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New guidance for doctors on end-of life decision making for different  cultures

It is difficult for most of us to think about the kind of death we’d wish to have, including the treatment and care we would want at the end of life. Medicine is becoming ever more complex and many of us may be faced with choices at the end of our lives that were not available in the past.

New guidance from the General Medical Council – the regulatory authority for doctors in the United Kingdom – asks doctors to take a holistic approach that takes account of a patient’s culture and religion, their personal preferences and input from their famil,y and the significance of these factors as they near the end of life.

So what does this mean for Sikh patients and their families? And what happens when they wish for the patient to be cared for at home, but a doctor has concerns about how this is managed? The GMC has considered how this scenario may play out in the fictional case of Mr Singh.

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Mr Singh is 82 and the head of a large family. He had a stroke two months ago which left him unable to communicate in any meaningful way, and with a reduced level of consciousness. He did, however, retain the ability to swallow soft food and his family has been caring for him and feeding him at home.

During the last week his consciousness level has declined and he is now having difficulties swallowing. Dr Dawson, Mr Singh’s GP for the past six years, suspects that he may be suffering from further bleeding in the brain.

She is concerned that Mr Singh may choke on his food or inhale it into his lungs and discusses her concerns with Mr Singh’s daughters. They want to continue caring for their father at home and feeding him by mouth if this is possible.

Dr Dawson asks Dr Garcia, a Palliative Care consultant, to assess Mr Singh at home. She recognises that Mr Singh has been very well cared for by his family, but Dr Garcia is concerned that Mr Singh’s swallowing difficulties mean that he may not get sufficient nutrition and hydration by mouth and might even be dehydrated.

Dr Dawson, the GP, knows how important it is for Mr Singh and his family for him to be at home, surrounded by his family and community and to be cared for in accordance with his cultural beliefs.

Dr Garcia concludes that Mr Singh should be given a drip to hydrate him but that he can continue to be cared for at home, including careful feeding of soft food, as long as his situation is closely monitored and reviewed by her team in case his situation declines further. Mr Singh’s daughters agree.

Unfortunately, two weeks later, Mr Singh is admitted to hospital with a chest infection caused by inhaling food into his lungs. He is treated with antibiotics and a drip is inserted to provide hydration while his situation is monitored.

A scan shows that Mr Singh has suffered progressive bleeding in the brain, and, sadly, it is clear that Mr Singh is no longer able to take food or fluids by mouth.

Dr Garcia judges that Mr Singh only has a few days to live and that nutrition or hydration by tube or drip would not extend his life any further. She believes that his care should now be focused on managing any pain and other symptoms and keeping him comfortable. She explains that this would mean Mr Singh could be transferred home if that was what he would want to happen.

The family struggle to come to terms with their father’s situation. They are anxious to meet his wishes to die at home but do not really understand what it will involve and are worried about him not receiving nutrition or hydration.

But they speak to the hospital’s multi-faith chaplaincy and the healthcare team, and the are reassured that they will continue to receive support from the palliative care team to help them care for Mr Singh. They agree that the care of their father should focus on managing any pain and other symptoms and ensuring their father’s dignity and comfort will be maintained.

The team is able to meet Mr Singh’s wishes to die at home. He is transferred home where he dies peacefully five days later.

This scenario is one of several case studies and materials produced by the GMC to help both doctors and patients to understand new guidance: Treatment and care at the end of life: good practice in decision-making.

The GMC hopes that the guidance will help to ensure better care for all patients – no matter what their culture or religion – when doctors are providing treatment and care for patients who are reaching the end of their lives. For further information, visit www.gmc-uk.org/guidance/end_of_life_care

Denim skirts, dresses, waist coats and vest tops are THE biggest trend for summer 2010. The great thing about this fabric is it can be worn as part of a casual outfit, or you can dress it up with a pair of killer heels and funky earrings, and get the boho chick look.

The high street has some great designs for all body shapes.  Levi’s have some great pieces or why not try H&M who have a selection of denim vests and dresses at affordable prices.

