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⭕️ CRT與ICD於心衰竭的治療

Part 4
HF ESC guidelines 2021

Key words:
ICD: Implantable Cardiac Defibrillator 心臟整流去顫器
CRT: Cardiac resynchronization Therapy心臟再同步化治療
CRT-P: CRT Pacemaker心臟再同步起搏器
CRT-D: CRT defibrillator心臟再同步去顫器

前言：

在開始敘述ESC HF指引的CRT及ICD治療之前，先簡單介紹這兩種心臟裝置，讓各位有個初步瞭解。除了心臟科醫師外，大家對CR及ICDT仍然是比較陌生的。就從簡單講起，然後再進入治療指引。

可以置入心臟內的裝置(Devices): CRT and ICD
CRT: 心臟再同步化治療(Cardiac Resynchronization Therapy)

⭕️ 心臟再同步化節律器

是一組類似一般心律調整器的機器，但比只放置兩條電線的傳統心律調整器，多放了一條電線到左心室，因而可以有效同時刺激左右心室，使其恢復同步而有效率的收縮，藉以達到改善心臟功能的目的，所以其適應症是左右心室不同步收縮的重度心臟衰竭。利用節律器將心臟左、右心室做同步化的跳動收縮，以增加心臟收縮能力，提升病人活動功能性。這就是心臟再同步化治療(CRT)。

這是綜合運用電生理、心導管、血管攝影及心臟節律器的技術，在病患是清醒的狀態下，經局部麻醉，在病患前胸皮下切開一個小傷口，經由Ｘ光透視將導線置放到心臟的左、右心室，使心臟能夠同步性的收縮。最後將再同步化節律器植入皮下，縫合傷口，完成手術。

心臨床上建議心臟衰竭合併左側支束傳導完全阻滯的治療仍以藥物為優先，經適當藥物治療仍無法改善其心臟衰竭時，才考慮進行心臟再同步化的節律器治療(CRT)。

對心衰竭病患的臨床好處：

包括症狀改善以及心臟功能的進步。心臟功能的進步方面，包括左心室的搏出分 率可以上升（大約上升 7%~10%），可以使得心臟的二尖瓣回流減少，亦可以使得左心的大小縮小，對於病患的血壓可以上升，而且在 NT-proBNP 的血清檢查可以發現有下降的跡象。再者，心臟電氣的變化，會使得在心電圖顯示QRS 波的寬度會較為縮短。

⭕️ ICD: 心臟整流去顫器(Implantable Cardiac Defibrillator)

「心臟性猝死」的定義是指：在沒有其它潛在疾病所導致死亡的病因下，由於心臟血管系統問題所導致的突然及非預期性死亡。在此所謂的「猝死」指的是在症狀發作之後一小時之內之個體死亡。雖然過去的四、五十年間，由於醫學治療及抗心律不整藥物的進步，因為心臟疾患而直接造成的死亡率呈現下降的趨勢，但是心臟性猝死仍然高居其中一半的原因，而其中絕大部份是來自心室頻脈及衍生心室的顫動。

心衰竭的死亡率很高。經過良好的治療可以改善其預後及生活品質，但是仍有一部份心衰竭的病人會因突發的心室頻脈、心室顫動而有猝死的風險。

心臟整流去顫器(ICD)是一種類似心律調節器的體內去顫器，植入病人體內後，它可以隨時主動偵測病人突發的心室頻脈、心室顫動，並在最短時間內放出適當的電流刺激及電擊治療，使心臟回到應有的心律跳動。心臟整流去顫器(ICD)雖不能改善心臟無力的症狀，但確實可降低因為心室頻脈或心室顫動而猝死的機會。

⭕️ 心衰竭的心律不整的治療方式

HF 患者的死亡比例很高，尤其是那些症狀較輕的患者較易突然發生。其中許多可能是由於心臟電生理異常，包括心室心律不整、心律過慢和心搏停止。改善或延緩心血管疾病進展的治療可以降低猝死的年發生率。植入式去顫器(ICD, intracardiac defibrillator)可有效治療潛在致命的室性心律不整，經由靜脈系統置入的情況下，還可預防心搏過緩。一些抗心律不整藥物可能會降低快速性心律不整和猝死的發生率，但不會降低總體死亡率，並且可能會增加。

⭕️心因性猝死的二級預防

與Amiodarone治療相比，ICD 可降低心臟驟停倖存者和經歷過持續症狀心室心律不整患者的死亡率。如果目的是提高生存率時，建議在此類患者中使用 ICD；植入的決定應考慮患者的觀點和他們的生活品質、LVEF（當 LVEF > 35% 時，存活利弊不確定）以及在接下來的一年內沒有其他可能導致死亡的疾病。

⭕️ 心因性猝死的一級預防

在對來自12項關鍵HF研究的40, 000多名患者的分析中，心因性猝死率在20 年間（從1990年代中期到2015年）下降了44%。這應歸功於HF治療的進步，因為許多關鍵的指南推薦療法，包括乙型阻斷劑、MRA、sacubitril/valsartan和CRT-P，可降低猝死風險。雖然上述HF療法已被證明可以降低 HFrEF 患者的死亡率，但Amiodarone卻沒有。但是，如果要使用Amiodarone，應謹慎小心，注意其顯著的副作用。相反，Dronedarone和Class I類抗心律不整藥：disopyramide, encainide, 及 flecainide，由於臨床研究顯示會增加死亡率，不應用於預防心律不整。

DANISH研究中，非缺血性心肌病 (NICM, non-ischemic cardiomyopathy) 患者的猝死率較低；追蹤5 年以上的 1116例患者中僅有 70例猝死。雖然電擊器的設備降低了猝死率，但這並沒有顯著改善整體之死亡風險。但亞組分析顯示，對於≤ 70歲的患者有好處。在最近對 ICD 對 NICM 影響的研究進行的綜合分析中，仍然看到了存活好處。

平均而言，IHD(Ischemic Heart Disease) 患者的猝死風險高於 NICM 患者，因此，儘管相對好處相似，但IHD患者的絕對獲益更大。兩項隨機對照研究顯示，心肌梗塞後40天內植入 ICD 的患者沒有實質好處。雖然心律不整之猝死減少了，但非心律不整死亡的增加，抵消了這一點。因此，在此期間禁止使用 ICD 進行一級預防。此外，至少3個月的優化的藥物治療(OMT) 未能將 LVEF 增加至 >35% 時，才推薦植入 ICD。優化的藥物治療理想地包括使用I類推薦的 HFrEF 藥物。然而，我們引用的 ICD 研究早於 ARNI 和 SGLT2 抑製劑的使用。植入ICD 是否能降低 LVEF > 35% 的死亡率尚不清楚。在心臟核磁共震掃描上存在疤痕的此類患者中，正在進行 ICD 治療研究。

