Wilson and colleagues are to be commended for their excellent work in exploring mental illnesses and desire for death in patients receiving palliative care with malignancy. [1] The piece thoughtfully explores the prevalence of depression, anxiety and mood disorders and the association between these diagnoses and a standardized quantification of the patient's desire for death. In all, the authors found that 30.5% of participants e...
Wilson and colleagues are to be commended for their excellent work in exploring mental illnesses and desire for death in patients receiving palliative care with malignancy. [1] The piece thoughtfully explores the prevalence of depression, anxiety and mood disorders and the association between these diagnoses and a standardized quantification of the patient's desire for death. In all, the authors found that 30.5% of participants experienced transient desire for death, and 12.2% of patients with a more pervasive and genuine wish that was described as "moderate", "strong", "severe", or "extreme."
Several aspects of these findings warrant comment. First, the authors report that it appears that those without a serious desire for death and without mental disorder seemed to be "coping well and achieving optimal palliative care outcomes." While I agree with this assessment and hope that the palliative care intervention contributed, in part, to this lesser distress, it remains unclear if the palliative care is helping in the situation, or if this results from coincidence or participation bias. Conversely, those participants with serious desire for death and current mental illness were noted to be experiencing a more difficult course despite palliative care intervention. This begs the question as to how such concerns were addressed aggressively by the interdisciplinary palliative care team yet still persisted.
Perhaps most critical are the findings that relate to the possibility of desire for death, mental disorder, and request for or completion of physician-assisted death in this population. The authors report data from the Netherlands where patients with depression and underlying psychological disorders, and concomitant terminal illness, are more likely to have their request for physician assisted death denied (citing 3 studies). [1] However, it is difficult to determine if practices have changed substantially over the past two years since their report was completed and now published in print. Furthermore, it can be challenging to tease out the research facts and findings at a population level, and extrapolate this information to the individual case level.
Indeed, in other recent analysis by Kim, De Vries and Peteet published electronically late in 2015, the authors reviewed 66 cases in the Netherlands where psychiatric conditions led to request and granting of euthanasia or assisted death for patients with purely psychiatric conditions [2] and not concurrent malignancy as was the case in Wilson and colleagues' paper. In Emanuel and colleagues' review of characteristics of euthanasia and physician-assisted suicide cases across the United States (in jurisdictions where legal), the Netherlands and Belgium, it was notable that 4.6% of all deaths in Belgium results from euthanasia, including 12% of those cases fitting into the "mental" health indication profile. [3]
Although euthanasia is not legal in the United States, discussion about physician assisted suicide are ongoing in many states, as well as in Canada. Discussions about the practice of physician assisted death are often extrapolated from the European experience, which frequently serves as the basis for policy discussion among North American clinicians and lawmakers. Credible media reports of euthanasia for "unbearable psychological suffering" have been openly reported in cases in Belgium [4] and Dignitas has reported provision of aid-in-dying to patients with underlying mental illness in Switzerland. [5] The data in aggregate from Kim and colleagues, and Emanuel and colleagues, suggest that these cases in the media are not necessarily rare or sporadic, but may be part of a small but regular population who seek hastened death and have their requests granted. While Wilson and colleagues suggest the possibility of "hesitation when [euthanasia or physician-assisted suicide are] used to relieve their expression of despair", the data in aggregate may suggest otherwise, and that heightened scrutiny of hastened death for individuals with concurrent mental disorders may not actually be the case.
References:
1. Wilson KG, Dalgleis TL, Chochinov HM et al. Mental disorders and the desire for death in patients receiving palliative care for cancer. BMJ Support Palliat Care 2016;6:170-177 doi:10.1136/bmjspcare-2013-000604
2. Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73:362-368.
3. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90.
4. Euthanasia twins 'had nothing to live for'. The Telegraph. Available at http://www.telegraph.co.uk/news/worldnews/europe/belgium/9801251/Euthanasia-twins-had-nothing-to-live-for.html Accessed July 14, 2016
5. Suicide-Clinic Entrepreneur: Depressed? 'We Never Say No'. Available at http://www.wnd.com/2006/04/35738/#! Accessed July 14, 2016
British and European palliative care physicians are not alone in
their concerns and reluctance to participate in Physician Assisted
Suicide/Euthanasia. Canadian Palliative care physicians struggle with this
issue as well.
