A
real
impediment
to
the
successful
treatment
of
tuberculosis
is
the
development
of
severe
adverse
drug
reactions,
and
patients
with
concurrent
HIV
infection
seem
to
be
particularly
at
risk.
This
is
shown
in
our
study
by
the
occurrence
of
Stevens-Johnson
syndrome
exclusively
in
patients
positive
for
HIV.
It
has
been
widely
speculated
that
thiacetazone
is
the
drug
respon-
sible
for
most
of
these
serious
rashes,'4"
but
this
is
not
yet
proved.
Hypersensitivity
to
any
antituber-
culous
drug
may
cause
a
rash,
and
studies
in
which
treatment
did
not
include
thiacetazone
have
also
shown
a
greater
incidence
of
adverse
drug
reactions
among
patients
positive
for
HIV.9
16
If,
however,
it
is
true
that
one
drug
is
responsible
for
most
drug
reactions
then
it
should
be
clearly
identified
so
that
its
use
in
patients
positive
for
HIV
may
be
avoided.
Another
outstanding
practical
question
regarding
the
management
of
tuberculosis
in
the
presence
of
HIV
infection
is
whether,
as
seems
likely,
the
immune
deficiency
caused
by
the
virus
leads
to
a
greater
danger
of
relapse.
Current
evidence
is
preliminary
and
confficting.9
1017
No
difference
in
HIV
prevalence
was
observed
in
our
study
between
relapsed
and
new
cases.
A
more
appropriate
comparison,
however,
is
between
patients
who
have
had
tuberculosis
and
have
or
have
not
relapsed;
further
studies
of
this
kind
are
needed.
As
well,
prospective
studies
are
needed
to
discover
whether
tuberculosis
causes
an
increased
rate
of
pro-
gression
to
AIDS
and
whether
the
prophylactic
use
of
antituberculous
drugs
in
asymptomatic
patients
positive
for
tuberculin
and
HIV
can
increase
their
span
of
healthy
life.
Serum
samples
were
analysed
by
Mr
Joseph
Syambango
and
the
staff
of
the
University
Teaching
Hospital
immuno-
logy laboratory
and
the
sputum
samples
by
Mr
K
Namaambo
and
the
staff
of
the
Chest
Diseases
Laboratory,
Chelston,
Lusaka.
The
study
was
supported
by
the
Commission
of
the
European
Communities,
contract
TS2.004.UK(H).
Further
assistance
was
received
from
Barclays
Bank
of
Zambia
and
the
commercial
community
in
Lusaka;
equipment
was
provided
at
low
cost
by
the
Joint
Mission
Hospital
Equipment
Board.
1
Tuberculosis
and
acquired
immunodeficiency
syndrome-New
York
City.
MMWR
1987;36:785-95.
2
Slutkin
G,
Leowski
J,
Mann
J.
The
effect
of
the
AIDS
epidemic
on
the
tuberculosis
problem
and
tuberculosis
programmes
and
priorities
for
control
and
research.
Bull
Int
Union
Tuberc
Lung
Dis
1988;63:2
1-4.
3
Legg
W,
Mahari
M,
Houston
S,
Neill
P,
Ray
C,
Marowa
E.
Association
of
tuberculosis
and
HIV
infection
in
Zimbabwe
[Abstract].
In:
Fifth
inter-
natonal
conference
onAIDS,
Montreal,
1989.
Ottawa:
International
Develop-
ment
Research
Centre,
1989.
4
Colebunders
R,
Ryder
R,
Nzilambi
N,
et
al.
HIV
infection
in
patients
with
tuberculosis
in
Kinshasa,
Zaire.
Am
Rev
Respir
Dis
1989;139:1082-5.
5
Blaser
MJ,
Cohn
DL.
Opportunistic
infections
in
patients
with
AIDS:
clues
to
the
epidemiology
of
AIDS
and
the
relative
virulence
of
pathogens.
Rev
Infect
Dis
1986;8:21-30.
6
Roselgaard
E,
Iversen
E,
Blocher
C.
Tuberculosis
in
tropical
Africa.
An
epidemiological
study.
Bull
WHO
1964;30:459-518.
7
Breslow
NE,
Day
NE.
Statistical
methods
in
cancer
research.