⭕️ 植入式心律復原除顫器(cardioverter-defibrillator)治療的患者選擇

1. HFrEF和QRS寬度≥130 ms 的患者可以考慮使用除顫器 (CRT-D) 而不是 ICD 進行 CRT。

2. 在中度或重度心衰患者中，猝死的減少可能被心衰惡化導致的死亡增加部分或全部抵消。因此，不推薦ICD治療NYHA Fc IV、嚴重症狀對藥物治療無效、不適合心室輔助裝置 (VAD) 或心臟移植的患者。這些患者的預期壽命非常有限，很可能死於泵故障。同樣，患有嚴重合併症且生活品質不太可能存活超過1年的患者不太可能從ICD中獲得實質益處。

3. 儘管 DANISH 研究並未顯示 ICD 治療對 NICM 患者有顯著益處，但應記住，NICM 是一種異質性疾病，某些亞組（如椎板病、結節病）猝死的風險較高，因此值得仔細考慮ICD 植入術。在這方面，幫助風險分層的工具（例如磁共振成像的疤痕負擔）可能會有所幫助。

✅ 應告知患者 ICD 的目的並參與決策過程。
✅ 他們還應了解與植入相關的潛在並發症、對駕駛的任何其他影響以及不當電擊的風險。
✅ 應告知患者除顫器（或 CRT-D 的除顫器組件）可能停用（例如晚期疾病）或移植（例如感染或 LV 功能恢復）的情況。
✅ 應與患者和護理人員及時就停用除顫器進行對話。
✅ 當 ICD 已達到使用壽命或需要外植時，不應自動更換。相反，應該進行共同決策。(參考圖1)
✅ 患者應由經驗豐富的心臟專家仔細評估，因為自植入以來治療目標可能發生了變化（致命性心律不整的風險可能較低，或非心律不整死亡的風險可能較高）。
✅ LVEF 顯著改善且在ICD的生命週期內不需要裝置治療的患者是否應該植入另一個裝置，這是一個存在爭議的問題。

⭕️ 植入式心律復原除顫器編程(programming)

植入ICD或CRT-D後不再進行常規除顫閾值測試，因為它不會提高電擊效果或減少心律不整死亡。ICD偵測心律不整到放電治療過程延長，保守編程可顯著降低不適當及適當但不必要的電擊的風險。通常，用於初級預防，去纖顫器的編程，以盡量減少起搏（例如心室需求在40 /分鐘起搏VVI），並用心動過速處理區> 200 /分鐘。對於二級預防之規劃應根據患者的具體需求進行調整。

⭕️ 皮下和可穿戴植入式心律轉復除顫器

皮下 ICD (S-ICD) 似乎與傳統經靜脈 ICD 一樣有效，但併發症發生率相似。儘管最初不適當電擊的風險似乎更高，但改進的患者選擇顯示 S-ICD 在這方面並不劣於經靜脈 ICD。對於靜脈管徑困難的患者或因感染需要ICD的患者，它們可能是首選。必須仔細選擇患者，因為 S-ICD不能治療緩慢性心律不整（電擊後起搏除外），也不能提供抗心動過速起搏或 CRT。

對於具有猝死高風險但不適合植入ICD的特定HF患者，可以在有限的時間內考慮使用能夠識別和治療室性心律不整的可穿戴式心律轉復除顫器。然而，大型 VEST 研究未能顯示，可穿戴式心律轉復除顫器減少近期急性心肌梗死後 LVEF ≤ 35% 的患者的心律不整死亡。
有關ICD使用/適應症的更詳細建議，請參閱 ESC/歐洲心律協會 (EHRA) 關於室性快速性心律不整和心因性猝死的指南。2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2015;36:2793_2867.

⭕️ 心臟再同步治療

CRT 用於治療HF之建議

在適當選擇的個體中，CRT可降低發病率和死亡率。CRT可改善心臟功能，並提高生活品質。

QRS 形態與 CRT 的有益反應有關。多項研究顯示，左束支傳導阻滯 (LBBB) 形態的患者更有可能對 CRT 產生良好反應，而非 LBBB 形態的患者則不確定。然而，LBBB 形態的患者通常具有更寬的 QRS 寬度，目前存在關於 QRS 寬度或 QRS 形態是否是 CRT 有益反應的主要預測因素的爭論。來自兩個 IPD 薈萃分析的證據顯示，在考慮QRS寬度後，幾乎沒有證據顯示QRS形態或疾病病因會影響 CRT 對發病率或死亡率的影響。

Echo-CRT研究和IPD薈萃分析建議從CRT可能的傷害時，QRS寬度是<130毫秒，因此，如果QRS寬度<130毫秒，不建議CRT植入。

✅ 處於SR和 LBBB，如果 QRS 介於 130 和 149 ms 之間，則應考慮 CRT-D。
✅ 如果 QRS ≥150 ms，則建議使用 CRT-D。
✅ 各國的臨床實踐差異很大，如果植入 CRT 的主要原因是為了緩解症狀，那麼臨床醫生應該選擇 CRT-P 或 CRT-D，以他們認為合適的為準。
✅ 唯一一項比較 CRT-P 和 CRT-D 210 的隨機研究並未證明這些技術在發病率或死亡率方面存在差異。
✅ NICM 患者的DANISH研究中，58%的患者接受了CRT，亞組分析沒有顯示 CRT-P不如CRT-D。

當 LVEF 降低時，RV 起搏可能會加劇心臟不同步。這可以通過 CRT 來預防，這可能會改善患者的預後。然而，在RAFT的亞組分析中未觀察到CRT和 RV 起搏之間的結果差異。

總的來說，對於有心室起搏的 HFrEF 患者，無論 NYHA 分級如何，都推薦 CRT 而不是 RV 起搏，以降低發病率，儘管沒有觀察到對死亡率的明顯影響。

接受傳統起搏器或ICD的HFrEF患者，即使已經給予優化的藥物治療，但隨後發展為 HF 惡化並伴有高比例的RV起搏，應考慮升級至CRT。

只有兩項小型研究比較了AF患者的單獨藥物治療與CRT治療，結果相互矛盾。多項研究顯示，在接受房室 (AV) 結電燒術的患者中，CRT優於RV起搏。

NEJM(2018)的一篇Catheter Ablation for Atrial Fibrillation with Heart Failure也指出導管電燒術優於OMT治療，全因死亡率 13.4% vs 25%

然而，AF不是CRT 患者進行房室結電燒術的指標，除非在少數情況下，儘管嘗試了藥物控制率，但心室率仍持續高。來自 RAFT研究的AF患者的亞組分析發現，與ICD相比，CRT-D 沒有益處，儘管不到一半的患者雙心室捕獲 >90%。鑑於CRT對AF患者的療效缺乏證據，它可能是特定患者尤其是 QRS ≥ 150 ms的患者）的一種選擇，以確保盡可能高的雙心室起搏比例。

觀察性研究報告說，當雙心室捕捉(Bi-ventricular Capture) <98% 時，CRT 患者的預後會下降。是否反映了再同步功能的喪失（可能通過設備編程來補救）、LV 導線放置不當，或者嚴重患病心肌的起搏更加困難，仍燃無法確定。