In 2010, the Canadian Society of Palliative Care physicians (300 members)
were surveyed. (1) The questions were specific: "Are you for or against
PAS/Euthanasia?" "Would you provide assisted suicide?" "W...
British and European palliative care physicians are not alone in
their concerns and reluctance to participate in Physician Assisted
Suicide/Euthanasia. Canadian Palliative care physicians struggle with this
issue as well.
In 2010, the Canadian Society of Palliative Care physicians (300 members)
were surveyed. (1) The questions were specific: "Are you for or against
PAS/Euthanasia?" "Would you provide assisted suicide?" "Would you provide
Euthanasia?" Forty-six percent of the membership responded to the survey.
The overwhelming majority was opposed to the legalization of euthanasia
(88%) or assisted suicide (80%). Ninety percent of responding members
would not be willing to participate in the act of euthanasia and 83% of
responding members would not be willing to aid in assisted suicide.
The Society followed with another survey in 2015 in response to the
growing public interest and in anticipation of a Supreme Court Ruling. The
January 2015 survey (350 members with a 74% response rate) indicated that
the majority of the membership was still opposed to legalization of
euthanasia (73%) or assisted suicide (69%). The majority (74%) believe
that euthanasia and physician assisted suicide, if legalized, should not
be provided by palliative care services or palliative care physicians. (2)
The Carter Decision (Carter v. Canada (Attorney General), 2015 SCC 5)
struck down the prohibition on assisted suicide, opening the way for new
legislation to enable physician assisted death for people with a "grievous
and irremediable medical condition". (3) There is no mention in the
decision that these people have to be terminally ill, nor are there any
specifications around assessment, restrictions, or processes. This Supreme
Court decision is one of the most liberal in the world. In opening up this
service to people without terminal illnesses it thereby makes this an
issue for all physicians, not just those in palliative care.
Canadian physicians are currently struggling with the implications this
decision has for their practice, their patients and their internal belief
as to what it means to be a physician. While the Canadian Medical
Association has stated that physicians can follow their conscience (4)
this will have to be balanced with the needs of the patients. Health care
in Canada is provincially funded and regulated, meaning that each province
could come up with its own way of providing physician assisted death.
Quebec has already done so. Physicians have urged government to engage in
a thoughtful, inclusive process to create the new laws and medical systems
but with a federal election poised for the fall, little has been heard on
this subject. Provincial Medical Colleges are left, in this void of
legislation, to scramble to come up with rules and regulations for this
new service. As of February 6, 2016, the prohibition against physician
assisted suicide will be gone and potentially no legislation or decisions
around practice will be in place.
Susan MacDonald MD CCFP FCFP
President, Canadian Society of Palliative Care Physicians
Associate Professor of Medicine and Family Medicine, Memorial University
of Newfoundland
Correspondence: Dr. Susan MacDonald, MD, CCFP, FCFP
Faculty of Medicine and Family Medicine, Memorial University
LA Miller Centre, 100 Forest Road
St. John's, NL A1A 1E5 CANADA
We read with interest the article by Harper et al in the last edition
of this journal (2011;1:306-309). By establishing a correlation between
infant mortality and the increased mortality risk of the parents, the
article speaks, albeit indirectly, to the possible links between emotional
and physical states - a topic of important and growing interest. However,
two points present themselves about the authors' analysis - the f...
We read with interest the article by Harper et al in the last edition
of this journal (2011;1:306-309). By establishing a correlation between
infant mortality and the increased mortality risk of the parents, the
article speaks, albeit indirectly, to the possible links between emotional
and physical states - a topic of important and growing interest. However,
two points present themselves about the authors' analysis - the first is
statistical, the second conceptual.
Harper et al are direct about possible confounding factors for which
they were unable to control but which may nullify any causal link implied
by the statistical correlation they identify (p308). However, given their
use of census data, there is one possible confounding factor that they
might have controlled for - age of parent at the time of birth.
