Breathlessness causes major disability to patients with COPD in the last year of life. The expertise of palliative care in treating breathlessness may be valuable in these patients many of whom lacked regular health service contact in the year before death. Patients who are housebound with high levels of morbidity require community health services. Respiratory nurse specialists were rarely involved in the patients' care and may provide a link between the GP, the chest physician and the palliative care team.

Nurses developed skills to manage interaction with callers in order to compensate for the absence of visibility. Skills were based on their professional backgrounds and experience and developed in an ad hoc way. Further research could examine the efficacy of these strategies, and be a prerequisite to adding them to training programmes.

Although the majority of GPs acknowledged a need to discuss prognosis in severe COPD, this was not reflected in their reported behaviour. It appears that the palliative care approach of open communication, whilst seen to be relevant to severe COPD, is not applied routinely in managing the disease in primary care. Uncertainty among GPs as to how patients view the discussion of prognosis and inadequate preparation may pose potential barriers.

The preference of African American parents for physical discipline is noted frequently in the literature, and it is suggested that this preference is responsible for the over representation of black children in foster care. Our research has found that African American parents in a social service intervention program clearly express this preference to their social workers, thereby further jeopardizing their chances of being judged fit parents. Studies of African American parenting styles show that there is a preference for physical discipline in combination with loving verbal reinforcement. This preference seems to represent a deep-seated set of cultural beliefs that cross many generations in the African American community. In spite of the importance of these claims, however, and the apparent cultural character of the preferences, there are relatively few studies of the African American use of physical discipline and none that report on the preference in any detail. This paper examines extended narrative accounts of why physical punishment is a preferred form of discipline in the African American community and how it is ideally to be used. Because the preference for physical discipline is thought to be a deep seated cultural form, and culture is often conveyed through narrative, we have paid careful attention to narrative in examining this preference.