早期研究顯示，不同步的影像學檢查在選擇 CRT 患者時沒有價值。然而，最近的一項研究顯示，兩個新的不同步標誌物（心尖擺動和間隔閃光）與 CRT 的反應有關，但這些尚未作為選擇標准或隨機研究中預先指定的亞組進行測試。有廣泛心肌瘢痕的患者使用 CRT 對 LV 功能的改善較少，但對於 HFrEF 的任何治療都是如此，並且不能可靠地預測較少的臨床益處。瘢痕心肌的起搏閾值較高，如果可能，導線放置應避開這些區域。儘管廣泛瘢痕形成的患者本質上預後較差，但幾乎沒有證據顯示他們從 CRT 中獲得較少的預後益處。

✅ 詳細全文在此，繼續閱讀～～
https://reurl.cc/V5p5lZ

References:
1. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021) 00, 1-128
2. CRT Guidelines ESC 2021. European Heart Journal (2021) 00, 1-94
3. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Eur Heart J 2015;36:2793-2867.
4. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378:417-427

《心血管疾病患者疫情期間之照護應變策略建議》
📣心血管病患須知：
心血管疾病患者或具有心血管疾病危險因子的病患在感染 COVID-19 後的嚴重程度較高，甚至是死亡，已廣為證實。
　
SARS-CoV-2 不僅會導致病毒性肺炎，對心血管系統也有重大影響。心血管或腦血管疾病患者和具有心血管危險因子的族群，如：男性、老年、糖尿病、高血壓和肥胖的病患，已被證實在感染 COVID-19 後發生併發症和死亡的機率會增加。此外，罹患COVID-19的人有相當大的比例可能會發生心臟損傷，而這也預示著院內死亡的風險增加。新冠肺炎造成心臟損傷的情況，除了血栓併發症，如：急性冠心症和靜脈栓塞，心肌炎亦是造成之後心衰竭的重要因素。此外，研究指出廣泛的心律不整會使 COVID-19 的病程複雜化，包括針對 COVID-19 和相關疾病的治療藥物其潛在的促成心律不整作用。由於醫療資源的重新分配，像是再灌注(reperfusion therapy)等的緊急治療可能會受到當地疫情嚴重程度所限制。此外，患者害怕在疫情期間就醫造成心血管緊急狀況的延遲出現逐漸受到關注。
　
基於上述理由，歐洲心臟病學會 (ESC) 召集了一群具有 COVID-19 照護經驗的專家和相關從業人員為疫情期間心血管照護等各方面提供相關指導文件。
　
📣心血管病患照護：
眾所周知，感染 COVID-19 的心血管病患於院內預後不佳的風險更高，這也是為什麼必須有效保護他們避免與COVID-19無症狀或輕症感染者接觸的原因。根據研究建議，因急性心臟病而入院且排除病毒感染的患者，在檢查及住院的過程中應徹底避免與COVID-19病患接觸。門診慢性心臟病患者應盡可能留在家中，而心臟病患者的住院天數應控制在可接受的最短時間內，並強烈建議限制訪客進出。
　
在疫情期間應避免非緊急處置，以維持醫療量能並降低疾病傳播的風險。現況下，為有效降低 COVID-19 傳播的風險，使用遠程醫療有其必要性，特別是針對免疫力較低的族群，如：老年患者。另外，遠程醫療提供各方專家進行共同會診的機會，從而使患者待在家中即可獲得完善的處置。遠程復健(或稱居家復健)亦是出院患者的復健選擇之一。隨著對心衰竭和使用心律調節器患者的遠程醫療越來越標準化，未來將可成為病患列入考慮的醫療照護選擇。遠程醫療有助於控制病毒傳播，同時防止心血管疾病患者因誤診或誤治而導致其病程惡化。
　
除了遠程醫療，在醫師及護理師佩戴適當個人防護裝備的前提下，“居家護理”和“移動診所”亦能讓患者在家接受治療。這兩個方案可防止許多臨床不穩定性的心臟疾病（如：慢性心衰竭）的產生，並確保患者得到長期治療，且有助於形成“以社區為中心”的照護形式，這可能比純粹的“以患者為中心”的照護更有利，如此一來，受感染的住院患者能擁有足夠的醫療資源。
　
當心血管病患因診斷或治療而需要進出醫院時，患者應全程配戴口罩、保持社交距離並以酒精清潔雙手來保護自己。
　
📣在COVID-19疫情期間的治療：
■ 感染COVID-19和長期口服治療的中斷，都有可能對長期心血管疾病的病患造成病情的不穩定，所以在做任何治療的調整之前，應該要先尋求醫生的指示。
■ 用於次級預防動脈粥狀硬化的阿斯匹靈沒有消炎的效果，除非有特殊原因(例如: 持續出血的併發症或是進行手術)，否則有心血管疾病的COVID-19病患，在治療期間不應該自行中斷阿斯匹靈的使用。
■ 有感染COVID-19風險的心血管疾病患者都有使用抑制腎素- 血管收縮素系統(Renin-Angiotensin System, RAS)的藥物，包括：血管張力素轉化酶抑制劑(Angiotensin Converting Enzyme Inhibitors, ACEI)類型的藥物。但是ACEI和血管張力素受體阻滯劑(Ang II type I receptor blockers)並不會阻止或是促進COVID-19病毒透過細胞表面受體蛋白ACE2 (Angiotensin-Converting Enzyme 2, ACE2)進入到細胞內。所以綜合以上因素，病人不應未經醫生指示而隨意停止治療。
■ 當病人進行COVID-19的治療時，對於原本心血管疾病的治療可能需要做調整。
　
📣關於心血管疾病患者的重要資訊：
■ 與他人的互動方面：
☑避免接觸生病的人。
☑人與人之間儘量保持兩公尺的社交距離。
☑勤洗手，並且使用肥皂搓洗至少20秒以上。
☑咳嗽或是打噴嚏時，要用紙巾或手肘內側摀住口鼻。
☑避免用手碰觸眼睛、鼻子和嘴巴。
☑用消毒劑時常消毒手會常碰觸到的地方，例如：門把或是手把。
☑出現發燒、咳嗽症狀，或是有呼吸道感染時，應自我在家隔離。
☑儘量待在家中。
☑維持身體活動以避免靜脈血栓栓塞（venous thromboembolism, VTE），同時也保持身體健康。
　
除了以上幾點之外，有心血管疾病的病人應該要遵照當地的衛生局或是醫生的指示來保持身體的健康。
　
■ 健康的生活習慣：
維持健康的生活習慣，例如: 均衡飲食、戒菸、不要過度飲酒、每天有充足的睡眠、維持運動習慣。長時間在家隔離和身體上的限制，使得運動量減少，可能會導致靜脈血栓栓塞(VTE)或其他併發症的發生風險增加，所以建議在家中也要有基本簡單的運動，或是在戶外有足夠的空間維持社交距離時運動，也建議可以利用網路進行遠距的社交活動。
　
■ 醫療照護建議：
☑有心血管疾病的COVID-19病患要持續的服用常規治療心血管疾病的處方藥物。
☑如果有胸痛或是其他症狀一定要趕快就醫，不要忽視症狀。
☑不要停止追蹤心臟的狀況，當心血管的狀況有惡化的情形時，應立即尋求心臟科醫生的專業建議。
　
📋參考資料
歐洲心臟醫學會 ：
https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance
　
📋參考論文
1. Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, Brown TS, Der Nigoghossian C, Zidar DA, Haythe J, Brodie D, Beckman JA, Kirtane AJ, Stone GW, Krumholz HM, Parikh SA. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. J Am Coll Cardiol 2020;75(18):2352-2371. https://doi.org/10.1016/j.jacc.2020.03.031.
　
2. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020. https://doi.org/10.1001/jama.2020.1585
　
3. Lee IK, Wang CC, Lin MC, Kung CT, Lan KC, Lee CT. Effective strategies to prevent coronavirus disease-2019 (COVID-19) outbreak in hospital. J Hosp Infect 2020;105(1):102-103. https://doi.org/10.1016/j.jhin.2020.02.022
　
4. Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020;382(18):1679-1681. https://doi.org/10.1056/NEJMp2003539
　
5. Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Pisano M, Goisis G, Bonacina D, Fazzi F, Naspro R, Longhi L, Cereda M, Montaguti C. At the epicenter of the COVID-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. Catalyst non-issue content 2020;1(2). https://doi.org/10.1056/CAT.20.0080
　
6. Rombola G, Heidempergher M, Pedrini L, Farina M, Aucella F, Messa P, Brunori G. Practical indications for the prevention and management of SARS-CoV-2 in ambulatory dialysis patients: lessons from the first phase of the epidemics in Lombardy. J Nephrol 2020;33(2):193-196. https://doi.org/10.1007/s40620-020-00727-y.
　
7. Danser AHJ, Epstein M, Batlle D. Renin-Angiotensin System Blockers and the COVID-19 Pandemic: At Present There Is No Evidence to Abandon Renin-Angiotensin System Blockers. Hypertension 2020;75(6):1382-1385. https://doi.org/10.1161/HYPERTENSIONAHA.120.15082
　
8. de Simone G, ESC Council on Hypertension, On behalf of the Nucleus Members. Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang (March 13, 2020; date last accessed).
　
9. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S, Group ESCSD. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37(29):2315-2381. https://doi.org/10.1093/eurheartj/ehw106
　
(林口長庚紀念醫院PGY何佳樺醫師、國立清華大學醫科系沈昆樺、林口長庚紀念醫院兒童內科部姚宗杰教授、群體健康科學研究所蔡慧如研究員摘要整理)
　
👉更多照護指引文章：
https://forum.nhri.edu.tw/covid19/tag/guideline/
　
林口長庚紀念醫院
國立清華大學
　
衛生福利部
衛生福利部護理及健康照護司
衛生福利部護理諮詢會
台北醫學大學護理學院
高雄醫學大學護理系學生會
高雄醫學大學護理學院
私立高雄醫學大學
台灣護理學會
中華民國護理師護士公會全國聯合會
護理正義
護理人護理魂-hi,I'm CC
　
財團法人國家衛生研究院
國家衛生研究院-論壇