Here to stay because we all love them, skinny jeans work with everything!  So make sure you have a few pairs in lighter colors, this season acid wash colours are a big hit.

Team your jeans, denim skirts and waist coats with a floral top. This pattern hit the catwalks and high street in spring 2010, but you will see more of this funky pattern in the high street this summer.  Tops, dresses, bags or scarves – you need to have at least one item in your wardrobe this summer.

If you don’t have the budget to buy yourself anything new, raid your cupboard (or your sisters closet), guaranteed you will find a denim dress lurking behind that floral skirt – the 80s are definitely back!

What started with bodysuits and leotards is now becoming a fully-fledged trend towards jumpsuits, playsuits, and rompers. As a unique style for spring 2010, they won’t be for everyone, but they will offer more options with different styles, prints and looks for both day and night.

Why not team up your jumpsuit with a boyfriend blazer?  Continuing to be another fashion favourite for summer 2010, the boyfriend blazer is a simple way to look chic. A slightly oversized jacket or blazer, sleeves rolled up, is every inch looking relaxed and cool.

Whether it is a casual, smart or evening look you are going for these hot tips will leave you looking effortlessly gorgeous.

A recent survey by NHS Choices, the UK’s National Health Service website, has revealed that many South Asians are unaware of how much greater the risk of diabetes and heart disease is for their ethnic group.

Only 34 per cent knew that as a South Asian they were much more likely to suffer diabetes and only a quarter understood the increased risks of heart disease.

Lack of recognition is particularly prevalent amongst the younger population, with just a quarter of South Asian 16-24 year olds realising that they are at a much higher risk of diabetes and only 15 per cent knowing that they’re at a much higher risk of heart disease.

This lack of understanding means that fewer people are making positive changes to lead a healthier lifestyle. Only 34 per cent have stopped using ghee, which is high in both cholesterol and fat, in their cooking.

The statistics also suggest lack of awareness of how much exercise is needed to keep healthy with 40 per cent not knowing that the recommended amount is 30 minutes a day on three to five days a week.

For this reason, NHS Choices aims to increase knowledge about South Asian health conditions by producing specific information available at www.nhs.uk/southasianhealth to provide tips and advice on how to eat more healthily and take exercise.

Dr Justin Zaman, chair of the cardiovascular working group at the South Asian Health Foundation and cardiologist at University College London Hospital, commented: “Diabetes is five times more prevalent and the death rate from heart disease is around 50 per cent higher in South Asians than the UK population as a whole. This survey shows that, while there is some recognition that people from a South Asian background are more likely to get diabetes, there isn’t sufficient understanding of how much higher the risks are.”

He added that accessing reliable information from NHS Choices would help people to make better lifestyle choices.

The survey questioned South Asians about their awareness of hereditary diseases and their cooking and exercise habits.

NHS Choices at www.nhs.uk is the UK’s most popular online source of health information, attracting eight million visits a month. It offers comprehensive A-Z advice on health conditions, guides to local health services and a daily analysis of the science behind the medical headlines.

Bal Sandhu

Bal Sandhu, a registered community dietician, specialising in diabetes and working for the NHS in Berkshire, offers this advice.

What is Diabetes?

Diabetes is an auto-immune condition in which the body produces very little insulin – the hormone needed to convert our food into energy that can be used by our muscles. There are two main types of Diabetes, insulin dependent and non-insulin dependent, which are often referred as Type 1 in which insulin is needed in injection form and Type 2 which can be often be controlled by diet alone or with the aid of tablets.

Research has shown that Asians and Afro Caribbean people are at higher risk of developing diabetes Type 2.

What are the symptoms of diabetes?

• Tiredness
• Thirst
• Blurred vision
• Weight loss
• Passing large amounts of urine

What do I do if I suspect I have diabetes?

Speak to your doctor who will test your blood sugars and if necessary send you for a glucose tolerance test. This entails a fasting blood test, then a sweet drink, then a blood sample taken 1.5 hours later. This measures your body’s response to sweet foods and sugars.