Harper et al imply that the small difference in mean age between the
comparison and control group means age should not raise concern. However,
if parent and infant mortality are more likely among both older and
younger parents, the difference in mean age might be minimal or invisible,
even though the casual implications of the chi-squared correlation would
be weakened. Previous research suggests that such a two-sided confounding
factor may exist for age. Young births, such as teenage pregnancies, have
been linked to worse outcomes for both mother and child (see, for example,
citations in Wellings and Kaye, 1999). Births to older parents are
similarly more likely to face complications and older parents would
naturally be closer to average life expectancies.
The results presented by the authors point towards this possibility.
The 'bereaved' group manifests a wider range of ages than the 'control'
group. The effect is most significant in the English data - the smallest
difference in standard deviations exists for the 1981-1991 cohort, which
is between 8.4 and 5.7. Since the English data manifest a higher relative
risk, it is worth exploring whether age may be such a confounding factor.
Year of birth might also be included in the analysis, to control for the
possibility that both infant and parent mortality risks may be shifting
over time.
The second concern is a conceptual one. If a ceteris paribus causal
link exists between the death of one's children and an increased mortality
risk for parents, it seems likely that this is linked to the trauma caused
by the loss of a loved one. But emotional bonds are not all equal - on
average, they might be expected to become stronger over time. From this
perspective, the average relative risk of parent mortality after a
miscarriage should be lower than death in childbirth, which would be lower
in turn than death in early infancy and the death of a young child.
The Dutch study (Li et al, 2003) referenced by Harper et al bears out
this principle - the relative risk of parent mortality in their study is
higher for a child dying aged between 1 and 11 months than a child dying
at less than one month. The analysis by Harper et al can be extended to
explore this hypothesis. Parents suffering stillbirths and infant
mortalities are currently combined into a single category - by splitting
the two groups, differences might be observed. The accidental inclusion of
parents whose child dies aged older than one in the 'non-bereaved' group
would bias effects downward, but differences may still be observable.
For the Scottish data, ethical non-identification reasons and small
sample sizes prevented such subgroup analysis (p307). However, the small
sample size resulted by design - the choice of 20 birthdays or 5.3% of the
population. Had the authors chosen a larger set of birthdays, it may have
been ethically possible to analyse the two subgroups in greater detail. No
such restriction applied to the English data.
The authors are to be congratulated on their research and we agree
with them that further statistical and case study work is required. We
hope that the suggestions are amenable to straightforward exploration on
similar datasets to those used by the authors.
Dr Wing Chu, ST1 Doctor in Palliative Care; Christian Percy,
Statistical Consultant
References
Wellings, K. and Kane, R. (1999), 'Trends in teenage pregnancy in England
and Wales: how can we explain them', J R Soc Med 1999;92:277-282
We read with great interest the paper by Rhondali et al.(1) and we
thank them for their contribution to a very worthwhile topic. We are
involved in palliative care research in Mauritania, West Africa, and we
appreciate this piece of research coming from France and we hope it will
stimulate more palliative care research, not just in France but throughout
the francophone world. As the likes of Uganda...
We read with great interest the paper by Rhondali et al.(1) and we
thank them for their contribution to a very worthwhile topic. We are
involved in palliative care research in Mauritania, West Africa, and we
appreciate this piece of research coming from France and we hope it will
stimulate more palliative care research, not just in France but throughout
the francophone world. As the likes of Uganda (2) and Malawi(3) have
benefitted from close ties to Anglophone palliative care researchers based
in Europe and North America, we believe that closer ties between France
and specifically francophone Africa would be greatly beneficial.
In addition to the barriers the paper identified, the authors propose
that difficulty with English could be a further barrier for investigators
in France. Given this suggestion we are a little surprised to note that
the authors chose to publish in an anglophone journal which perhaps could
limit the potential impact of this paper.
In the introduction, the authors state that only 2% of European
Palliative Care research came from France, however this is biased as the
citing source excluded non-English research(4) and the authors acknowledge
that most of the palliative care research from France is published, in
French, in the journal Medecine Palliative. A more encouraging picture is
gained from the 2nd Francophone Palliative Care Congress which was held in
Canada in 2013 where research was presented from Africa, North America,
Europe and Asia. We look forward to the 3rd congress which will be held in
Tunisia, 2015 and at this occasion we hope to see many more francophone
researchers coming from Africa.