這是前些日子爆出已經被加拿大法院接理對藏傳佛教噶舉派法王的訟訴。（加拿大法院鏈接在此：https://www.bccourts.ca/jdb-txt/sc/21/09/2021BCSC0939cor1.htm?fbclid=IwAR2FLZlzmUIGTBaTuKPVchEqqngcE3Qy6G_C0TWNWVKa2ksbIYkVJVMQ8f8）

這位法王的桃色事件，我是幾年前才聽到。但，藏傳佛教的高層有這些性醜聞，我已經聽了幾十年。我以前的一位前女友也被一些堪布藉故上她的家摟抱過，也有一些活佛跟她表白。（這不只是她，其他地方我也聽過不少）

這是一個藏傳佛教裡面系統式的問題。

很多時候發生這種事情，信徒和教主往往都是說女方得不到寵而報仇，或者說她們也精神病，或者說她們撒謊。

我不排除有這種可能性，但，多過一位，甚至多位出來指證的時候，我是傾向於相信『沒有那麼巧這麼多有精神病的女人要撒謊來報仇』。

大寶法王的桃色事件，最先吹哨的是一位台灣的在家信徒，第二位是香港的女出家人，現在加拿大又多一位公開舉報上法庭。

對大寶法王信徒來說，這一次的比較麻煩，因為是有孩子的。（關於有孩子的，我早在法王的桃色事件曝光時，就有聽聞）

如果法庭勒令要驗證DNA，這對法王和他的信徒來說，會很尷尬和矛盾，因為做或不做，都死。

你若問我，我覺得『人數是有力量的』，同時我也覺得之後有更多的人站出來，是不出奇的。

我也藉此呼籲各方佛教徒，如果你們真的愛佛教，先別說批判，但如鴕鳥般不討論這些爭議，你是間接害了佛教。

（下面是我從加拿大法院鏈接拷貝下來的內容，當中有很多細節。）

Table of Contents

INTRODUCTION

BACKGROUND

ANALYSIS

A. The Spousal Support Claim in this Case

B. The Test to Amend Pleadings

C. Pleadings in Family Law Cases

D. The Legal Concept of a Marriage-Like Relationship

E. Is There a Reasonable Claim of a Marriage-Like Relationship?

F. Delay / Prejudice

CONCLUSION



INTRODUCTION
[1] The claimant applies to amend her notice of family claim to seek spousal support. At issue is whether the claimant’s allegations give rise to a reasonable claim she lived with the respondent in a marriage-like relationship, so as to give rise to a potential entitlement to spousal support under the Family Law Act, S.B.C. 2011, c. 25 (“FLA”).

[2] The facts alleged by the claimant do not fit within a traditional concept of marriage. The claimant does not allege that she and the respondent ever lived together. Indeed, she has only met the respondent in person four times: twice very briefly in a public setting; a third time in private, when she alleges the respondent sexually assaulted her; and a fourth and final occasion, when she informed the respondent she was pregnant with his child.

[3] The claimant’s case is that what began as a non-consensual sexual encounter evolved into a loving and affectionate relationship. That relationship occurred almost entirely over private text messages. The parties rarely spoke on the telephone, and never saw one another during the relationship, even over video. The claimant says they could not be together because the respondent is forbidden by his station and religious beliefs from intimate relationships or marriage. Nonetheless, she alleges, they formed a marriage-like relationship that lasted from January 2018 to January 2019.

[4] The respondent denies any romantic relationship with the claimant. While he acknowledges providing emotional and financial support to the claimant, he says it was for the benefit of the child the claimant told him was his daughter.

[5] The claimant’s proposed amendment raises a novel question: can a secret relationship that began on-line and never moved into the physical world be like a marriage? In my view, that question should be answered by a trial judge after hearing all of the evidence. The alleged facts give rise to a reasonable claim the claimant lived with the respondent in a marriage-like relationship. Accordingly, I grant the claimant leave to amend her notice of family claim.

BACKGROUND
[6] It should be emphasized that this is an application to amend pleadings only. The allegations by the claimant are presumed to be true for the purposes of this application. Those allegations have not been tested in a court of law.