Vol
2.
The
analysis
of
case-control
studies.
Lyons:
International
Agency
for
Research
on
Cancer,
1980.
8
Luo
NP,
Dallas
ABC,
Chipuka
L,
Nshimbi
R,
Tedder
R,
Siyambango
J.
HIV
seroprevalence
amongst
healthy
blood
donors
in
31
hospitals
in
Zambia
[Abstract].
In:
Fifth
international
conference
on
AIDS,
Montreal,
1989.
Ottawa:International
Development
Research
Centre,
1989:246.
9
Chaisson
RE,
Schecter
GF,
Theuer
CP,
Rutherford
GW,
Echenberg
DF,
Hopewell
PC.
Tuberculosis
in
patients
with
the
acquired
immunodeficiency
syndrome.
Am
Rev
Respir
Dis
1987;136:570-4.
10
Perriens
J,
Karahunga
C,
Willame
J,
Kaboto
M,
Pauwels
P,
Colebunders
R.
Mortality,
treatment
results
and
relapse
rates
of
pulmonary
tuberculosis
in
African
HIV
(+)
and
HIV
(-)
patients
[Abstract].
In:
Fifth
international
conference
on
AIDS,
Montreal,
1989.
Ottawa:
International
Development
Research
Centre,
1989:193.
11
Revision
of
the
CDC
surveillance
case
definition
for
acquired
immuno-
deficiency
syndrome.
MMWR
1987;36(suppl):3-16S.
12
Pitchenik
AE,
Rubinson
HA.
The
radiographic
appearance
of
tuberculosis
in
patients
with
the
acquired
immunodeficiency
syndrome
(AIDS)
and
pre-
AIDS.
Am
Rev
Respir
Dis
1985;131:393-6.
13
Acquired
Immunodeficiency
Syndrome
(AIDS).
WHO/CDC
case
definition
for
AIDS.
Weekly
Epidemiological
Record
1986;61:69-76.
14
Tuberculosis
and
AIDS.
Statement
on
AIDS
and
tuberculosis.
Geneva:
March
1989.
Bull
Int
Union
Tuberc
LungDis
1989;64:8-1
1.
15
Pinching
AJ.
Prophylactic
and
maintenance
therapy
for
opportunistic
infec-
tions
in
AIDS.
AIDS
1988;2:335-43.
16
Soriano
E,
Mallolas
J,
Gatell
JM,
et
al.
Characteristics
of
tuberculosis
in
HIV-
infected
patients:
a
case-control
study.
AIDS
1988;2:429-32.
17
Sunderam
G,
Mangurs
BT,
Lombardo
JM,
Reichman
LB.
Failure
of
'optimal'
short-course
chemotherapy
in
a
compliant
patient
with
human
immuno-
deficiency
virus.
Am
Rev
RespirDis
1987;136:1475-8.
(Accepted
133june
1990)
MRC
Epidemiology
and
Medical
Care
Unit,
Northwick
Park
Hospital,
Harrow
HAl
3UJ
Joy
Townsend,
MSC,
scientific
staff
Sandra
Dyer,
MSC,
scientific
staff
Olive
Karran,
administrative
staff
Anne
Walgrove,
SRN,
nursing
staff
Northwick
Park
Hospital,
Harrow
HAl
3UJ
A
0
Frank,
FRCP,
consultant,
rehabilitation
medicine
David
Fermont,
FRCR,
consultant
oncologist
Mary
Piper,
FRCP,
consultant,
geriatric
medicine
Correspondence
to:
Mrs
Townsend.
BrMedJ
1990;301:415-7
Terminal
cancer
care
and
patients'
preference
for
place
of
death:
a
prospective
study
Joy
Townsend,
A
0
Frank,
David
Fermont,
Sandra
Dyer,
Olive
Karran,
Anne
Walgrove,
Mary
Piper
Abstract
Objective-To
assess the
preference
of
terminally
ill
patients
with
cancer
for
their
place
of
final
care.
Design-Prospective
study
of
randomly
selected
patients
with
cancer
from
hospital
and
the
community
who
were
expected
to
die
within
a
year.
Patients
expected
to
live
less
than
two
months
were
inter-
viewed
at
two
week
intervals;
otherwise
patients
were
interviewed
monthly.