This paper highlights multiple barriers which, from our experience,
reflects our context. Here, and in France, we believe creative and
multidimensional solutions are required to overcome these barriers, or
perhaps challenges is a more suitable term implying that they are
surmountable.
Yours sincerely,
David Fearon
PhD Student and Advocate for Palliative Care in Mauritania
Lancaster University
d.fearon@lancaster.ac.uk
Ahmedou Ould Ahmedou
Chief Medical Officer
Centre National d'Oncologie
Nouakchott
Mauritania
1. RHONDALI, W., BERTHILLER, J., HUI, D., et al. 2014. Barriers to
research in palliative care in France. BMJ Support Palliat Care 2014;4:182
-189
2. GRANT, L., BROWN, J., LENG, M., et al. 2011. Palliative care
making a difference in rural Uganda, Kenya and Malawi: three rapid
evaluation field studies. BMC Palliat Care, 10, 8.
3. MURRAY, S. A., GRANT, E., GRANT, A. et al. 2003. Dying from cancer
in developed and developing countries: lessons from two qualitative
interview studies of patients and their carers. BMJ, 326, 368.
4. HUI D, PARSONS HA, DAMANI S, et al. Quantity, design, and scope of
the palliative oncology literature. Oncologist 2011;16:694-703.
I read with interest the letter from McKenna and others describing
the evolution of an algorithm to aid decision making in the withdrawal of
life-sustaining medical devices (LSMDs) (1). The briefly described
scenario involving the development of cancer in a patient with a left
ventricular assist device (LVAD) as a bridge to transplantation is
familiar to us in cardiovascular medicine, as is the resulting need for
decis...
I read with interest the letter from McKenna and others describing
the evolution of an algorithm to aid decision making in the withdrawal of
life-sustaining medical devices (LSMDs) (1). The briefly described
scenario involving the development of cancer in a patient with a left
ventricular assist device (LVAD) as a bridge to transplantation is
familiar to us in cardiovascular medicine, as is the resulting need for
decision making in the moment which often becomes the default position.
While the occurrence of this comorbidity could not have been
anticipated in this transplant candidate, such events will be increasingly
encountered in heart failure patients supported for prolonged periods with
LVADs as destination therapy, and given the exponential rise in implant
rates, this situation will be commonplace in those surviving with
implantable cardioverter defibrillators (ICDs).
While the proposed decision tree provides a useful checklist for LSMD
withdrawal, my impression is that at initiation, the protocol appears
largely reactive. The flow chart seems to imply that any discussion
concerning device withdrawal is broached for the first time at the point
of an unanticipated patient request or when the device recipient is
subject to what may be a rapidly evolving irrecoverable clinical
situation. Any notion of advance care planning is described only in the
setting of assessment of capacity relevant to the Mental Capacity Act.
Given the prognostic ambiguity intrinsic to the heart failure disease
trajectory, advance care planning might offer significant advantage to
these patients and their families encumbered with such uncertainty. While
the use of advance directives by those with heart failure is increasing,
specific device related decision making remains the exception (2,3).
However, preparedness planning for end of life care incorporating
palliative care consultations has been shown to be of benefit in those
being considered for LVAD therapy (4), and prospective pre-implantation
discussion about this issue is mandated in the in the position statement
on ICD deactivation from the Heart Rhythm Society in the United states and
supported by the European Heart Rhythm Association (5). Such a dialogue
would also be necessary as part of the description of the benefits and
burdens of device therapy required of an ethically framed valid informed
consent process and central to the premise of shared decision making in
advanced heart failure (6).
Having been opened prior to device implantation, it would seem
appropriate to revisit these end of life care discussions at intervals
during follow up, perhaps reducing the complexity of the management of the
inevitable crises, and avoiding some of the dilemmas linked to clinical
situations such as that described (7). The authors may wish to consider
incorporating an element referring to device related advance care planning
early in their proposed algorithm.
References
1) McKenna M, Wrightson N, Regnard C, Clark S. Life-sustaining medical
devices at the end of life. BMJ Support Palliat Care
doi:10.11.1136/bmjspcare-2012-000364.
2) Habal MV, Micevski V, Greenwood S. et al. How aware of advanced care
directives are heart failure patients, and are they using them? Canad J
Cardiol 2011, 27:376-81.