[7] The respondent, Ogyen Trinley Dorje, is a high lama of the Karma Kagyu School of Tibetan Buddhism. He has been recognized and enthroned as His Holiness, the 17th Gyalwang Karmapa. Without meaning any disrespect, I will refer to him as Mr. Dorje in these reasons for judgment.

[8] Mr. Dorje leads a monastic and nomadic lifestyle. His true home is Tibet, but he currently resides in India. He receives followers from around the world at the Gyuto Monetary in India. He also travels the world teaching Tibetan Buddhist Dharma and hosting pujas, ceremonies at which Buddhists express their gratitude and devotion to the Buddha.

[9] The claimant, Vikki Hui Xin Han, is a former nun of Tibetan Buddhism. Ms. Han first encountered Mr. Dorje briefly at a large puja in 2014. The experience of the puja convinced Ms. Han she wanted to become a Buddhist nun. She met briefly with Mr. Dorje, in accordance with Kagyu traditions, to obtain his approval to become a nun.

[10] In October 2016, Ms. Han began a three-year, three-month meditation retreat at a monastery in New York State. Her objective was to learn the practices and teachings of the Kagyu Lineage. Mr. Dorje was present at the retreat twice during the time Ms. Han was at the monastery.

[11] Ms. Han alleges that on October 14, 2017, Mr. Dorje sexually assaulted her in her room at the monastery. She alleges that she became pregnant from the assault.

[12] After she learned that she was pregnant, Ms. Han requested a private audience with Mr. Dorje. In November 2017, in the presence of his bodyguards, Ms. Han informed Mr. Dorje she was pregnant with his child. Mr. Dorje initially denied responsibility; however, he provided Ms. Han with his email address and a cellphone number, and, according to Ms. Han, said he would “prepare some money” for her.

[13] Ms. Han abandoned her plan to become a nun, left the retreat and returned to Canada. She never saw Mr. Dorje again.

[14] After Ms. Han returned to Canada, she and Mr. Dorje began a regular communication over an instant messaging app called Line. They also exchanged emails and occasionally spoke on the telephone.

[15] The parties appear to have expressed care and affection for one another in these communications. I say “appear to” because it is difficult to fully understand the meaning and intentions of another person from brief text messages, especially those originally written in a different language. The parties wrote in a private shorthand, sharing jokes, emojis, cartoon portraits and “hugs” or “kisses”. Ms. Han was the more expressive of the two, writing more frequently and in longer messages. Mr. Dorje generally participated in response to questions or prompting from Ms. Han, sometimes in single word messages.

[16] Ms. Han deposes that she believed Mr. Dorje was in love with her and that, by January 2018, she and Mr. Dorje were living in a “conjugal relationship”.

[17] During their communications, Ms. Han expressed concern that her child would be “illegitimate”. She appears to have asked Mr. Dorje to marry her, and he appears to have responded that he was “not ready”.

[18] Throughout 2018, Mr. Dorje transferred funds in various denominations to Ms. Han through various third parties. Ms. Han deposes that these funds were:

a) $50,000 CDN to deliver the child and for postpartum care she was to receive at a facility in Seattle;

b) $300,000 CDN for the first year of the child’s life;

c) $20,000 USD for a wedding ring, because Ms. Han wrote “Even if we cannot get married, you must buy me a wedding ring”;

d) $400,000 USD to purchase a home for the mother and child.

[19] On June 19, 2018, Ms. Han gave birth to a daughter in Richmond, B.C.

[20] On September 17, 2018, Mr. Dorje wrote, ”Taking care of her and you are my duty for life”.

[21] Ms. Han’s expectation was that the parties would live together in the future. She says they planned to live together. Those plans evolved over time. Initially they involved purchasing a property in Toronto, so that Mr. Dorje could visit when he was in New York. They also discussed purchasing property in Calgary or renting a home in Vancouver for that purpose. Ms. Han eventually purchased a condominium in Richmond using funds provided by Mr. Dorje.

[22] Ms. Han deposes that the parties made plans for Mr. Dorje to visit her and meet the child in Richmond. In October 2018, however, Mr. Dorje wrote that he needed to “disappear” to Europe. He wrote:

I will definitely find a way to meet her

And you

Remember to take care of yourself if something happens

[23] The final plan the parties discussed, according to Ms. Han, was that Mr. Dorje would sponsor Ms. Han and the child to immigrate to the United States and live at the Kagyu retreat centre in New York State.

[24] In January 2019, Ms. Han lost contact with Mr. Dorje.

[25] Ms. Han commenced this family law case on July 17, 2019, seeking child support, a declaration of parentage and a parentage test. She did not seek spousal support.

[26] Ms. Han first proposed a claim for spousal support in October 2020 after a change in her counsel. Following an exchange of correspondence concerning an application for leave to amend the notice of family claim, Ms. Han’s counsel wrote that Ms. Han would not be advancing a spousal support claim. On March 16, 2020, counsel reversed course, and advised that Ms. Han had instructed him to proceed with the application.

[27] When this application came on before me, the trial was set to commence on June 7, 2021. The parties were still in the process of discoveries and obtaining translations for hundreds of pages of documents in Chinese characters.

[28] At a trial management conference on May 6, 2021, noting the parties were not ready to proceed, Madam Justice Walkem adjourned the trial to April 11, 2022.

ANALYSIS
A. The Spousal Support Claim in this Case
[29] To claim spousal support in this case, Ms. Han must plead that she lived with Mr. Dorje in a marriage-like relationship. This is because only “spouses” are entitled to spousal support, and s. 3 of the Family Law Act defines a spouse as a person who is married or has lived with another person in a marriage-like relationship:

3 (1) A person is a spouse for the purposes of this Act if the person

(a) is married to another person, or

(b) has lived with another person in a marriage-like relationship, and

(i) has done so for a continuous period of at least 2 years, or

(ii) except in Parts 5 [Property Division] and 6 [Pension Division], has a child with the other person.

[30] Because she alleges she has a child with Mr. Dorje, Ms. Han need not allege that the relationship endured for a continuous period of two years to claim spousal support; but she must allege that she lived in a marriage-like relationship with him at some point in time. Accordingly, she must amend the notice of family claim.

B. The Test to Amend Pleadings
[31] Given that the notice of trial has been served, Ms. Han requires leave of the court to amend the notice of family claim: Supreme Court Family Rule 8-1(1)(b)(i).

[32] A person seeking to amend a notice of family claim must show that there is a reasonable cause of action. This is a low threshold. What the applicant needs to establish is that, if the facts pleaded are proven at trial, they would support a reasonable claim. The applicant’s allegations of fact are assumed to be true for the purposes of this analysis. Cantelon v. Wall, 2015 BCSC 813, at para. 7-8.

[33] The applicant’s delay, the reasons for the delay, and the prejudice to the responding party are also relevant factors. The ultimate consideration is whether it would be just and convenient to allow the amendment. Cantelon, at para. 6, citing Teal Cedar Products Ltd. v. Dale Intermediaries Ltd. et al (1986), 19 B.C.L.R. (3d) 282.

