The use of psychostimulants to relieve opioid-induced drowsiness and symptoms of depression in medically ill patients has become increasingly established in North America. The role of psychostimulants in the care of patients receiving palliative care is beginning to be debated in the United Kingdom both in the hospice and hospital setting. Delirium has been well defined and reported as a significant problem in populations of patients receiving palliative care. Two case histories are presented to illustrate the potential benefit of psychostimulants in hypoactive delirium.

The value of integrating palliative with curative modes of care earlier in the course of disease for people with life threatening illnesses is well recognized. Whereas the now outdated model of waiting for people to be actively dying before initiating palliative care has been clearly discredited on clinical grounds, how a better integration of modes of care can be achieved, financed and sustained is an ongoing challenge for the health care system in general as well as for specific institutions. When the initiative comes from a hospital or academic medical center, which may, for example, begin a palliative care consultation service, financial benefits have been well documented. These palliative care services survive mainly by tracking cost savings that can be realized in a number of ways around a medical center. We tried to pilot 3 simple models of potential cost savings afforded to hospice by initiating a palliative care program. We found that simple models cannot capture this benefit (if it in fact exists). By adding palliative care, hospice, while no doubt improving and streamlining care, is also taking on more complex patients (higher drug costs, shorter length of stay, more outpatient, emergency room and physician visits). Indeed, the hospice was absorbing the losses associated with having the palliative care program. We suggest that an avenue for future exploration is whether partnering between hospitals and hospice programs can defray some of the costs incurred by the palliative care program (that might otherwise be passed on to hospice) in anticipation of cost savings. We end with a series of questions: Are there financial benefits? Can they be modeled and quantified? Is this a dilemma for hospice programs wanting to improve the quality of care but who are not able on their own to finance it?

I have been living with Multiple Sclerosis (MS) for 20 years. For 20 years I have gone to sleep with MS, awakened with MS, worked with MS, fell in love with MS, got married with MS, went through five miscarriages with MS, gave birth to a beautiful son with MS, raised a son whose life would be marked by the MS of a parent, and most importantly, I will go on living with MS for as long as fate allows. My wife Rachel has MS.

Patrick began writing a journal in 1998 just before he retired from paid work as a result of effects of Multiple Sclerosis. He continued to write irregularly over the subsequent 5 years until he moved into a long-term care facility. He used the journal as a writing exercise, but lived with the frustrations of having to rely upon the computer first to translate his spoken words into written text and then to speak those words back to him. Although Patrick was legally blind, a wheelchair user, and lived with debilitating fatigue, he never let himself be defined by those features. Rather it was his imagination, humor, and quality of thought that captured those around him. These journal excerpts document his reflections on “life, the universe, and everything” in the words of Douglas Adams, a favorite author. The poems were written with the assistance of scribes while Patrick lived in a care facility. Patrick died on January 11, 2004 of pneumonia, having embraced the process of dying as he had his living over the previous 45 years. His family, including his research and life partner, Deborah Stienstra, and their children Rebecca and Cailum, celebrate his life and contributions.

Yizkor Minyan: Memorial suite.

The effects of a disease alter every aspect of the person's being. Even with a fairly mild illness, treatment of the disease will change the patient's work and social habits, family relationships, and outlook. When the illness is cancer, and when, as in this particular case, death was almost certain in a short and measured time, the effect on the person is enormous. Generally, medicine, in accord with traditional religious teaching, stressed the division of man into two parts: body and soul. The body was the proper focus of temporal care and the soul belonged to the spiritual domain, the churches and their clergy. Church teaching explained that the body waged a constant battle with the soul and was a source of temptation and sin—sloth, greed, lust, and pride—these appetites had to be chastened so the soul could survive its brief earthly visit and enjoy eternal salvation after the death of the body. Medicine, therefore, looked at all parts of the body and tried to make them work well together. What kind of a person was left, after the body had been worked on, was not the concern of medicine.

End-of-life care provides an opportunity to help a patient find meaning in the experience of dying. This is a challenge because the experience of dying can rob a patient of meaning. The first step is to look at death as being a process of life rather than an event. This is brought about by welding the broken pieces of the mind–body connection. Medicine cannot always fix broken pieces, but spiritual welding always puts us back together again. Compassionate end-of-life care helps a patient connect spirituality with the search for meaning and transcendence.

He was slim in build, and even as he sat in his wheelchair, you could see that he was tall. Infected, he claimed, by a serious bout of sexual promiscuity with women and too much alcohol. He gave me an overenthusiastic grin, trying just a bit too hard to be nonchalant, and said “Hey good-looking, coming to see me next?” I nodded absent-mindedly, trying to get through the note I was writing and simultaneously fending off the 20-odd patients clamoring the halls, all keen to get a word in with the doctor before their chance at an intervention disappeared for another week. Even though we frequented the nursing home far more often than mandated by state regulations, there still seemed to be so much to do and such little time to do it in. I told Mr. J I'd be with him in a minute, and he smiled affably. “I'll be waiting in my room,” he said pointedly, knowing full well it would take me too long to get to him.

Modern medicine is currently confronting a crisis of meaning that is manifesting in a dispirited and demoralized profession. Palliative medicine and the care of patients with incurable diseases provide clinicians with an opportunity to rediscover the meaning in their work. In particular, with its emphasis on compassion, palliative medicine reconnects us to the Socratic ideal and an “ethics of experience.” Our rediscovery of this perennial philosophy is necessary if we are to develop the wisdom necessary to containing our enormous scientific capabilities.

Clinical update: Literature abstracts.

Clinical update: Literature abstracts.

Clinical update: Literature abstracts.

Clinical update: Literature abstracts.

Calendar of events.

Calendar of events.

Calendar of events.

Calendar of events.