3) Tajouri TH, Ottenberg AL, Hayes DL, Mueller PS. The use of advance
directives among patients with implantable cardioverter defibrillators.
Pacing Clin Electrophysiol. 2012 , 35:567-73.
4) Swetz KM, Freeman M, AbouEzzeddine OF. et al. Palliative medicine
consultation for preparedness planning in patients receiving left
ventricular assist devices as destination therapy. Mayo Clin Proc 2011,
86:493-500.
5) Lampert R, Hayes DL, Annas GJ. et al. HRS Expert Consensus Statement
on the Management of Cardiovascular Implantable Electronic Devices (CIEDs)
inpatients nearing end of life or requesting withdrawal of therapy. Heart
Rhythm. 2010, 7:1008-26.
6) Allen LA, Stevenson LW, Grady KL. et al. Decision making in advanced
heart failure: a scientific statement from the American Heart Association.
Circulation 2012, 125:1928-52.
Kirkpatrick JN, Fedson SE, Verdino R. Ethical dilemmas in device
treatment for advanced heart failure. Curr Opin Support Palliat Care.
2007, 1:267-73.
I am perplexed why this paper by Jandhyala and Fullarton has
concluded that "FBT (fentanyl buccal tablet) may have some efficacy
advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC
(compressed lozenge oral transmucosal fentanyl)..." in the management of
breakthrough cancer pain when a paper published at the same time in
another journal (Smith H, A comprehensive review of rapid-onset opioids
for breakthr...
I am perplexed why this paper by Jandhyala and Fullarton has
concluded that "FBT (fentanyl buccal tablet) may have some efficacy
advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC
(compressed lozenge oral transmucosal fentanyl)..." in the management of
breakthrough cancer pain when a paper published at the same time in
another journal (Smith H, A comprehensive review of rapid-onset opioids
for breakthrough pain, CNS Drugs 2012;26(6)509-535)concludes that "The
findings of this review suggest that the efficacy and safety of the
approved rapid-onset opioids are comparable".
Some concerns arise. Jandhyala and Fullarton in their introduction quote
the Portnoy definition of cancer breakthrough pain as "typically rapid in
onset (within a few minutes) and short in duration (around 30 min", go on
to show)that FBT produces similar levels of pain relief as ODT within that
period but then base their conclusions on pain relief up to 60 minutes
after pain initiation.
Further, the differences in pain intensity when FBT and ODT are considered
after 60 minutes, for example, are 0.75. Under the "Contributors"
section, Dr Jandhyala is listed as undertaking the clinical interpretation
of the data. In his clinical experience is such a change in pain score
clinically meaningful?
One last concern. This paper concludes that FBT may have some advantages
over the other fentanyl preparations (in contrast to the conclusions of
Smith quoted above). As this paper was funded by Cephalon, the
manufacturer of FBT and the lead author is the Interim Medical Manager of
that company only very definite data should have allowed an endorsement of
their product to avoid potential claims of a conflict of interest.
Re: Opinions of the patients with cancer on the relative importance
of place of death in the context of 'good death'.
By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative
Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011
study on opinion of patient with cancer on the relative importance of
place of death.
Having looked at the four highlighted domains ass...
Re: Opinions of the patients with cancer on the relative importance
of place of death in the context of 'good death'.
By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative
Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011
study on opinion of patient with cancer on the relative importance of
place of death.
Having looked at the four highlighted domains associated with a 'good
death' stated as:
? Being treated as an individual, with dignity and respect
? Being without pain and other symptoms
? Being in familiar environment
? Being in the company of close family and/or friends
If the patient fit into the above domains, I think the place of death is
not very important as per the result of this study. I would also add to
the above domains that, no matter the place a patient may prefer to die
what is important is that every individual want to have a peaceful death,
settling/making restitution, forgiving and being forgiven for any wrongs
with family members/friends, and making right standing with God. Fukui,
Kawagoe & Masako (2003) stated that most patients prefer home death or
hospice, despite these facts, most cancer patients in the United Kingdom
die in hospital bed. Most people currently die in hospital despite the
vast majority saying they would prefer to die at home in familiar
surroundings, close to family and friends (Lansley, 2010). From the above
citations,it means that their wishes are not very important.