Their
main
carer
was
interviewed
three
months
after
the
patient's
death.
Setting-District
general
hospital,
hospices,
and
patients'
homes.
Main
outcome
measure-Stated
preferred
place
of
final
care;
actual
place
of
death;
reason
for
final
hospital
admission
for
those
in
hospital;
community
care
provision
required
for
home
care.
Results-Of
98
patients
approached,
84
(86%)
agreed
to
be
interviewed,
of
whom
70
(83%)
died
during
the
study
and
59
(84%)
stated
a
preferred
place
of
final
care:
34
(58%)
wished
to
die
at
home
given
existing
circumstances,
12
(20%)
in
hospital,
12
(20%)
in
a
hospice,
and
one
(2%)
elsewhere.
Their
own
home
was
the
preferred
place
of
care
for
17
(94%)
of
the
patients
who
died
there,
whereas
of
the
32
patients
who
died
in
hospital
22
(69%)
had
stated
a
preference
to
die
elsewhere.
Had
circumstances
been
more
favourable
67%
(41)
of
patients
would
have
preferred
to
die
at
home,
16%
(10)
in
hospital,
and
15%
(9)
in
hospice.
Conclusion-
With
a
limited
increase
in
community
care
50%
more
patients
with
cancer
could
be
supported
to
die
at
home,
as
they
and
their
carers
would
prefer.
Introduction
Place
of
death
and
quality
of
final
care
are
important
components
of
terminal
cancer
care
for
both
the
patient
and
the
family.
The
proportion
of
patients
with
cancer
dying
at
home
has
fallen
steadily
in
the
United
Kingdom,
from
37%
in
1965
to
27%
in
1987.'
In
Edinburgh
and
Western
Australia,
however,
the
provision
of
cancer
care
services
has
enabled
as
many
as
41%
and
70%
respectively
of
patients
with
cancer
to
die
at
home.2
3
There
are
no
studies
in
the
United
Kingdom
reporting
patient
preferences
about
place
of
terminal
care.
This
study
was
therefore
undertaken
to
determine
prospectively
the
needs
and
wishes
of
patients
who
were
dying
from
cancer,
their
symptoms
and
symptom
BMJ
VOLUME
301
1
SEPTEMBER
1990
415
relief,4
where
they
wished
to
die,
and
the
resources
required
for
their
home
and
hospital
care.
Patients
and
methods
Patients
were
referred
to
the
study
from
Northwick
Park
Hospital
and
local
community
nursing
services
between
August
1986
and
September
1987.
The
path-
ology,
haematology,
and
cytology
departments
of
the
hospital
routinely
informed
us
of
patients
diagnosed
as
having
cancer,
and
those
whom
the
consultant
thought
likely
to
live
for
less
than
one
year
were
identified
as
eligible
for
the
study.
A
random
sample
(50%
reducing
to
25%
towards
the
end
of
the
study,
when
interviewer
time
was
limited)
were
approached
for
interview.
Patients
who
were
considered
by
the
medical
team
in
charge
of
their
care
to
have
less
than
two
months
to
live
were
interviewed
at
fortnightly
intervals;
otherwise
interviews
were
monthly.
The
interviewer,
who
was
experienced
in
interviewing
the
dying
and
bereaved,
travelled
to
the
patient
on
all
occasions.
A
specially
devised
structured
questionnaire
was
used.
The
patient's
view
of
his
or
her
illness
was
sought
by
asking
specific
questions
such
as,
"Tell
me
some-
thing
about
the
progress
of
your
illness."
Further
questions
concerned
use
of
health
and
social
services,
medication,
care
in
the
home,
availability
of
care,
activities
of
daily
living,
and
mobility.4
Quality
of
life
and
level
of
pain
and
other
symptoms
were
assessed.56
Patients
were
then
asked,
"Do
you
have
any
plans
for
your
future
care?"
and
"What
would
you
like
for
your
future
care
were
it
possible?"
and
also
if
they
were
content
in
their
present
place
of
care.
If
a
clear
answer
was
not
forthcoming
a
range
of
possible
alternatives
was
given,
including
"Would
you
like
to
go
to
hospital;
go
home;
go
to
a
friend,
or
stay
as
at
present?"
