Food for thought: ethics case discussion as slow nourishment in a fast world.

Case discussion offers important opportunities to do good medical ethics, but do we understand what the benefits might be? This paper looks at the 'Case Conference' series in the JME, its origins and methods, examines some cases in outline, and reviews issues that arise that are not usually taken into account. Cases are harder to publish now, not least because of ethical constraints. Ways past this apparently paradoxical outcome are suggested.

The last year of life of COPD: a qualitative study of symptoms and services.

INTRODUCTION: To assess the symptoms experienced and their impact on patients' lives in the last year of life of COPD, and to assess patients' access to and contact with health services. METHOD: Qualitative analysis using the framework approach of in-depth interviews with 25 carers of COPD patients who had died in the preceding 3-10 months. RESULTS: The average age of death was 77.4 years. The majority of patients died in hospital. The major symptom reported by the carers was breathlessness which impaired the deceased's mobility and contributed to their being housebound. Anxiety and panic were also associated with breathlessness. Depression was reported. Oxygen, though beneficial, was seen to impose lifestyle restrictions due to increasing dependence on it. Some patients only health care contact was through repeat prescriptions from their GP whereas three had regular follow up by a respiratory nurse specialist who linked community and secondary care. Overall, follow-up, systematic review or structured care were uncommon. DISCUSSION: Breathlessness causes major disability to patients with COPD in the last year of life. The expertise of palliative care in treating breathlessness may be valuable in these patients many of whom lacked regular health service contact in the year before death. Patients who are housebound with high levels of morbidity require community health services. Respiratory nurse specialists were rarely involved in the patients' care and may provide a link between the GP, the chest physician and the palliative care team.

The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice.

INTRODUCTION: The demonstration of appropriate attitudinal behaviour is crucial in the professional development of doctors. This study explores the experiences of UK medical schools in developing and assessing the behaviour associated with the attitudes of undergraduate medical students. METHODS: A qualitative in-depth interview study was based on a questionnaire survey of all UK medical schools. Six heads of medical schools or their nominated representatives were interviewed. Outcome measures were the perceptions and experiences of developing and assessing appropriate attitudes and behaviour in their undergraduate students. RESULTS: Aspects of the hidden curriculum, especially the negative role modelling encountered during clinical practice, were seen to undermine the attitudinal messages of the formal curriculum. Some participants believed that students could still qualify as doctors despite having inappropriate attitudes or behaviour. Others felt certain that this was now unlikely in their school, and this confidence seemed to be backed up with the knowledge that strategies, systems and structures were in place to detect and act upon poor behaviour. DISCUSSION: The conviction that it is right to assess students on their attitudinal behaviour does not yet appear to be held consistently across all schools and we suggest that this may reflect some fundamental tensions arising from differing views about the essential elements of good medical practice, tensions that are also shaping the hidden curriculum.

The healthcare needs of chronic obstructive pulmonary disease patients in the last year of life.

Chronic obstructive pulmonary disease (COPD) causes almost as many deaths as lung cancer, yet evidence about the impact of COPD in the latter stages of illness is limited. We assessed the healthcare needs of COPD patients in the last year of life through a retrospective survey of the informants of 399 deaths from COPD in four London health authorities between January and May 2001. We assessed symptoms, day to day functioning, contact with health and social services, formal and informal help with personal care, information received and place of death. We obtained data on 209 (52%) deceased subjects (55% male), average age at death was 76.8 years. Based on the reports of informants of the deaths: 98% were breathless all the time or sometimes in the last year of life; other symptoms reported all the time or sometimes included fatigue or weakness (96%), low mood (77%) and pain (70%); breathlessness was partly relieved in over 50% of those treated; control of other symptoms was poor, with low mood relieved in 8% and no treatment for low mood received by 82% of sufferers; 41% left the house less than once a month or never; 47% were admitted to hospital at least twice in the last year of life; 51% received regular check-ups for their chest; 36% had check-ups by a hospital consultant; 35% saw their general practitioner (GP) less than once every three months or never; 63% knew they might die; 67% died in hospital. Patients who died from COPD lacked surveillance and received inadequate services from primary and secondary care in the year before they died. The absence of palliative care services highlights the need for research into appropriate models of care to address uncontrolled symptoms, information provision and end of life planning

The contribution of narrative ethics to issues of capacity in psychiatry.

Cognitive and rational assessments of competence do not fully capture the way in which individuals normally make decisions. Human beings have always used stories to explain their experiences and values. Narrative ethics should be used to understand the perspective in context of a patient whose competence is in question, and so avoid a destructive clash. Psychiatry and professionals within it also have a narrative that may join with that of science, but there is no special privilege for these narratives unless survival is at stake. The narrative approach should be used to try to make different stories compatible. This article examines the background to this approach, and indicates some ways in which it could be used in the specific cases addressed in the series.

An obstructed death and medical ethics -- a case conference revisited: commentary 2.

The dilemma of whether or not a doctor should tell a patient dying of cancer the truth remains a difficult one, as the disagreement between the two previous writers shows. One favours giving priority to patient autonomy, the other feels the doctor's duty of beneficence should be the overriding principle governing such decisions. To this contributor it seems both approaches have something to offer. By being sensitive to what and how much the patient wishes to know and by learning from the insights provided by the study of medical ethics, doctors can learn how to make better moral decisions in this and in other areas. Both lying and truth-telling carry risks of harm to the patient. Learning to work with and balance these risks is part of clinical practice. So is minimising risks by clear thinking.