Taking one site (setting) for the study does not give a result that could
be generalized. This is because most patients in some part of the world
diagnosed with advanced cancer do not see any need of going to the
hospital for treatment. They/family members feel that death is eminent as
such spending money in hospital bed is a waste. Evidence shows that
patients make fewer visits to their Doctors after psychological
interventions (Chiles et al, 2006). The setting should have included
homes, nursing homes and palliative/hospice centers.
The study may not be well applied to most part of the world due to
either non-availability of nursing homes or poverty to really have options
to where they would prefer to die. To the patient what is important is
getting quality care in the last days of life.
Reference
Chile J. A. et al 2006. The impact of psychological interventions on
medical cost offset: a meta-analytic review clinical psychology: Science
and Practice, 6:2,204-220
Fukui S, Kawagoe H, and Masako S. 2003. Determinants of the place of death
among terminally ill cancer patients under home hospice care in Japan.
Palliative Med. 17: 445-53
Lansley, A. 2010. Patients to have choice of where to die. Health Service
Journal. From: http://www.hsjjobs.com/?wTmc_id=HSJ
Akon E. Ndiok: Department of Nursing Science, University of Calabar,
Calabar. Nigeria.
This study generated discussion in our hospice about the importance
of breaking bad news well and also the importance of these discussions in
non cancer related disease. It was interesting the study showed 'people
with heart failure had engaged in much less discussion about their
condition, and most did not recall a specific conversation with their
doctor about their prognosis'. I recently reviewed the literature on
chr...
This study generated discussion in our hospice about the importance
of breaking bad news well and also the importance of these discussions in
non cancer related disease. It was interesting the study showed 'people
with heart failure had engaged in much less discussion about their
condition, and most did not recall a specific conversation with their
doctor about their prognosis'. I recently reviewed the literature on
chronic heart failure and a recurrent theme is that patients with chronic
heart failure have frequent thoughts about death both during acute
exacerbations and also in more chronic stable phases of their illness. As
clinician's we need to be aware of the predictors of end stage heart
failure and preferably embark on end of life conversations with our
patient's before this time. One study (Setoguchi S et al. Hospitalizations
in patients with heart failure. J Am Coll Cardiol. 2009;54(18):1703) found
approximately one third of patients die within a year of an admission for
heart failure and mortality figures are similar to that of bowel and
ovarian cancer so it is crucial to discuss advance care planning and
prognosis which can help alleviate patient fears, address concerns and
overall aim for better palliative care in the patients preferred setting.
I welcome this small but useful study highlighting the fear and
reluctance of patients and practitioners in using morphine in the setting
of chronic heart failure. Over 50% of chronic heart failure patients
suffer from pain and caution is needed with nearly all analgesics- NSAIDS
and COX2 are contraindicated, neuropathics agents can trigger arrhythmias,
steroids exacerbate salt and water retention, soluble drugs such as c...
I welcome this small but useful study highlighting the fear and
reluctance of patients and practitioners in using morphine in the setting
of chronic heart failure. Over 50% of chronic heart failure patients
suffer from pain and caution is needed with nearly all analgesics- NSAIDS
and COX2 are contraindicated, neuropathics agents can trigger arrhythmias,
steroids exacerbate salt and water retention, soluble drugs such as co-
codamol can contain a high salt content,and transdermal analgesics may be
limited with significant oedema , so not only is morphine useful for
managing dyspnoea in chronic heart failure but it may be a useful
medication to provide analgesia when options are limited. Clinicians need
not fear morphine use as it can have excellent results for symptom control
when used appropriately in this group of patients.
Many patients are ill because of wrong choices they made in their
life (eg smoking, excessive drinking, poor diet etc). How are we going to
ensure that they make the 'right choices' with their individual budgets
particularly if direct cash payments are made? How do we prevent the
exploitation of these individuals? This is not a 'paternalistic 'concern.
The checks and balances needed would be no more different from havin...
Many patients are ill because of wrong choices they made in their
life (eg smoking, excessive drinking, poor diet etc). How are we going to
ensure that they make the 'right choices' with their individual budgets
particularly if direct cash payments are made? How do we prevent the
exploitation of these individuals? This is not a 'paternalistic 'concern.
