Clive Seale

Changing patterns of death and dying.

This paper reviews changing patterns of mortality worldwide, paying particular attention to differences between developed and developing countries and the consequences of demographic and epidemiological transitions. These involve gains in life expectancy and a shift from infectious to degenerative conditions as causes of death. Reversals to these transitions in certain Eastern European and African countries, due respectively to the social disorganisation accompanying the collapse of communism and to AIDS is described. The implications of changing population structures for the experience of old age and dying are explored and gender and socio-economic differences within countries is highlighted. The current state of knowledge about differences in the dying trajectories of different causes of death is summarised and gaps in this knowledge identified. The availability of lay health care in the community at different points in the demographic transition is described, and the problems and dilemmas of formal health care provision for dying people in both developed and developing countries outlined, including an analysis of the reasons for public support for euthanasia in some Western countries. In particular, the appropriateness of models of specialist palliative care outside the cultures in which such care originally developed is questioned. Finally, there is discussion of the extent to which medical and scientific measures erode traditional religious consolations for the problems involved in dying and bereavement.

Euthanasia: Why people want to die earlier

The results from two surveys in England of relatives and others who knew people in samples drawn from death certificates are reported. The main focus is on a sample of 3696 people dying in 1990 in 20 health authorities, with supporting analysis from an earlier national sample of 639 people dying in 1987. The incidence of people saying they wanted to die sooner, and of requests for euthanasia are reported. Excluding a proportion who did not wish to express a view, or did not know the answer, about a quarter of both respondents and the people who died expressed the view that an earlier death would be, or would have been, preferable. 3.6% of people in the 1990 study were said to have asked for euthanasia at some point in the last year of life. The extent to which such views were determined by the experience of pain, other distressing symptoms, dependency and social and cultural factors such as religious belief and social class is explored. The finding that dependency was important in causing the feeling that an earlier death would have been better, as well as requests for euthanasia, is related to the public debate about euthanasia, which often contains the assertion that fear of pain is a dominant factor. Pain was found to be a significant factor in death from cancer, but not as important for other causes of death. Social class, place of residence of the deceased, and strength and type of religious faith were found to be largely insignificant in influencing feelings about an earlier death and requests for euthanasia.

Developing a new line of patter: can doctors change their consultations for sore throat?

Background and Objectives  Doctors report pressure from peers to reduce prescribing of antibiotics for minor respiratory illnesses, and from patients to do the opposite. It has been suggested that doctors adopt a more patient‐centred consulting style in order to encourage patient satisfaction and shared decision‐making. No evidence exists that such changes are achievable. We developed a new, on‐site method for training postgraduates and used this for teaching patient‐centred intervention. Here, we examine whether this training method is associated with changes in consulting patterns in consultations for sore throat with children, among doctors from a single group practice.