When and how to initiate discussion about prognosis and end-of-life issues with terminally ill patients

The aim of this study was to explore by whom, how, and when discussions about prognosis and end-of-life issues should be initiated with terminally ill patients, and the context in which these issues can be optimally discussed. Focus groups and individual interviews were conducted with 19 palliative care (PC) patients, 24 carers, and 22 PC health professionals (HPs). Participants had disparate views regarding by whom and when such discussions should be initiated, although a similar range of perspectives was expressed by all participant groups. Four main approaches were identified: wait for the patient/carer to raise the topic; HPs to offer all PC patients and their carers the opportunity to discuss the future (preferred by the majority of participants); HPs to initiate the discussion when the patient/family need to know; or HPs to initiate the discussion when the patient/family seem ready. Four themes emerged regarding the optimal context of the discussion: importance of the relationship with HP, clarifying the patient/carers' understanding and how much detail they want to know, negotiating who should be present during the discussion, and who should deliver the information. Initiating prognostic discussions with terminally ill patients requires considerable skill and sensitivity. Communication skills training for HPs may be required to optimize such discussions.     

Bancroftian filariasis and the reticulo-endothelial system

In Bancroftian filariasis the rise and the fall of the microfilarial tide are caused by different mechanisms. There is now anatomical evidence, furnished by O'Connor, that the rise is caused by timed parturition of female worms, and here the significance of spent worms has been imperfectly grasped either as a normal daily event or as a result of their sterilization by drugs. The fall of the tide is caused by the mobile cells of the reticulo-endothelial system, for which statement the line of argument runs thus. When helminths enter the tissues of a host animal, it is these very cells which collect and attack them actively. For Bancroftian filariasis their presence was reported years ago, but their fundamental importance has been missed. They destroy microfilariae in lymph nodes before they get into the blood, and by their accumulation and their development to the end cell of the series, the fibroblast, they cause lymphatic obstruction; the lymph conditions then become those of a culture medium which may be four million times better suited to the haemolytic streptococcus than is normal lymph, and when infection with this bacterium has set in they become still more favourable for growth of fibroblasts and increase of elephantiasis.