British medical bulletin
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Most deaths in Britain occur in old age, and old people dying have as many symptoms as do the young. Management is complicated by diagnostic difficulty, by the frequency of mental disorder (sometimes treatable) and of severe disability, and by the difficulty in ascertaining patients' feelings. Decisions about the management of dying are inevitable, and multifactorial, and views of others may be helpful. ⋯ Palliative care is important, not only in cancer. Euthanasia is seldom requested at present, and in The Netherlands is carried out less in old people than young. It would do little for the most serious problems of old age.
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One of the major dilemmas for the clinician caring for people with chronic disabling conditions is how to provide not only a good quality of life but also the best quality of dying. It is my view that the clinician should provide the opportunity for living before giving the opportunity to die. By this I mean that the clinician has the responsibility to ensure that efforts have been made to improve the quality of life by controlling clinical situations and providing psychological and emotional support. ⋯ In addition, a more satisfactory procedure than application to the High Court for a directive on withdrawal of tube feeding needs to be found. This method is very stressful for family and staff already in distress and is an extremely expensive approach. An independent ethical panel to ensure that the decision to end the patient's life is clinically appropriate, is being carried out purely for the best interests of the patient and is not influenced by the other considerations.
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The tobacco industry's strong-arm tactics have been used consistently over many years. These tactics include: using the industry's size, wealth, and legal resources to intimidate individuals and local governmental bodies; setting up 'front groups' to make it appear that it has more allies than it really does; spending large sums of money to frame the public debate about smoking regulations around 'rights and liberty' rather than health and portraying its tobacco company adversaries as extremists; 'investing' thousands of dollars in campaign contributions to politicians; and using financial resources to influence science. These tactics are designed to produce delay, giving the nicotine cartel more time to collect even more profits at the direct expense of millions of lives around the world.
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Smokeless tobacco practices are common in some parts of the world and the use seems to be increasing. Nicotine exposure is similar in smokeless tobacco users and smokers, often leading to strong physical dependence. As a rule, smokeless tobacco products contain high levels of nitrosamines with carcinogenic potency in experimental animals. ⋯ A recent study suggests that smokeless tobacco use is related to cardiovascular disease, which could be of great public health importance. The known and suspected health risks associated with the use of smokeless tobacco provide a basis for preventive action. In particular, efforts are needed to limit the introduction of such practices among young people, which may serve as a gateway to smoking.
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The politics of rationing are messy and treacherous. As long as rationing remained implicit, politicians were shielded from the impact of decisions about who to treat and who not to treat. Explicit rationing changes all this by making the process of reaching choices more visible. ⋯ There is, nevertheless, scope for improving the process and making it more open and accountable. While efforts to terminate ineffective treatments are welcome and overdue, they are not a substitute for rationing. Finally, while politicians are being called upon to set national priorities and guidelines for rationing care, there is resistance to doing so when the decisions are so context specific and can only be made effectively at a micro level.