The relationship between general practitioners, hospital consultants and community nurses when caring for people in the last year of their lives

The general practitioners, hospital consultants and community nurses who had cared for a random sample of people who died were asked about their relationships with the other professional groups and for their views and experiences of specialist domiciliary terminal care services. Many of the general practitioners and the nurses were critical of hospital communication over discharge. The most frequent criticism made by community nurses of general practitioners was that they did not ask for nursing help early enough for people who were dying. This may be because many general practitioners regarded the community nursing services as overstretched. General practitioners were rather less enthusiastic than the other two professional groups about specialist medical or nursing domiciliary terminal care services. They were, however, more convinced of the helpfulness of these services if they had some experience of them.

Balance of care for the dying between hospitals and the community: perceptions of general practitioners, hospital consultants, community nurses and relatives

A survey was made of the general practitioners, hospital consultants and community nurses who had cared for a random sample of people dying in 1987. Their views and experiences of the balance of care between hospital and the community are reported. All three groups wanted more people to be looked after in their homes rather than in hospital if adequate care could be arranged at home. But they perceived inadequacies in home help and district nursing services and many wanted other community services expanded or introduced. The main shortcomings of the hospital service were seen as inadequate numbers of hospice beds, difficulty obtaining admission for people needing long term care, discharge too early and some over-treatment of people who were dying. There was some evidence from relatives that pain control was better in hospital than at home, and the district nurses also reported that pain was not controlled satisfactorily for patients dying at home as often as it could be. It is concluded that inadequacies in community services may discourage some people from taking on the care of their relatives at home.

The role of hospitals in caring for people in the last year of their lives

This study explored the role of hospitals in caring for people in the last year of their lives by examining hospital use and the characteristics of people admitted to hospital and changes between 1969 and 1987. Results were based on an 80% random sample of 800 adult deaths in ten areas of England in 1987. People dying when they were 85 or more were the least likely to be admitted to hospital in the last year of their lives. Results raise questions about the traditional emphasis of hospital care, the training of medical students, the adequacy of care for the very elderly in the last year of their lives and the balance of care between the hospital and the community.

Identification and characterization of the hamster polyomavirus middle T antigen

Hamster polyomavirus (HaPV) is associated with lymphoid and hair follicle tumors in Syrian hamsters. The early region of HaPV has the potential to encode three polypeptides (which are related to the mouse polyomavirus early proteins) and can transform fibroblasts in vitro. We identified the HaPV middle T antigen (HamT) as a 45-kDa protein. Like its murine counterpart, HamT was associated with serine/threonine phosphatase, phosphatidylinositol-3 kinase, and protein tyrosine kinase activities. However, whereas mouse middle T antigen associates predominantly with pp60c-src and pp62c-yes, HamT was associated with a different tyrosine kinase, p59fyn. The ability of HaPV to cause lymphoid tumors may therefore reside in its ability to associate with p59fyn, a potentially important tyrosine kinase in lymphocytes.

Changes in life and care in the year before death 1969-1987

Studies based on random samples of adult deaths in 1969 and 1987 show that, although more people in the recent study were living alone in the year before they die (32 per cent compared with 15 per cent in the earlier study), there had also been an increase in the proportions living in institutions and being admitted to hospital in the 12 months before their death. More of those dying in 1987 than in 1969 had had a home help, whereas the proportion receiving care from district nurses was similar for the two studies and the amount of home visiting by general practitioners had fallen. A higher proportion of those dying of cancer in 1987 than in 1969 were thought to have known that they were dying (44 per cent against 16 per cent) and that they had cancer (73 per cent compared with 29 per cent). However, the proportion of relatives and others who thought the dying person's awareness, or lack of awareness, of the prognosis was 'best as it was' was lower for people dying of cancer in the more recent study (57 per cent against 69 per cent). The symptoms reported for those dying in 1969 and 1987 were generally similar but more of those who died in 1987 had suffered from mental confusion, depression and incontinence for a year or more. This reflects the increased age at which people were dying in the later study: longer life was sometimes associated with the prolongation of unpleasant symptoms.

Is religion a help around the time of death?

Based on reports from relatives and other associates about a random sample of adults who had recently died, the data suggest that three-fifths of the people who died were perceived as having some sort of religious faith that had been helpful to them in the time before they died. Acceptance of death was seen as more common among those thought to have had a strong religious faith, but was not related to believing or not believing in some sort of life after death. It was less frequent among those thought to be uncertain about this. The majority of relatives who said they had a religious faith felt it had been helpful to them over their bereavement, but religious faith was not related to whether or not they felt they had come to terms with the person's death. Those with a religious faith were more likely than others to describe their relationship with the person who died as having been 'very good'. The data can be interpreted in various ways and it is not possible to say with certainty that a religious faith is helpful around the time of death.