If
these
questions
did
not
elicit
the
preferred
place
of
death,
and
the
patient
had
already
acknowledged
the
diagnosis
and
prognosis,
further
questions
were
put
such
as,
"And
if
your
illness
gets
worse,
where
would
you
like
to
be?"
The
aim
was
to
determine
preferences
for
place
of
final
care,
firstly,
given
the
existing
situation
and,
secondly,
if
circumstances
were
instituted
to
allow
the
choice.
We
acknowledged
the
sensitivity
of
this
area
of
questioning
and
it
was
with
this
in
mind
that
the
questions
were
put
and
the
interviews
conducted.
The
answer
was
used
in
analysis
of
data
only
if
an
unambiguous
response
was
made.
Carers
of
the
patients
who
died
in
the
first
half
of
the
study
were
interviewed
for
their
assessment
of
the
patient's
care.
These
interviews
took
place
three
months
after
the
death
of
their
relative.
Inpatient
stay
in
Northwick
Park
Hospital
was
monitored
for
all
patients
in
the
study,
whether
interviewed
or
not.
Those
interviewed
were
asked
about
the
community
support
received
at
the
time
of
admission,
and
the
resources
needed
for
the
patient
to
be
discharged
home
were
assessed.
Patients
were
monitored
until
the
end
of
the
study
on
1
February
1988.
Results
Of
the
230
patients
referred
to
the
study,
98
were
randomly
selected
to
be
approached
for
interview
and
84
agreed
to
be
seen.
Forty-
four
were
men
and
40
women.
Eight
patients
or
their
families
declined,
and
six
patients
were
not
interviewed
for
other
reasons.
The
median
number
of
interviews
was
three
(range
1-15).
Six
patients
declined
further
interview
in
the
later
stages
of
their
illness.
Seventy
of
the
interviewed
patients
(83%)
died
during
the
period
of
the
study,
39
of
whom
(56%)
were
interviewed
within
the
last
14
days
of
their
life.
The
distribution
of
cancer
sites
in
patients
in
the
study
was
not
significantly
different
from
the
national
distribution.7
Sixty
seven
(80%)
of
the
patients
interviewed
lived
with
one
or
more
people,
16
(19%)
lived
alone,
and
one
(1%)
lived
in
an
old
people's
home.
Among
the
51
patients
with
a
principal
carer,
the
carer
of
39
was
a
spouse
(76%),
of
seven
a
son
or
daughter
(14%),
of
three
another
relative
(6%),
and
of
two
a
friend
(4%).
At
least
16
(31%)
of
the
principal
carers
were
in
bad
health.
Fifteen
(29%)
were
aged
over
70
and
33
(65%)
were
over
60.
The
distribution
of
place
of
death
in
the
study
was
similar
to
the
national
figures
for
all
patients
dying
from
cancer
in
Britain
(table
I).7
Of
the
70
patients
who
died
during
the
study,
59
(84%)
said
on
at
least
one
occasion
where
they
would
prefer
to
die
given
existing
circumstances.
A
further
two
patients
said
only
where
they
would
prefer
to
die
given
ideal
circumstances.
Six
did
not
acknowledge
their
diagnosis
or
prognosis,
and
the
remaining
three
knew
their
diagnosis
but
not
their
immediate
prognosis.
The
initial
choice
of
those
stating
a
realistic
pre-
ference
for
place
of
death
was
58%
(34)
at
home,
20%
(12)
in
hospital,
20%
(12)
in
a
hospice,
and
one
(2%)
elsewhere
(table
II).
The
choice
stated
finally
was
49%
(29)
at
home,
24%
(14)
in
hospital,
and
25%
(15)
in
a
hospice.
The
change
in
preference
was
not
of
a
significant
order
but
tended
to
be
towards
hospital
or
hospice-probably
reflecting,
given
the
resources
available
at
the
time,
a
realistic
response
to
pressure
on
carers
as
the
illness
progressed.
The
preferences
given
ideal
circumstances
moved
the
other
way,
from
67%
(41)
to
70%
(43)
preferring
home,
16%
(10)
to
10%
(6)
hospital,
and
15%
(9)
to
18%
(11)
hospice.