What are the health risks associated with Diabetes?

• Renal problems – kidney failure
• Eyesight
• Poor blood circulation
• Heart disease

What is the treatment for diabetes?

If you are diagnosed with diabetes it is essential to make some lifestyle and dietary changes to avoid developing related complications.

Diet. Do not use diabetic products as they are higher in fats – instead  a balanced diet low in added sugars and low in fat is advised .

Exercise.  Thirty minutes daily walking is recommended for general well-being.

Medications. Discuss with your GP or practice nurse an individual plan. The treatment that works for one person may not be suitable for another so it is vital to seek medical assistance.

What is the best diet for people with diabetes?

Diabetes is best managed by a balanced healthy diet. This means eating a variety of different foods. There is no need to buy special diet foods or diabetic foods. A balanced diet is a diet low in fat and sugar with a sensible amount of high fibre foods.

The most important dietary points to consider with diabetes are:

Maintain a regular eating pattern through the day – you must eat at regular times. It is not helpful for your diabetes management if you have long gaps between meal times or if you have large meals once a day

With drinks choose low sugar alternatives, such as ‘diet’ or ‘no added sugar drinks’. Do not take added sugar in drinks such as teas and coffee.

Include a high fibre starch food at each meal, such as wholemeal cereal, granary bread or chapatis made with wholemeal flour.

Aim to have three fruits as snacks through the day and have plenty of salad or vegetables with meals.

Sweet foods such as Indian sweets can be eaten in small amounts. These foods are less detrimental to diabetes control if taken with meals.

Thirty minutes daily walking is recommended for general well-being. If you are unable to walk consistently for 30 minutes then aim to do two sessions of 10 minutes in a day.

According to the National Obesity Forum (NOF), research shows that nearly half of adults have an inaccurate picture of their own weight – meaning, typically, that they underestimate it.

National Obesity Week (November 2-8) was heralded by a shock report that the number of people diagnosed with diabetes in the UK had increased by more than 145,000 in the previous year.  People of South Asian origin are among the vulnerable sectors of society.

New data from GP practices showed that there are now more than 2.6 million people with diabetes in the UK and more than 5.2 million registered as obese.

In addition, there are up to half a million people in the UK who have Type 2 diabetes and don’t know it.

One in every 10 people is being treated for obesity and one in 20 for diabetes.

Around 90 per cent of people with diabetes have Type 2 diabetes, which is often, but not always, linked to lifestyle factors such as being overweight or obese, leading a sedentary lifestyle and eating an unhealthy diet.

According to the International Diabetes Federation (IDF), worldwide, 80 per cent of people with Type 2 diabetes are overweight or obese at the time of diagnosis.

Douglas Smallwood, chief executive of Diabetes UK, described the figures as extremely worrying.

“Diabetes is a serious condition that causes heart disease, stroke, amputations, kidney failure and blindness, and more deaths than breast and prostate cancer combined,” he said. “Many, but not all, people with Type 2 diabetes are overweight or obese, therefore we need to do all we can to raise awareness of diabetes and help people understand how following a balanced diet and leading an active lifestyle can help reduce their risk of developing Type 2 diabetes”.

“If we don’t stop the rising tides of obesity and diabetes, millions will face a future of ill-health and will put an ever-growing strain on NHS resources.”

Type 2 diabetes can go undetected for ten years or more, which means that around half of people already have complications by the time they are diagnosed.

Risk factors for Type 2 diabetes include:

• Having a large waist* or being overweight
• Being of Black or South Asian origin
• Having a family history of the condition
• Being over 40 years old, or over 25 if you’re Black, Asian or from an ethnic minority group.

*At-risk waist measurements are 37 inches or more for men, except those of South Asian origin who are at risk at 35 inches or more, and 31.5 inches or more for all women.

Saturday November 14 was set as World Diabetes Day for 2009. WDD is the primary global awareness campaign of the diabetes world, established by the International Diabetes Federation (IDF) and the World Health Organisation (WHO) in response to the rise of diabetes worldwide.