Collecting data about drug use by elderly people

A random sample of 805 people aged 65 or more were interviewed in their homes in England about the drugs they were taking, and about their experiences with and views about the way drugs were prescribed. Assessments by a pharmacologist and pharmacists identified inappropriate prescribing and labelling and revealed the extent of elderly people's knowledge of their drugs. Information obtained from general practitioners, with the consent of the elderly people, showed that over a third of the elderly people were taking prescribed drugs of which their physician was unaware, but over four-fifths of the drugs reported by both patients and physicians were thought by both groups to be taken appropriately or as prescribed. The processes and problems of drug utilization and drug prescribing are demonstrated by approaching both patients and physicians and further illuminated by the expertise of pharmacologist and pharmacist.

Medicine taking by people aged 65 or more

Older people consult their doctors less than younger people in relation to both their reported morbidity and their prescribed medication. Some of the large iceberg of symptoms among the elderly might respond to a modification of their current drug regimens. Assessments of medicine taking patterns among the elderly revealed various inadequacies in supervision and a substantial proportion of questionable prescribing. General practitioners were often unaware that elderly patients lived alone, or that they drank alcohol or drove--even when they were taking prescribed medicines for which drinking or driving were contraindicated. Just over a third of elderly people were taking prescribed medicines of which their general practitioners were apparently unaware. The way doctors prescribe for their elderly patients and supervise this prescribing is suggested as a suitable field for audit. The completeness of their records in relation to prescriptions, drinking, driving, and living alone is another possible area for study. So too is the home visiting of the very elderly, particularly those living alone.

Who else responds to postal questionnaires? Are those involved in the subject of the study more likely to do so?

In a postal screen to identify people who had attended hospital outpatient departments, it was predicted that attenders would be more likely to respond than non-attenders. An experiment was set up to explore this. The response rates were 76 per cent among attenders compared with 70 per cent for the others--a difference which did not reach significance at the 5 per cent level.

Identification of people attending outpatients: congruity between hospital records and response to a postal screen

A comparison of information obtained from a postal screen of people on the electoral register about attendance at outpatient clinics with data extracted from hospital records found agreement between the two sources for 87 per cent of people. This rose to 90 per cent after an interview follow-up of those whose replies were unclear. Given the complexities of defining outpatient attendances clearly, these levels of agreement seemed good. Fewer consultations were omitted by people when a three rather than a 12-month study period was used, but the particular three-month period used (January-March) may have contributed to this difference.

Unintended pregnancies that lead to babies

Among a random sample of women giving birth to a live baby in 1984 in England, just over a quarter described the pregnancy as unintended. This, together with the ratio of legal terminations to live or still births, suggests that about two-fifths of conceptions are unintended. Data from the study suggest that babies resulting from unintended pregnancies are somewhat disadvantaged physically as well as socially, while maternity services may contribute to the disadvantages.

Monitoring maternity services by postal questionnaires to mothers

There are a number of gaps in existing statistics about maternity services and no systematic collection of data about women's views and experiences of maternity care. Much useful information could be obtained by regular surveys of random samples of mothers obtained from birth registration. Results from a series of studies carried out by the Institute for Social Studies in Medical Care show that this is a practical and useful proposition.

Identifying a sample of elderly people by a postal screen

This paper describes how a sample of elderly people were identified from the electoral register using an initial postal screen, and reports a technique that was used to increase the response to the screen.

Some experiments with factors that might affect the response of mothers to a postal questionnaire

The effects of a number of controllable factors on the response rate of mothers to a postal questionnaire were assessed by a series of experiments. In one a factorial design was used to look at seven factors with a random sample of 1600 mothers. The main findings were that the responses to questionnaires of 8, 16 or 24 pages were similar, but that rather more mothers replied when the questionnaires contained only factual questions than when they covered both facts and attitudes. Another experiment, based on a similar sample, compared the response rates when the questionnaires were sent out by a government organization or by the Institute for Social Studies in Medical Care, and found no difference. The final experiment looked at the effect of precoding the answers or asking respondents to tick boxes beside their replies and again found no difference in response rates. The overall response rate was 79 per cent, but this varied between 66 and 87 per cent in the ten randomly selected study areas--a much greater variation than that found with any of the experimental factors.