Of
the
32
who
died
in
hospital,
20
(63%)
had
stated
a
final
preference
to
die
elsewhere,
whereas
for
the
18
who
died
at
home
this
was
the
chosen
place
for
17
(94%).
Hospice
was
the
preferred
place
for
seven
(78%)
of
the
nine
who
died
there.
Answers
to
the
questions
on
future
plans
were
often
quite
explicit,
such
as
"I
hope
to
go
home
and
will
make
arrangements
to
go
to
a
hospice
for
the
end";
"I
want
to
stay
at
home
till
the
end";
"I
have
to
stay
here
in
hospital
while
on
the
antibiotics,
then
the
doctor
says
I
can
go
home-I'd
rather
stay
here
in
hospital,
but
I'm
afraid
they'll
need
the
bed."
Of
the
30
carers
who
were
interviewed
three
months
after
the
death
of
their
relative
and
stated
an
opinion
on
where
he
or
she
had
died,
21
(70%)
were
satisfied.
Five
carers
(28%)
of
the
18
patients
who
died
in
hospital
would
have
preferred
to
have
cared
for
them
at
home.
Of
the
11
carers
whose
relatives
died
at
home,
seven
were
satisfied;
three
accepted
the
patient's
wish
to
die
at
home,
although
they
thought
they
would
have
been
TABLE
I-Deaths
from
cancer
in
study
and
in
England
and
Wales
by
place
of
death.
Values
are
percentages
(numbers)
England
and
Wales'
Place
of
death
Study*
(1986-8)
(1987)
Home
29
(20)
27
NHS
hospital
57
(40)
56
Elsewhere
14
(10)t
-17
Hospicet
14
(10)
t
Total
100
(70)
*Place
of
death
as
given
on
death
certificates.
tDeaths
in
hospices
:Proportion
of
deaths
in
hospices
not
known.
TABLE
II-Actual
place
of
death
of
patients
with
cancer
and
preferred
place
of
death,
given
existing
circumstances,
as
stated
in
interview
Initial
(final)
preferred
place
Actual
place
Home
Hospital
Hospice
Other
Home
(n=
18)
17
1
Hospital
(n=32)
15
(11)
10
(12)
6
(5)
1
Hospice
(n=9)
2
(1)
1
6
(7)
Total
(n=59)
34
(29)
12
(14)
12
(15)
1
BMJ
VOLUME
301
1
SEPTEMBER
1990
416
TABLE
iii-Requirements
to
permitpatient
to
die
at
home,
assessed
during
last
stay
in
hospital
(median
time
to
death
13
days).
Values
are
numbers
(percentages)
Requiring
and
No
of
patients
not
yet
receiving
Already
receiving
Requiring
more
Service
not
Service
assessed
service
service
of
service
needed
Macmillan
nurse
53
37
(70)
6
(11)
5
(9)
5
(9)
Special
mattress
51
33
(65)
2
(4)
1
(2)
15
(29)
Other
aids
49
30
(61)
2
(4)
4
(8)
13
(27)
District
nurse
53
32
(60)
1
(2)
15
(28)
5
(9)
24
Hour
care
53
19
(36)
1
(2)
33
(62)
Home
care
worker
52
28
(54)
2
(4)
6
(11)
16
(31)
Nightcheck
52
16
(31)
1(2)
35(67)
Day
centre
53
14
(26)
1
(2)
38
(72)
Respite
care
53
2
(4)
51(96)
better
in
hospital;
and
one
would
have
preferred
hospital
but
there
had
been
no
time
to
arrange
for
admission.
Comments
on
hospital
care
were
made
by
23
patients.
Many
were
favourable,
but
others
reflected
the
problems
of
caring
for
dying
patients
on
acute
wards
and
confirmed
other
reports.8
1012-14
Difficulties
in
communication
between
hospital
staff
and
patient
or
family
and
between
hospital
and
community
services
were
stated.
Patients
or
relatives
said
that
on
occasions
promises
were
made
about
the
availability
of
commun-
ity
support
but
they
did
not
materialise.
The
position
of
the
bed
in
the
ward
not
infrequently
created
difficulties.
Patients
were
often
at
the
less
supervised
end
of
the
ward
and
were
sometimes
overlooked
for
periods
of
an
hour
or
more.