C. Pleadings in Family Law Cases
[34] Supreme Court Family Rules 3-1(1) and 4-1(1) require that a claim to spousal support be pleaded in a notice of family claim in Form F3. Section 2 of Form F3, “Spousal relationship history”, requires a spousal support claimant to check the boxes that apply to them, according to whether they are or have been married or are or have been in a marriage-like relationship. Where a claimant alleges a marriage-like relationship, Form F3 requires that they provide the date on which they began to live together with the respondent in a marriage-like relationship and, where applicable, the date on which they separated. Form F3 does not require a statement of the factual basis for the claim of spousal support.

[35] In this case, Ms. Han seeks to amend the notice of family claim to allege that she and Mr. Dorje began to live in a marriage-like relationship in or around January 2018, and separated in or around January 2019.

[36] An allegation that a person lived with a claimant in a marriage-like relationship is a conclusion of law, not an allegation of fact. Unlike the rules governing pleadings in civil actions, however, the Supreme Court Family Rules do not expressly require family law claimants to plead the material facts in support of conclusions of law.

[37] In other words, there is no express requirement in the Supreme Court Family Rules that Ms. Han plead the facts on which she relies for the allegation she and Mr. Dorje lived in a marriage-like relationship.

[38] Rule 4-6 authorizes a party to demand particulars, and then apply to the court for an order for further and better particulars, of a matter stated in a pleading. However, unless and until she is granted leave and files the proposed amended notice of family claim, Ms. Han’s allegation of a marriage-like relationship is not a matter stated in a pleading.

[39] Ms. Han filed an affidavit in support of her application to amend the notice of family claim. Normally, evidence would not be required or admissible on an application to amend a pleading. However, in the unusual circumstances of this case, the parties agreed I may look to Ms. Han’s affidavit and exhibits for the facts she pleads in support of the allegation of a marriage-like relationship.

[40] Because this is an application to amend - and Ms. Han’s allegations of fact are presumed to be true - I have not considered Mr. Dorje’s responding affidavit.

[41] Relying on affidavit evidence for an application to amend pleadings is less than ideal. It tends to merge and confuse the material facts with the evidence that would be relied on to prove those facts. In a number of places in her affidavit, for example, Ms. Han describes her feelings, impressions and understandings. A person’s hopes and intentions are not normally material facts unless they are mutual or reasonably held. The facts on which Ms. Han alleges she and Mr. Dorje formed a marriage-like relationship are more important for the present purposes than her belief they entered into a conjugal union.

[42] Somewhat unusually, in this case, almost all of the parties’ relevant communications were in writing. This makes it somewhat easier to separate the facts from the evidence; however, as stated above, it is difficult to understand the intentions and actions of a person from brief text messages.

[43] In my view, it would be a good practice for applicants who seek to amend their pleadings in family law cases to provide opposing counsel and the court with a schedule of the material facts on which they rely for the proposed amendment.

D. The Legal Concept of a Marriage-Like Relationship
[44] As Mr. Justice Myers observed in Mother 1 v. Solus Trust Company, 2019 BCSC 200, the concept of a marriage-like relationship is elastic and difficult to define. This elasticity is illustrated by the following passage from Yakiwchuk v. Oaks, 2003 SKQB 124, quoted by Myers J. at para. 133 of Mother 1:

[10] Spousal relationships are many and varied. Individuals in spousal relationships, whether they are married or not, structure their relationships differently. In some relationships there is a complete blending of finances and property - in others, spouses keep their property and finances totally separate and in still others one spouse may totally control those aspects of the relationship with the other spouse having little or no knowledge or input. For some couples, sexual relations are very important - for others, that aspect may take a back seat to companionship. Some spouses do not share the same bed. There may be a variety of reasons for this such as health or personal choice. Some people are affectionate and demonstrative. They show their feelings for their “spouse” by holding hands, touching and kissing in public. Other individuals are not demonstrative and do not engage in public displays of affection. Some “spouses” do everything together - others do nothing together. Some “spouses” vacation together and some spend their holidays apart. Some “spouses” have children - others do not. It is this variation in the way human beings structure their relationships that make the determination of when a “spousal relationship” exists difficult to determine. With married couples, the relationship is easy to establish. The marriage ceremony is a public declaration of their commitment and intent. Relationships outside marriage are much more difficult to ascertain. Rarely is there any type of “public” declaration of intent. Often people begin cohabiting with little forethought or planning. Their motivation is often nothing more than wanting to “be together”. Some individuals have chosen to enter relationships outside marriage because they did not want the legal obligations imposed by that status. Some individuals have simply given no thought as to how their relationship would operate. Often the date when the cohabitation actually began is blurred because people “ease into” situations, spending more and more time together. Agreements between people verifying when their relationship began and how it will operate often do not exist.

[45] In Mother 1, Mr. Justice Myers referred to a list of 22 factors grouped into seven categories, from Maldowich v. Penttinen, (1980), 17 R.F.L. (2d) 376 (Ont. Dist. Ct.), that have frequently been cited in this and other courts for the purpose of determining whether a relationship was marriage-like, at para. 134 of Mother 1:

1. Shelter:

(a) Did the parties live under the same roof?

(b) What were the sleeping arrangements?

(c) Did anyone else occupy or share the available accommodation?

2. Sexual and Personal Behaviour:

(a) Did the parties have sexual relations? If not, why not?

(b) Did they maintain an attitude of fidelity to each other?

(c) What were their feelings toward each other?

(d) Did they communicate on a personal level?

(e) Did they eat their meals together?

(f) What, if anything, did they do to assist each other with problems or during illness?

(g) Did they buy gifts for each other on special occasions?

3. Services:

What was the conduct and habit of the parties in relation to:

(a) preparation of meals;

(b) washing and mending clothes;

(c) shopping;

(d) household maintenance; and

(e) any other domestic services?

4. Social:

(a) Did they participate together or separately in neighbourhood and community activities?

(b) What was the relationship and conduct of each of them toward members of their respective families and how did such families behave towards the parties?

5. Societal:

What was the attitude and conduct of the community toward each of them and as a couple?

6. Support (economic):

(a) What were the financial arrangements between the parties regarding the provision of or contribution toward the necessaries of life (food, clothing, shelter, recreation, etc.)?

(b) What were the arrangements concerning the acquisition and ownership of property?

(c) Was there any special financial arrangement between them which both agreed would be determinant of their overall relationship?

7. Children:

What was the attitude and conduct of the parties concerning children?

[46] In Austin v. Goerz, 2007 BCCA 586, the Court of Appeal cautioned against a “checklist approach”; rather, a court should "holistically" examine all the relevant factors. Cases like Molodowich provide helpful indicators of the sorts of behaviour that society associates with a marital relationship, the Court of Appeal said; however, “the presence or absence of any particular factor cannot be determinative of whether a relationship is marriage-like” (para. 58).

[47] In Weber v. Leclerc, 2015 BCCA 492, the Court of Appeal again affirmed that there is no checklist of characteristics that will be found in all marriages and then concluded with respect to evidence of intentions:

[23] The parties’ intentions – particularly the expectation that the relationship will be of lengthy, indeterminate duration – may be of importance in determining whether a relationship is “marriage-like”. While the court will consider the evidence expressly describing the parties’ intentions during the relationship, it will also test that evidence by considering whether the objective evidence is consonant with those intentions.

