BMJ 28 Oct 2006

This study randomised primary care patients with osteoarthritis to six sessions of self-management instruction plus a booklet or just the booklet. At one year, there was no difference in scores of pain, physical functioning or contact with primary care. A third of the patients randomised to the training sessions dropped out. Maybe they reasoned that if their joints hurt, they would like them to stop hurting.

Of all widely applicable evidence-based treatments, cognitive behavioural therapy is probably the most scandalously under-provided in the UK. The general neglect of mental health in the NHS and the need to employ trained therapists are probably the main reasons. This study finds that CBT can be provided by telephone and in half the time usually given for conventional face-to-face CBT. Sounds almost too good to be true.

It has become part of received wisdom in palliative care circles that patients should be able to discuss their dying openly with trained professionals. That seems reasonable in the context of advanced cancer, but having read most of the studies of advanced heart failure, advanced respiratory disease, and now of end-stage renal disease, I feel some disquiet. Two facts stand out quite clearly: doctors are very bad at giving an accurate prognosis in these conditions, and patients do not usually cope by intellectual acceptance and control, but more often by a strategy of living for the day and leaving major decisions to the professionals. The editorial by Scott Murray suggests that the right kind of discussion can help to re-tune people’s coping mechanisms and still leave space for hope, though perhaps hope in the possibility of a good death rather than in a longer life. I hope so: but we have a long way to go in providing a guaranteed good death for non-malignant disease.

890 Measles in the United Kingdom: can we eradicate it by 2010?

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