Some
were
disturbed
by
noisy
p4tients,
and
others
were
very
lonely
in
a
side
ward.
There
was
a
recurrent
theTme
of
inadequate
facilities
for
families
visiting
dying
relatives,
including
lack
of
privacy,
accessibility
of
food,
and
overnight
facilities.
Several
families
related
problems
about
not
being
advised
of
the
likely
imminence
of
death
within
the
next
day
or
so.
Although
this
may
reflect
the
difficulty
of
making
this
judgment,
it
seems
clear
that
some
hospital
staff
may
not
have
been
aware
of
the
importance
of
this
issue
to
relatives.
As
well
as
their
anxieties
about
the
illness,
many
patients
and
their
families
had
financial
problems,
including
problems
with
paying
for
necessary
prescriptions,
special
food,
and
heating.
Of
the
79
patients
who
died
before
the
end
of
the
study
(including
nine
not
interviewed),
42
(53%)
died
in
Northwick
Park
Hospital;
reasons
for
admission
were
known
for
30
(71%).
Ten
(33%)
were
admitted
for
terminal
care,
nine
(30%)
for
management
of
symp-
toms,
nine
for
investigation,
and
two
for
specific
treatment
(radiothera-py
and
chemotherapy).
Only
a
few
needed
the
resources
of
an
acute
care
ward.
An
assessment
was
made
during
their
last
stay
in
hospital
of
the
requirements
of
patients
to
enable
them
to
be
cared
for
at
home
(53
patients;
table
III).
This
showed
that
less
than
40%
(19)
needed
24
hour
care
but
indicated
the
need
for
more
short
term
care
from
the
district
nursing
and
home
care
services,
as
well
as
support
from
a
continuing
care
(Macmillan)
nurse.
Discussion
A
very
high
proportion
of
patients,
over
90%,
were
aware
of
their
diagnosis,
and
at
least
95%
of
these
knew
their
long
term
if
not
their
immediate
prognosis.
Thus,
many
more
patients
than
we
had
expected
were
informed
and
prepared
to
state
their
preference
for
place
of
final
care.
Most
patients
were
admitted
for
investigation
or
treatment
but
often
stayed
for
respite
and
symptom
control.
Few
admissions
were
for
pain
control.
In
some
patients
the
disease
progressed
too
rapidly
to
allow
community
support
to
be
mobilised
easily.
Of
those
who
died
in
hospital,
63%
had
stated
a
last
preference
to
die
elsewhere
and
82%
would
ideally
have
preferred
to
die
elsewhere.
It
would
not
be
practicable
for
all
those
dying
in
hospital
to
return
home,
and
neither
would
this
be
their
wish
or
that
of
their
carers.8
Half
of
the
patients,
however,
would
have
preferred
to
be
at
home,
and
28%
of
carers
of
those
dying
in
hospital
also
wished
for
them
to
be
at
home.
It
was
assessed
that
nearly
two
thirds
of
the
patients
in
hospital
for
the
last
admission
did
not
need
24
hour
care
but
could
have
been
looked
after
adequately
with
the
support
of
visits
from
the
continuing
care
and
district
nursing
services,
short
term
use
of
equipment
such
as
a
pressure
relieving
mattress
when
needed,
and
some
home
care
support.
It
is
estimated
that
over
a
quarter
of
those
dying
in
hospital
had
a
carer
willing
to
care
for
them
at
home
and
wished
for
this
option,
which
would
have
been
possible
with
fairly
limited
flexible
short
term
support
from
health
and
social
services.
This
suggests
that,
including
the
29%
of
patients
who
died
at
home
and
for
whom
this
was
their
and
their
carers'
place
of
choice,
44%
of
patients
could
have
been
supported
to
die
at
home.
The
abolition
of
a
qualifying
period
for
attendance
allowance,
effective
from
November,
has
been
pro-
posed
for
those
who
are
terminally
ill.
It
is
hoped
that
this
will
alleviate
some
of
the
financial
anxieties
of
many
such
patients
and
their
carers.
Some
expansion
of
health
and
social
service
com-
munity
support
for
the
terminally
ill
is
needed
to
facilitate
policies
for
those
who
wish
to
die
at
home.9
10
In
recognition
of
this,
Harrow
Health
Authority
has
now
considerably
increased
community
nursing
for
the
dying
to
include
a
small
team
of
four
Macmillan
nurses,
a
nurse
"sitting"
service,
and
provision
of
equipment.