[24] The question of whether a relationship is “marriage-like” will also typically depend on more than just their intentions. Objective evidence of the parties’ lifestyle and interactions will also provide direct guidance on the question of whether the relationship was “marriage-like”.

[48] Significantly for this case, the courts have looked to mutual intent in order to find a marriage-like relationship. See, for example, L.E. v. D.J., 2011 BCSC 671 and Buell v. Unger, 2011 BCSC 35; Davey Estate v. Gruyaert, 2005 CarswellBC 3456 at 13 and 35.

[49] In Mother 1, Myers J. concluded his analysis of the law with the following learned comment:

[143] Having canvassed the law relating to the nature of a marriage-like relationship, I will digress to point out the problematic nature of the concept. It may be apparent from the above that determining whether a marriage-like relationship exists sometimes seems like sand running through one's fingers. Simply put, a marriage-like relationship is akin to a marriage without the formality of a marriage. But as the cases mentioned above have noted, people treat their marriages differently and have different conceptions of what marriage entails.

[50] In short, the determination of whether the parties in this case lived in a marriage-like relationship is a fact-specific inquiry that a trial judge would need to make on a “holistic” basis, having regard to all of the evidence. While the trial judge may consider the various factors listed in the authorities, those factors would not be treated as a checklist and no single factor or category of factors would be treated as being decisive.

E. Is There a Reasonable Claim of a Marriage-Like Relationship?
[51] In this case, many of the Molodowich factors are missing:

a) The parties never lived under the same roof. They never slept together. They were never in the same place at the same time during the relationship. The last time they saw each other in person was in November 2017, before the relationship began.

b) The parties never had consensual sex. They did not hug, kiss or hold hands. With the exception of the alleged sexual assault, they never touched one another physically.

c) The parties expressed care and affection for one another, but they rarely shared personal information or interest in their lives outside of their direct topic of communication. They did not write about their families, their friends, their religious beliefs or their work.

d) They expressed concern and support for one another when the other felt unwell or experienced health issues, but they did not provide any care or assistance during illness or other problems.

e) They did not assist one another with domestic chores.

f) They did not share their relationship with their peers or their community. There is no allegation, for example, that Mr. Dorje told his fellow monks or any of his followers about the relationship. There is no allegation that Ms. Han told her friends or any co-workers. Indeed, there is no allegation that anyone, with the exception of Ms. Han’s mother, knew about the relationship. Although Mr. Dorje gave Ms. Han’s mother a gift, he never met the mother and he never spoke to her.

g) They did not intend to have a child together. The child was conceived as a result of a sexual assault. While Mr. Dorje expressed interest in “meeting” the child, he never followed up. He currently has no relationship with the child. There is no allegation he has sought access or parenting arrangements.

[52] The only Molodowich factor of any real relevance in this case is economic support. Mr. Dorje provided the funds with which Ms. Han purchased a condominium. Mr. Dorje initially wrote that he wanted to buy a property with the money, but, he wrote, “It’s the same thing if you buy [it]”.

[53] Mr. Dorje also provided a significant amount of money for Ms. Han’s postpartum care and the child’s first year of life.

[54] This financial support may have been primarily for the benefit of the child. Even the condominium, Ms. Han wrote, was primarily for the benefit of the child.

[55] However, in my view, a trial judge may attach a broader significance to the financial support from Mr. Dorje than child support alone. A trial judge may find that the money Mr. Dorje provided to Ms. Han at her request was an expression of his commitment to her in circumstances in which he could not commit physically. The money and the gifts may be seen by the trial judge to have been a form of down payment by Mr. Dorje on a promise of continued emotional and financial support for Ms. Han, or, in Mr. Dorje’s own words, “Taking care of her and you are my duty for life” (emphasis added).

[56] On the other hand, I find it difficult to attach any particular significance to the fact that Mr. Dorje agreed to provide funds for Ms. Han to purchase a wedding ring. It appears to me that Ms. Han demanded that Mr. Dorje buy her a wedding ring, not that the ring had any mutual meaning to the parties as a marriage symbol. But it is relevant, in my view, that Mr. Dorje provided $20,000 USD to Ms. Han for something she wanted that was of no benefit to the child.

[57] Further, Ms. Han alleges that the parties intended to live together. At a minimum, a trial judge may find that the discussions about where Ms. Han and the child would live reflected a mutual intention of the parties to see one another and spend time together when they could.

[58] Mr. Dorje argues that an intention to live together at some point in the future is not sufficient to show that an existing relationship was marriage-like. He argues that the question of whether the relationship was marriage-like requires more than just intentions, citing Weber, supra.

[59] In my view, the documentary evidence referred to above provides some objective evidence in this case that the parties progressed beyond mere intentions. As stated, the parties appear to have expressed genuine care and affection for one another. They appear to have discussed marriage, trust, honesty, finances, mutual obligations and acquiring family property. These are not matters one would expect Mr. Dorje to discuss with a friend or a follower, or even with the mother of his child, without a marriage-like element of the relationship.

[60] A trial judge may find on the facts alleged by Ms. Han that the parties loved one another and would have lived together, but were unable to do so because of Mr. Dorje’s religious duties and nomadic lifestyle.

[61] The question I raised in the introduction to these reasons is whether a relationship that began on-line and never moved into the physical world can be marriage-like.

[62] Notably, the definition of a spouse in the Family Law Act does not require that the parties live together, only that they live with another person in a marriage-like relationship.

[63] In Connor Estate, 2017 BCSC 978, Mr. Justice Kent found that a couple that maintained two entirely separate households and never lived under the same roof formed a marriage-like relationship. (Connor Estate was decided under the intestacy provisions of the Wills, Estates and Succession Act, S.B.C. 2009, c. 13 ("WESA"), but courts have relied on cases decided under WESA and the FLA interchangeably for their definitions of a spouse.) Mr. Justice Kent found:

[50] The evidence is overwhelming and I find as a fact that Mr. Chambers and Ms. Connor loved and cared deeply about each other, and that they had a loving and intimate relationship for over 20 years that was far more than mere friendship or even so-called "friendship with benefits". I accept Mr. Chambers' evidence that he would have liked to share a home with Ms. Connor after the separation from his wife, but was unable to do so because of Ms. Connor's hoarding illness. The evidence amply supports, and I find as a fact, that Mr. Chambers and Ms. Connor loved each other, were faithful to each other, communicated with each other almost every day when they were not together, considered themselves to be (and presented themselves to be) "husband and wife" and were accepted by all who knew them as a couple.

[64] Connor Estate may be distinguishable from this case because Mr. Chambers and Ms. Connor were physically intimate for over 20 years, and presented themselves to the world as a married couple.

[65] Other decisions in which a marriage-like relationship has been found to exist despite the parties not living together have involved circumstances in which the couple lived under the same roof at previous points in the relationship, and the issue was whether they continued to be spouses after they took up separate residences: in Thompson v. Floyd, 2001 BCCA 78, the parties had lived together for a period of at least 11 years; in Roach v. Dutra, 2010 BCCA 264, the parties had lived together for approximately three years.