The IDF’s World Diabetes Day theme for 2009 to 2013 is ‘Diabetes Education and Prevention’. This broad theme allows everyone affected by diabetes to take part in the campaign. The campaign slogan for 2009 is ‘Understand Diabetes and Take Control’.

Even if exposure is limited to brief outdoor lunches or a 20-minute walk, cumulative exposure is enough to cause the signs of skin aging. The first line of daily defense against sun damage is daily use of SPF. Even on cloudy or overcast days, UV light can strike skin and cause damage, so simply wearing sunscreen on sunny days isn’t enough.

Fortunately, more sophisticated sunscreen formulations with skin health benefits (think less chalky, less greasy) have made SPF a convenient addition to our morning routine.

Exfoliation – how much is too much?

Exfoliation delivers a tighter, firmer, smoother look and feel of skin. Because of this result, many fall into the trap of over-exfoliation: an over-zealous approach that can actually reduce skin’s vitality and make it more susceptible to damage from UV light.

Over-exfoliation triggers the inflammatory response, leading to a compromised lipid barrier that won’t function properly, a sensitised skin condition, and accelerated premature aging.

Tell-tale signs of over-exfoliated skin include:

• noticeable dehydration
• patchy areas of dryness
• skin tautness
• redness and itchiness
• increased sensitivity
• inflammatory acne and irritation

If you’re showing the signs of over-exfoliation, speak with a professional skin therapist, who will most likely prescribe a calming cleanser and toner, and a protective moisturizer to start the recovery process. Sun protection is a must: wear a sunscreen with physical UV blockers Titanium Dioxide or Zinc Oxide that won’t irritate skin.

After skin recovery, begin exfoliating with a gentle exfoliant designed for daily use. If you desire a more intense level of exfoliation, look to non-abrasive exfoliants containing chemicals like Salicylic or Lactic Acid. Pair a more gentle regimen with professional exfoliation treatments from your professional skin therapist to enjoy smoother skin without the undesirable side effects.

Understanding AGEs, MMPs and other causes of skin aging

In recent years, scientists have come to understand the actual biochemical triggers that manifest skin aging, such as wrinkles, altered pigmentation, and loss of skin tone. These triggers are known as:

• Reactive Oxygen Species (ROS), also known as free radicals.
• Matrix Metalloproteinases (or MMPs).
• Advanced Glycation End-products (AGEs).

Reactive Oxygen Species (ROS) are dangerous oxygen molecules generated by UV rays and pollution. ROS attack and react with stable skin cell molecules, causing cross-linking of collagen and elastin (the cause of wrinkles) while lessening skin’s ability to repair itself.

Matrix Metalloproteinases (MMPs) are enzymes activated by UV exposure or inflammation. MMPs contribute to the breakdown of collagen while inhibiting new collagen formation.

The same glucose (sugar) that provides energy for our cells can also react with proteins, including the skin’s collagen. This reaction results in the formation of Advanced Glycation End-products (AGEs), which can contribute to loss of elasticity, wrinkles, inflammation, inhibited skin cell growth and accelerated aging.

Because we understand these triggers, skin care professionals are better equipped to effectively treat, and control, the signs of skin aging.

A veneer is a facing on the front of your teeth usually your top teeth, which is just like a false finger nail.

Veneers are made out of porcelain and are used mainly for aesthetic reasons.

Veneers make teeth look natural and healthy, and because they are very thin and are held in place by a special strong bond (rather like super-glue) very little preparation of the tooth is needed.

Veneers can improve the colour, shape and position of teeth. A precise shade of porcelain can be chosen to give the right colour to improve a single discoloured or stained tooth or to lighten front teeth (usually the upper ones) generally.

Veneers can also be used to close small gaps, when orthodontics (braces) are not suitable. If one tooth is slightly out of position, a veneer can sometimes be fitted to bring it into line with the others.

