An approach using aetiology-based guidelines in the management of N&V is moderately effective, although there are some patients with N&V refractory to standard antiemetic regimens.

Malignancy-related ascites gives rise to troublesome symptoms and carries a poor prognosis. Abdominal paracentesis is a widely used and effective procedure for symptom relief, but practice with regard to the procedure itself may vary considerably. Evidence obtained in the context of liver disease probably influences practice in malignancy, although the pathophysiology involved is different. Anecdotal evidence suggested a difference in practice between the Exeter and District Hospice and the adjoining hospital, and this was confirmed by a review of case notes. Patients undergoing paracentesis in the hospital were more likely to have prior ultrasound assessment and to be given intravenous fluids, and had longer drainage times and longer inpatient stays. It seemed that some practices were placing unnecessary burdens on patients whose life expectancy was short. A set of clinical guidelines for the procedure was drawn up, based on the limited evidence available and the practice within the hospice. These guidelines emphasise performing ultrasound investigations only in cases of diagnostic uncertainty, allowing up to 5 L of fluid to drain without clamping, leaving drains in for no more than 6 h and giving intravenous fluids only when specifically indicated. These guidelines were introduced on the oncology ward of the adjoining hospital. The impact on practice was assessed by means of a retrospective case note review of all procedures carried out on the ward in the 6 months before and after the guidelines were introduced. The introduction of guidelines resulted in significant reductions in prior ultrasound assessment, mean length of time drains were left in and mean length of inpatient stay for planned procedures. There were no cases of symptomatic hypotension in the postguidelines group.

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, but it may return to Parliament in Autumn 2006. Assisted dying is being promoted as a logical extension to patient autonomy for those who are terminally ill and suffering intolerably, and proponents claim to have overwhelming public support. Those who have most experience of caring for the terminally ill, however, come out most strongly against any change in the current law. This paper suggests that estimates of public opinion are unreliable; that assisted dying is unnecessary if we are prepared to prioritise good end-of-life care; and that a change in the law would do little to protect patients but would put other vulnerable members of society at risk.

Brain impairment is a distressing manifestation of human immunodeficiency virus (HIV) disease characterized by progressive cognitive impairment leading eventually to dementia and death. Patients with advanced brain impairment are clinically difficult to manage and usually require residential care. In 1997, a brain impairment unit opened at the Mildmay Hospital UK in London to meet the needs of this patient group. It began as a nurse-led unit, has adopted an interdisciplinary approach to care and aims to maximize the quality of life until death. In a study of patients admitted during its first year, it emerged that while the condition of many patients declined resulting in death, some patients improved sufficiently with rehabilitation and ongoing medical treatment to return to independent living. The possible reasons for this are discussed in this article. Study findings have not only affected the approach to care but have also highlighted some unexpected problems; the importance of adopting an interdisciplinary approach in caring for the group of patients becomes evident.