Family size, contraceptive practice and fertility intentions in England and Wales, 1967--1975

In Britain, as in the United States over the last decade, there has been a considerable decline in the birthrate, in average family size and in the number of children wanted, at the same time that use of the most effective forms of contraception--the pill, the IUD and contraceptive sterilization--and use of abortion have become more and more widespread.

Some comparisons of data from medical records and from interviews with women who had recently had a live birth or stillbirth

Data from interviews with 131 women who had a live birth and 109 who had a stillbirth about their experience of childbearing have been compared with information obtained from doctors.

For the live births medical information was more often obtained for those in teaching than in non-teaching hospitals. It is estimated that 84% of miscarriages, abortions and stillbirths were reported by women whereas 62% were recorded accessibly in the notes. Nerves and depression during pregnancy were reported much more frequently by the women than by the doctors.

Correlations over gestation were around 0·8. Concordance was greater over induction than over acceleration; it was high in relation to epidural anaesthesia and less good for other types of anaesthetic. Among the live births, reports of the baby's weight fell in the same half-pound group in 82% of instances and within adjoining groups for a further 12%. There appeared to be a tendency for mothers to report a slightly higher weight. In general agreement was less good for the stillbirths than for the live births.

Probable reasons for the discrepancies are discussed. Problems of precise definition, inaccuracies and inadequacies in the medical records and limitations of women's knowledge appeared to be the main sources of disparities.

Purification and partial characterization of protein 35/7.7 a cytosol protein that is abundant in rapidly growing hepatomas

Protein 35/7.7 is an abundant cytosol protein of Morris hepatoma 3924A and Novikoff hepatoma which was not found in normal liver. Protein 35/7.7 was isolated from the cytosol of Novikoff hepatoma ascites cells by ammonium sulfate precipitation and DEAE-cellulose chromatography. It migrated as a single major spot on two-dimensional isoelectric focusing-SDS polyacrylamide gels. The N-terminal hexapeptide is Val-Asx-Pro-Thr-Val-Phe and its carboxyl-terminal amino acid is phenylalanine.

Isolation and characterization of a cytosol protein (64/7.2) present in large amounts in rapidly growing hepatomas

Protein 64/7.2 (molecular weight/isoelectric point) is present in the cytosol of several hepatomas including the Novikoff hepatoma and Morris hepatomas 9618A, 7794A, and 3924A, but it is not present in liver or 18-hr regenerating liver. Quantitatively, its concentration was highest in Novikoff hepatoma (150 microgram/g tissue) and Morris hepatoma 3924A (550 microgram/g tissue), which are rapid-growing tumors, less in Morris hepatoma 7794A (72 microgram/g tissue), which is of intermediate growth rate, and least in the slow-growing Morris hepatoma 9618A (25 microgram/g tissue). Protein 64/7.2 was isolated from Novikoff hepatoma ascites cells in high purity as shown by its migration as a single band on one-dimensional acid-urea-polyacrylamide gels and a single spot on two-dimensional isoelectric focusing sodium dodecyl sulfate-polyacrylamide gels. Its amino acid composition has an acidic to basic amino acid ratio of 1.6. Its amino-terminal amino acid is lysine, and its carboxyl-terminal amino acid is glycine. Interestingly, the amino acid composition is strikingly similar to that of the phosphorylated Novikoff hepatoma chromatin Protein Cg', partially characterized in our laboratory.

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in "teaching" hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother's age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had "bad pains" for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.

The repeatability of data obtained in a fertility survey

This small study has looked at only one aspect of the reliability of survey data–their repeatability at an interval of 2–6 months with a different interviewer. Even for basic factual data such as date of birth, household composition and number of children there were some errors. Some were coding errors, some punching, some appeared to be reporting errors, but the numbers were small and no discernible patterns emerged.

For other factual data, such as ability to have more children or the use of different methods of contraception, the repeatability seemed to vary with the hardness of the categories. Sterilization was reported consistently, but more loosely defined characteristics, such as difficulty in conceiving or carrying a pregnancy to term, proved relatively unreliable; birth control methods which involved use of an appliance were more consistently reported than withdrawal and the safe period.

If ‘hard’ facts were reported more consistently than ‘soft’ ones it might be thought that attitudes would be reported less consistently than facts. But the dimension of hard versus soft cuts across both factual and opinion data. Fortunately for us, the question about whether they wanted more children appeared relatively hard; only 2% appeared to have changed their minds radically about this. Their memory of their intentions about becoming pregnant on the last occasion was more consistent than their reports about use of contraception around the time of conception.