Article sponsored by

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Anandpur Sahib is revered as the place where the tenth Sikh Guru, Gobind Singh, founded the Khalsa (the body of pure believers) on April 13 1699.

Health authorities there are reported to have collected 18,207 units of blood inside 16 hours during a mass blood camp coinciding with the Hola Mohalla celebrations from 7.25pm on March 10.

Expectations had risen to the point where the organisers were said to be looking to collect 25,000 units in 24 hours.

That never happened but it seems as if the previous Guinness Book record will have been narrowly overtaken. The current entry is for an effort by Dera Sacha Sauda, Sirsa, for a blood donation camp at Bapu Ji village in Sri Gangananagar, which attracted 17,921 donors in October, 2004.

The Anandpur Sahib tally will be submitted to the Guinness Book for ratification. Record or not, the event provides a major boost to blood supplies in a country where voluntary donations lag far behind need.

The camp comprised 14 blocks of 50 beds. One hundred doctors supervised around 3,000 paramedics plus many hundreds of volunteers in taking the blood, which was gratefully accepted by more than 100 blood banks from all over India.

A surprising feature was the substantial contribution from women, thought to be more than 30 per cent.

The Hola Mohalla celebrations centred on the Sikh shrine of Keshgarh Sahib with the blood donation camp sited on the campus of Khalsa College.

The camp was organised by the Akal Takht, Sikhism’s highest temporal seat, the Shiromani Gurudwara Prabandhak Committee (SPGC) and the Akal Purakh ki Fauj (Army of the Almighty). It was envisaged as a firm statement that for Sikhs there should be no objection to donating blood.

The celebrations attracted Sikhs and their neighbours from all over Punjab and India. The colourful festival included a mock battle between opposing forces – the Hola and the Mohalla – drawn from the ranks of the Sikhs’ Nihang warrior sect.

Blood donation in India is often arranged around large gatherings, community groups recognising the constant need to volunteer fresh supplies.

Over several years the government has been trying to reduce the volume of blood given by professional donors. In 2002 the World Health Organisation caclulated that only 52.42 per cent came from volunteers in India. The balance came from family members – and those who sold their blood.

Professional donors, many of whom are drug addicts, are major contributors to the spread of HIV and Aids infections. There are thought to be 2,000 blood banks in the country and half of these are unlicensed. In addition, many pathology laboratories are said to supply blood without scientific testing.

Though buying and selling of blood is banned, the business of paid blood donation goes on even though paid donors can often be identified by multiple puncture marks on their arms and by low haemoglobin, resulting from donating every week instead of once every three months which gives a donor time to rebuild the iron in his or her system.

Paid donors often pose as members of the families of patients needing a transfusion.
Health authorities in India await the introduction of a new blood transfusion act which will sanction punishments including jail for some for who violate blood collection, storage and transfusion rules. It will go hand in hand with efforts to build an effective national transfusion service.

There are thought to be more than four million HIV positive people in India.

Sikhs in Britain who wish to donate blood in the UK can find out how to do it by consulting the UK National Blood Service site at www.blood.co.uk

English Translation

Interviewer:
Hello, Baba Fauja Singh Ji…Today you ran in the Edinburgh marathon, how was it?

Fauja Singh:
It was very good. It was very busy with a lot of people. Many boys who had previously ran a 26 mile marathon ran very well and also some people who only ran a bit also done very well. The whole event was very well organised

Interviewer:
It was very cold today, how did you cope in this weather?

Fauja Singh:
It rained a lot and it was very cold. For the people who were running I guess they did not feel as much as the supporters who were sitting.

Along the route there was a first aid centre, like a small make-shift medical camp which we relied on in this cold weather, otherwise it would be very difficult to complete the run.

Interviewer:
So, where is your next run going to be?

Fauja Singh:
Wherever the next run takes place and wherever I get invited, I will be there (laughs with interviewer)

Interviewer:
What is your message to young people? Should they run and how?

Fauja Singh:

Yes, everyone should run both boys and girls. We already have many people who participate in marathons, which is good to see.

More on Fauja Singh…