% disagreed, 31.5% neutral) agreed with the right of a patient to decide whether or not to hasten the end of life. 48.6% agreed (34% disagreed, 17.4% neutral) that high quality palliative care nearly removes all requests for euthanasia. 60.4% agreed (23.9% disagreed, 15.7% neutral) that physicians should aim to preserve life. Each doctor cared for an average of 10.5 EoL (95%CI: 8.45-12.64) patients in the prior 12 months. 32.1% of doctors withdrew or withheld treatment in the care of these patients. Of the remaining 67.9%, 36.6% agreed with such practices. 50.3% had intensified analgesia at EoL with the possibility of hastening death. Only 6% had sedated patients at EoL. Lastly, 11.9% received request for euthanasia whilst 90.2% of doctors would never consider euthanasia. Significant correlations were observed between considering euthanasia, importance of religion, withdrawing/withholding treatment, doctors’ specialty, preservation of life and request for euthanasia. A thematic analysis of comments highlighted the importance of the topic, feeling uncomfortable in EoL care, the religious aspect of care, lack of legal framework and the challenge of symptom control. Conclusions: The overall majority of doctors is against euthanasia. There is a strong sense of guidance by their religious beliefs when it comes to EoL care. Doctors believe in preserving life as a guiding principle at the end of life, but do not shun intensification of analgesia at the end of life. Different specialties have slightly different views on EoL. Doctors need guidance – legal and moral - on this subject, in the absence of which, their religion and philosophy of life is used to guide them in this rather difficult area of practice.peer-reviewe

Rethinking care for the sick elderly

It is well established that Geriatrics and Gerontology are specialties in their own right meriting separate tertiary and primary care training.1 Health Care for the elderly also forms a newly added subject to the field of biomedical ethics.2 Demographic studies are consistently predicting the increasing proportion of "aged" members in our global population.3 Positive conceptions of 'healthy aging' are rightly displacing negative ageist perceptions that indiscriminately cast the elderly as weak, vulnerable, or incapable of self-determination.4 When, through the natural course of aging or due to illness or injury, body or mind begin to fail, a legitimate need for intervention - and care - will arise. In this article we discuss what is morally justified for the elderly population and recommend changes necessary in Malta especially in view of the established postwar rise in the elderly population. 5 to which Malta has been no exception. The President of the Malta College of Family Doctors is of the opinion that, "As medical technology continues to develop and new treatments and health care costs escalate, governments all over the world must devise more morally explicit principles whereby health care resources are allocated". He also points out that there exist dilemmas at sectorial levels where different groups of people, with different special needs, may feel disadvantaged. The elderly, for example, he says have less priority than the young in getting `life-saving cardiac treatment', whilst benefiting from other services helping them to remain active members of society.6 No one doubts that the institutions that were available in Malta for the elderly until a few years ago left much to be desired. The phrase "Tax-Xjuh" for the elderly was associated with either "tal-Frankuni" (Mount Carmel Hospital) for the psychiatrically ill or with "L-Imgieret" (St. Vincent De Paul Residence) and many were the elderly who shied away from wanting to spend the last few years of their life in such institutions. Although changes have been recently implemented to improve the quality of care and the quality of the environment in these institutions, much still needs to be done.peer-reviewe

An evaluation of palliative care education in the specialist training programme in family medicine

Aim: The study aimed to evaluate the teaching in palliative care (PC) provided during the Specialist Training Programme in Family Medicine (STPFM) in Malta. Methodology: A questionnaire was used, based on two other validated questionnaires used in a similar population. Fifteen topics commonly encountered in PC were analysed. Results: Twenty-two (74.4%) trainees returned the questionnaire. All trainees received exposure to palliative care patients, but only 5 (22.7%) felt involved in their care and only 6 (27.3%) ever used a syringe driver. Most PC teaching in the STPFM was formal in nature. Trainees felt that palliative care subjects were covered well in the STPFM, but non-medical areas received lower scores. Trainees’ confidence closely mirrored the scores for subject coverage. The Half-Day Release Programmes were the most useful palliative care teaching resource. A correct answer for the question on pain management was obtained by 63.3% of trainees and 23.7% got a correct answer for the question on the use of a syringe driver. Concerns on managing dying patients in the community were raised by 40.9% of trainees. Trainees judged overall positively their STPFM. Conclusion: GP trainees need to be trained in PC in a manner that adequately addresses their future caseload. Changes need to be made in the PC teaching within the STPFM to address areas such as ethical issues in end-of-life; using a syringe driver; selfcare and managing patients in the community.peer-reviewe