There
are
at
present
not
as
many
hospice
beds
as
patients
would
like,
and
there
is
a
need
for
complementary
hospital
care,"
1
such
as
a
small
unit
of
12
to
15
beds
to
support
the
community
team,
run
on
a
hospice
basis'0'6
to
provide
necessary
inpatient
palliative
and
terminal
care,
including
provision
for
relatives.
This
would
alleviate
some
of
the
inevitable
problems
of
caring
for
dying
patients
on
a
busy
acute
ward.
8
1012
14
The
cost
would
be
considerably
less
than
that
of
the
acute
beds
used
at
present.
Many
colleagues
from
Harrow
district
and
neighbouring
districts
helped
in
the
study,
which was
funded
by
Harrow
Health
Authority
and
the
Rehabilitation
Research
Fund.
We
thank
Jacqueline
Cooper
for
help
with
computing.
1
Ford
GR,
Pincherle
G.
Arrangements
for
terminal
care
in
the
NHS
(especially
those
for
cancer
patients).
Health
Trends
1978;10:73-6.
2
Doyle
D.
Domiciliary
terminal
care:
demands
on
statutory
services.
J
R
Coll
Gen
Pract
1982;32:285-91.
3
Allbrook
D.
Dying
of
cancer-home,
hospice
or
hospital.
Med
7
Aust
1984;141:
143-4.
4
Townsend
J,
Dyer
S,
Karran
0,
et
al.
Continuing
and
terminal
care
in
Harroz:
a
report
on
resource
requirements
by
a
working
party
to
the
Harrow
Health
A
uthority.
Harrow:
MRC
Epidemiology
and
Medical
Care
Unit,
1988.
5
Spitzer
WO,
Dobson
AJ,
Hall
J,
et
al.
Measuring
the
quality
of
life
of
cancer
patients:
a
concise
QL
index
for
use
by
physicians.
J
Chronic
Dis
1981
;34:585-97.
6
Morris
JN,
Suissa
S,
Sherwood
S,
Wright
SM,
Greer
D.
Last
days:
a
study
of
the
quality
of
life
of
terminally
ill
cancer
patients.
I
Chronic
Dis
1986;39:47-62.
7
Office
of
Population
Censuses
and
Surveys.
Mortality
statistics
for
1987.
England and
Wales.
London:
HMSO,
1989.
8
Hockley
JM,
Dunlop
R,
Davies
RJ.
Survey
of
distressing
symptoms
in
dying
patients
and
their
families
in
hospital
and
the
response
to
a
symptom
control
team.
BrMedJ
1988;296:1715-7.
9
National
Association
of
Health
Authorities.
Care of
the
dying-a
guide
for
health
authorities.
Birmingham:
NAHA,
1987.
10
Subcommittee
on
Cancer.
Terminal
care:
report
of
a
working
group.
London:
HMSO,
1981.
(E
Wilkes, chairman.)
11
Cartwright
A,
Hockley
L,
Anderson
JL.
Life
after
death.
London:
Routledge
and
Kegan
Paul,
1973.
12
Bates
T,
Clarke
D,
Hoy
AM,
Laird
PP.
The
St
Thomas's
Hospital
terminal
care
support
team.
A
new
concept
in
hospice
care.
Lancet
1981
;i:
1201-3.
13
Hoskin
PJ,
Hanks
GW.
The
management
of
symptoms
in
advanced
cancer:
experience
in
a
hospital-based
continuing
care
unit.
R
Soc
Med
1988;81:341-4.
14
Parkes
CM.
The
dying
patient.
Terminal
care:
home,
hospital
or
hospice?
Lancet
1985;i:155-7.
15
Saunders
C,
Summer
DH,
Teller
N.
Hospice:
the
living
idea.
London:
Edward
Arnold,
1981.
16
Rees
WD.
Role
of
the
hospice
in
the
care
of
the
dying.
Br
Med
J
1982;285:
1766-8.
(Accepted
26
june
1990)
BMJ
VOLUME
301
1
SEPTEMBER
1990
417
