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1/3. Withdrawal of life support: intensive caring at the end of life.

    The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.
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2/3. A smoking related triad: PAD, COPD and CCF.

    BACKGROUND: tobacco smoking is the modifiable risk factor responsible for the greatest burden of disease (loss of health and premature mortality) in australia. OBJECTIVE: This article discusses the complexities of management of a patient suffering from a smoking related triad of illnesses: peripheral arterial disease, chronic obstructive pulmonary disease and ischaemic heart disease related congestive cardiac failure. DISCUSSION: As well as considering optimal management of the individual conditions, the patient's mental health and overall quality of life needs to be considered. Even at this late stage, smoking cessation is critically important. The patient is likely to require 6-8 medications, creating the potential for interactions and confusion, so careful medication management and patient education is required. The support of a multidisciplinary team will be required, with coordination of care being the key. Care planning and case conferencing between the general practitioner, the patient and other health professionals is essential for optimal care.
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3/3. Putting policy into practice: the example of COPD.

    Chronic lung disease is one of the commonest reasons for consulting a health professional, and there may be as many as 3 million people in the UK with undiagnosed chronic obstructive pulmonary disease (COPD). This fourth article in a series on long-term conditions examines the policy developments that have been put in place to manage the burden of chronic disease in england and wales, and argues that more remains to be done if COPD is to be properly addressed.
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