A Practical Comparison between Islamic and Christian End-of-Life Moral Guidelines towards Harmonization of End-of-Life Care

This paper aims to identify common ground on end-of-life issues between the Islamic and Christian cultures. Since these two cultures are more and more coming to live in the same countries, it is important to acknowledge common ground since the laws of countries apply to all. The paper will deal with several issues, including the stopping of futile treatment, the administration of ordinary and extraordinary care, defining the difference between death and allowing one to die, and accepting death as sometimes being an inevitable and acceptable outcome. The paper will also discuss palliative care including pain relief and sedation. From here one delves into the case of Persistent Vegetative States and the morality of over-enthusiastic treatment which pushes people into this state. It will also focus on the differences, such as passive euthanasia and analyze whether this is merely a difference in the interpretation of terms. There is also a phenomenon in some countries on querying the removal futile treatment and on lacking a legal framework in general on end-of-life. At least one study shows concern on religious moral grounds. The conclusion attempts to identify the common grounds on the end-of-life and whether morality and laws in this regard are guided by religious positions. It is important that laws respect the moral normative values of populations, especially with pressure coming from more liberal positions. Even if practices such as euthanasia (the discussion of which is not the scope of this paper) are introduced in countries, it is important that health care (and legislation) recognizes the common moral ground, the lack of which may lead to more suffering

Ethical issues in umbilical cord blood banking : part 2

Clearly it was found that there is no evidence that the Autologous use of cord blood (storing one's own cord blood) has any benefit over using cord blood from other sources. The EU therefore is strongly of the opinion that in order for people to have equal access, if anything, it is public banks that should be looked into. Moreover such public banks will then network together in order to have immediate access should the need arise. However it stresses that couples should be free to make a choice based on sound information which should stress that they are still very much in the experimental stage.peer-reviewe

Research in children

The Centre for Bioethics and Patient Advocacy has been taking part in the European Forum for Good Clinical Practice (EFGCP)'s formulation of guidelines for implementing Directive 2001/20/EC relating to good clinical practice in the conduct of clinical trials on human subjects. The document produced by this group focused on clinical trials in children and their protection thereof. As clinical trials become more important and common, a harmonization of the application of this directive across Europe was deemed important.peer-reviewe

Negligence and malpractice

Negligence is a departure from a due standard of care. Standards of care are set up by the profession not merely as a guideline to doctors, but as a minimum requirement. It is about proper management and also about patient rights. Continuing Medical Education programmes that do not aim to divulge what the standard of care is, may not be imparting to professionals what is expected from them. Although practices may vary before they become actual 'standards', some practices may also be abandoned, and those who continue to practice them may of course be guilty of malpractice .peer-reviewe

The implications of the abortion referendum in Ireland

This paper concerns the implications of the abortion referendum in Ireland, or rather, to be precise, a vote in favour of the Thirty-sixth Amendment of the Constitution of Ireland Bill 2018, which was intended to repeal the Eight Amendment of the same constitution which guarantees the unborn child for the right to life unless the pregnancy is life threatening. The current Bill will (by an act of parliament) replace Article 40.3.3 of the Constitution which was added in 1983 and subsequently amended in 1992.2 One must immediately point out that the 1983 amendment made no reference to the philosophical doctrine of double effect whereby harm can be caused even if it is foreseen but is not intended and indirect. As we will see this has important consequences in a Catholic Hospital which was accused, rightly so, of a medical misadventure in Ireland causing the death of a woman who was 17 weeks pregnant, where the termination could have been done also on principle of double effect.peer-reviewe