The checks and balances needed would be no more different from having a
legally binding 'lower speed limit' around schools rather than relying on
individual's common sense.
What about postcode lottery?. Individual service costs in London are
generally higher than in north but ill health is more prevalent in north.
[1] Would the patients from different regions have a different budget for
the same service? What criteria would be adopted for funding each region?
If age is used, people in north would certainly lose out. [2]
Individual budgets are, in principle, a very good idea but the
practicalities of implementation can make it into a white elephant . [3]
Lessons need to be leant from the Dutch experience.[4]
References
1 Hacking JM, Muller S, Buchan IE. Trends in mortality from 1965 to 2008
across the English north-south divide: comparative observational study.
BMJ 2011;342:d508-d508.
2 Bambra CL. Clear winners and losers are created by age only NHS
resource allocation. BMJ 2012;344:e3593-e3593.
3 Duffy SJ. Why Clinicians Should Embrace Individual Budgets. BMJ
Support Palliat Care Published Online First: 31 March 2012.
doi:10.1136/bmjspcare-2011-000118
4 Ginneken E v., Groenewegen PP, McKee M. Personal healthcare
budgets: what can England learn from the Netherlands? BMJ 2012;344:e1383-
e1383.
British and European palliative care physicians are not alone in their concerns and reluctance to participate in Physician Assisted Suicide/Euthanasia. Canadian Palliative care physicians struggle with this issue as well. In 2010, the Canadian Society of Palliative Care physicians (300 members) were surveyed. (1) The questions were specific: "Are you for or against PAS/Euthanasia?" "Would you provide assisted suicide?" "W...
We read with interest the article by Harper et al in the last edition of this journal (2011;1:306-309). By establishing a correlation between infant mortality and the increased mortality risk of the parents, the article speaks, albeit indirectly, to the possible links between emotional and physical states - a topic of important and growing interest. However, two points present themselves about the authors' analysis - the f...
Dear Editor,
We read with great interest the paper by Rhondali et al.(1) and we thank them for their contribution to a very worthwhile topic. We are involved in palliative care research in Mauritania, West Africa, and we appreciate this piece of research coming from France and we hope it will stimulate more palliative care research, not just in France but throughout the francophone world. As the likes of Uganda...
I read with interest the letter from McKenna and others describing the evolution of an algorithm to aid decision making in the withdrawal of life-sustaining medical devices (LSMDs) (1). The briefly described scenario involving the development of cancer in a patient with a left ventricular assist device (LVAD) as a bridge to transplantation is familiar to us in cardiovascular medicine, as is the resulting need for decis...
I am perplexed why this paper by Jandhyala and Fullarton has concluded that "FBT (fentanyl buccal tablet) may have some efficacy advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC (compressed lozenge oral transmucosal fentanyl)..." in the management of breakthrough cancer pain when a paper published at the same time in another journal (Smith H, A comprehensive review of rapid-onset opioids for breakthr...
Re: Opinions of the patients with cancer on the relative importance of place of death in the context of 'good death'. By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011 study on opinion of patient with cancer on the relative importance of place of death. Having looked at the four highlighted domains ass...
This study generated discussion in our hospice about the importance of breaking bad news well and also the importance of these discussions in non cancer related disease. It was interesting the study showed 'people with heart failure had engaged in much less discussion about their condition, and most did not recall a specific conversation with their doctor about their prognosis'. I recently reviewed the literature on chr...
I welcome this small but useful study highlighting the fear and reluctance of patients and practitioners in using morphine in the setting of chronic heart failure. Over 50% of chronic heart failure patients suffer from pain and caution is needed with nearly all analgesics- NSAIDS and COX2 are contraindicated, neuropathics agents can trigger arrhythmias, steroids exacerbate salt and water retention, soluble drugs such as c...
Many patients are ill because of wrong choices they made in their life (eg smoking, excessive drinking, poor diet etc). How are we going to ensure that they make the 'right choices' with their individual budgets particularly if direct cash payments are made? How do we prevent the exploitation of these individuals? This is not a 'paternalistic 'concern. The checks and balances needed would be no more different from havin...
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