[66] However, as Mr. Justice Kent noted in Connor Estate:

[48] … [W]hile much guidance might be found in this case law, the simple fact is that no two cases are identical (and indeed they usually vary widely) and it is the assessment of evidence as a whole in this particular case which matters.

[67] Mr. Justice Kent concluded:

[53] Like human beings themselves, marriage-like relationships can come in many and various shapes. In this particular case, I have no doubt that such a relationship existed …

[68] As stated, Ms. Han’s claim is novel. It may even be weak. Almost all of the traditional factors are missing. The fact that Ms. Han and Mr. Dorje never lived under the same roof, never shared a bed and never even spent time together in person will militate against a finding they lived with one another in a marriage-like relationship. However, the traditional factors are not a mandatory check-list that confines the “elastic” concept of a marriage-like relationship. And if the COVID pandemic has taught us nothing else, it is that real relationships can form, blossom and end in virtual worlds.

[69] In my view, the merits of Ms. Han’s claim should be decided on the evidence. Subject to an overriding prejudice to Mr. Dorje, she should have leave to amend the notice of family claim. However, she should also provide meaningful particulars of the alleged marriage-like relationship.

F. Delay / Prejudice
[70] Ms. Han filed her notice of family claim on July 17, 2019. She brought this application to amend approximately one year and nine months after she filed the pleading, just over two months before the original trial date.

[71] Ms. Han’s delay was made all that more remarkable by her change in position from January 19, 2021, when she confirmed, through counsel, that she was not seeking spousal support in this case.

[72] Ms. Han gave notice of her intention to proceed with this application to Mr. Dorje on March 16, 2021. By the time the application was heard, the parties had conducted examinations for discovery without covering the issues that would arise from a claim of spousal support.

[73] Also, in April, Ms. Han produced additional documents, primarily text messages, that may be relevant to her claim of spousal support, but were undecipherable to counsel for Mr. Dorje, who does not read Mandarin.

[74] This application proceeded largely on documents selected and translated by counsel for Ms. Han. I was informed that Mandarin translations of the full materials would take 150 days.

[75] Understandably in the circumstances, Mr. Dorje argued that an amendment two months before trial would be neither just nor convenient. He argued that he would be prejudiced by an adjournment so as to allow Ms. Han to advance a late claim of spousal support.

[76] The circumstances changed on May 6, 2021, when Madam Justice Walkem adjourned the trial to July 2022 and reset it for 25 days. Madam Justice Walkem noted that most of the witnesses live internationally and require translators. She also noted that paternity may be in issue, and Mr. Dorje may amend his pleadings to raise that issue. It seems clear that, altogether apart from the potential spousal support claim, the parties were not ready to proceed to trial on June 7, 2021.

[77] In my view, any remaining prejudice to Mr. Dorje is outweighed by the importance of having all of the issues between the parties decided on their merits.

[78] Ms. Han’s delay and changes of position on spousal support may be a matter to de addressed in a future order of costs; but they are not grounds on which to deny her leave to amend the notice of family claim.

CONCLUSION
[79] Ms. Han is granted leave to amend her notice of family claim in the form attached as Appendix A to the notice of application to include a claim for spousal support.

[80] Within 21 days, or such other deadline as the parties may agree, Ms. Han must provide particulars of the marriage-like relationship alleged in the amended notice of family claim.

[81] Ms. Han is entitled to costs of this application in the cause of the spousal support claim.

“Master Elwood”

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今回は半額STEP1で当たった「零式弐型LV2」の動画です。
星3MSなのであまり期待してなかったのですが無事サブ垢で取得することができました。
トークン貯めとかないとねぇ・・・(サザビーは絶対に欲しい

楽しんでいただけると幸いです。
こちらは「ゆっくり実況」となります。

▷【ご報告】2019年5月8日よりUUUMネットワークに参加させて頂きました。

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【バトオペ2 】逆シャア時代に突入！ついに登場量産機『ジェガン』！この時代ではそこまで大型ではない！【ゆっくり実況】
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【バトオペ2 】環境！？止まらない暴君『ボリノークサマーン』！強襲機底上げに伴って恐怖のクマとなる！【ゆっくり実況】
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【バトオペ2 】ようやく手に入れた『ガルスJ』！謎のアッパー調整で更に強くなったコスト500の環境機！【ゆっくり実況】
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【再生リスト】
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今回はいつ手に入れたのか？全く覚えていない『ボリノークサマーン』LV1の動画です。
正直他のレベルも持っているかと思ったのですが、本垢はLV1、サブ垢はLV2しか持ってませんでした。
いつかLV4ほしいなぁ・・・

楽しんでいただけると幸いです。
こちらは「ゆっくり実況」となります。

▷【ご報告】2019年5月8日よりUUUMネットワークに参加させて頂きました。

【バトオペ2 ゆっくり実況リスト】https://www.youtube.com/playlist?list=PLJYdJDKi6eZsnqQsc7wX4jK253O1UDW9C
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【オススメ動画】
————————————————————
【バトオペ2 】ようやく手に入れた『ガルスJ』！謎のアッパー調整で更に強くなったコスト500の環境機！【ゆっくり実況】
https://youtu.be/clTdTFPWoPE
【バトオペ2 】ついに登場『ハイパーメガランチャー』装備のZガンダム！12連グレネードが環境に刺さる支援機！【ゆっくり実況】
https://youtu.be/5k5d5_oNjH4
【バトオペ2 】「攻撃姿勢制御」を手に入れた『ディジェSE-R』！更にゴリゴリ押せるようになったMSとなる！【ゆっくり実況】
https://youtu.be/qoJHIF6cSls

【再生リスト】
————————————————————
【バトオペ2】LIVEリスト
https://www.youtube.com/playlist?list=PLJYdJDKi6eZuO3WvskFbWKerXRFWWL8hD

【楽曲提供】
————————————————————
Production Music by http://www.epidemicsound.com
UUUMUSIC
Soundcloud https://soundcloud.com/discover
On-Jin(音人) https://on-jin.com/kiyaku.php
musmus http://musmus.main.jp/
Music is VFR http://musicisvfr.com/
甘茶の音楽工房 http://amachamusic.chagasi.com/
OtoLogic https://otologic.jp/
DOVA-SYNDROME 旅立つキミに
https://dova-s.jp/bgm/play12813.html

【ガチャMusic】
————————————————————
DOVA-SYNDROME written by ISAo. https://dova-s.jp/bgm/play9331.html
LAZZULI LUVS feat norico

【closing song】
————————————————————
NCS: Music Without Limitations
NCS Spotify: http://spoti.fi/NCS
Free Download / Stream: http://ncs.io/loveu
Razihel - Love U [NCS Release]
https://www.youtube.com/watch?v=OJBxNA8cX-E

【素材提供】
————————————————————
PIXTA
————————————————————
#バトオペ2 #ゆっくり実況 #キシオゲームズ