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BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an increasing cause of mortality. However, people with COPD are unlikely to receive care that meets the needs of themselves or their carers at the end of life. AIMS: To explore the needs of people with end-stage COPD in South Australia and develop recommendations for a model of care. METHODS: Three related studies were undertaken: in Study 1, 15 people with advanced COPD and their carers were interviewed twice, 6 months apart; Study 2 investigated views of an Expert Panel and Study 3 conducted focus groups and interviews with service providers and community groups to examine service availability and accessibility. RESULTS: This project demonstrated that the needs of people with COPD are not being met. There was an absence of a coordinated pathway for support. Care was fragmented, episodic and reactive. The role of carers was poorly recognised. Health professionals identified the lack of a clear transition to an end-stage and significant barriers to obtaining support for activities of daily living. Communication issues were identified in all studies, including the absence of advance care planning conversations. CONCLUSIONS: A flexible model of care is needed that assists people with COPD to navigate the health system. This should be patient centred and coordinated across primary, acute and community sectors. Neither respiratory nor palliative care services alone can adequately support people with COPD. The integration of a multidisciplinary palliative approach within a chronic disease management strategy will be central for the best care for people living with advanced COPD.

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This retrospective clinical study reports on the experience of palliative venting gastrostomy (PVG) in an integrated acute teaching hospital and hospice-based palliative care service over a seven-year period (1989-97). PVG was performed for 51 patients with refractory nausea and vomiting resulting from varying degrees and levels of persisting or intermittent malignant bowel obstruction. There were 32 females and 19 males; the mean age was 61 years (range 25-86 years). All patients had advanced and incurable cancer with intra-abdominal spread, originating from the following primary sites: colon and rectum (27), ovary (16), breast (2), pancreas (2), and other (4). The venting gastrostomy tube was inserted endoscopically by a railroading technique in 46 patients (using a 16- to 20-French Dobhoff PEG tube), at open laparotomy in four cases and under radiological (abdominal computerized tomography) control in one case. Endoscopic insertion was attempted and abandoned for technical reasons in a further two cases. The median survival of all 51 patients from the time of gastrostomy insertion was 17 days (range 1-190). In 47/51 (92%), the symptoms of nausea and vomiting were relieved by the procedure, and these patients experienced restoration of some level of oral soft food and fluid intake. Twenty patients were discharged home, and six died at home. In a small group of highly selected patients, for whom pharmacological measures failed to palliate the effects of malignant bowel obstruction, PVG was shown to be a safe and effective means of abolishing or substantially improving vomiting. Provided that the intervention is appropriate to the given clinical situation and acceptable to the patient, it should be considered.

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This study compares subcutaneous (s.c.) morphine and fentanyl with respect to pain control and side effects using a 6-day randomized, double-blind, cross-over design. Results were obtained from 23 patients (12 males and 11 females: mean age of 70.5 years) who could tolerate morphine. Thirteen patients were randomized to receive morphine for the first 3 days followed by fentanyl; 10 received fentanyl first followed by morphine. There were no significant differences in the scores for pain between the two drugs, suggesting that fentanyl is equally efficacious and the conversion ratio of morphine 10 mg: fentanyl 150 micrograms is appropriate. Patients had more frequent bowel movements during days 4-6 while on the fentanyl arm [t-test, df (22), P = 0.015]. Other measures for nausea, delirium, and cognitive function showed no differences between the two drugs. This study highlights the need to further assess the role of various opioids in hospice patients, and emphasizes the requirement for sensitive and simple cognitive tests in this population.

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A series of 48 children with scaphocephaly has been reviewed. 44 had synostosis of the sagittal suture alone, and four had additional involvement of other sutures. Although six children showed significant developmental delay, with eventual mental retardation in five cases, it does not appear that this is caused by mechanical constriction of the brain. In the majority of cases, scaphocephaly appears to be a benign variant in cranial development. Operation by linear craniectomy was performed for cosmetic reasons in 14 cases, and in general the results were good. Operation was not performed in the other 34 cases, including 15 seen in infancy, and review of these has shown a high incidence of anxiety among parents and children. Therefore there is an acceptable case for cosmetic correction of severe scaphocephaly in infancy.

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A burn refers to the damage caused to the skin, and sometimes deeper structures, by heat (flame, scald, contact, electricity), chemical agents or radiation. Methods of first-aid treatment of burns are varied, imprecise and sometimes harmful. This article deals with the major principles involved in first-aid, which when implemented will limit the damage created by the burn. The medical profession must be aware of what can be achieved and the necessary steps in the initial treatment of the burn. The profession is called upon to offer first-aid, to give advice and to lecture on accidents in our community, so it is necessary to have a clear plan of treatment.

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