Minerva
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7451.1326 (Published 27 May 2004) Cite this as: BMJ 2004;328:1326All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
This is one of those hypothetical questions that are impossible to
answer.
It should not be necessary to have to give up some healthy life to
gain a comfortable send off.
Even if this Pact with the Devil was made, it would be changed, and
the period of comfortable send off would be negotiated away as the amount
of healthy life given up was lengthened. The research in the USA talked
about the amount of life that people would be prepared to 'trade'. It is
not ours to trade, and who is the business partner with whom we would be
trading?
To deal with the problem of avoiding an unnecessarily medicalised
last month, we need the foresight to know that it is indeed the end, and
not just a bump in the road. We have all struggled with this dilemma and
I am not aware that there is yet a complete solution. Of course I want to
avoid an unpleasant end, but I also do not wish to miss my grandchildren
growing up as long as I can enjoy them and they me.
A friend has just died from breast cancer 9 years after being told
that she had at best another 12 months. She enjoyed most of the extra 8
years. I know for certain she wouldn't have missed a day.
I think that it is touching that 50% of us have the faith to say Yes.
They must be young!
Competing interests:
Still working, but qualify for a bus pass
Competing interests: No competing interests
This proposal takes the development of a consumer based NHS to new
and exciting levels. Statistics are regularly used to imply reason or
certainty in a random biological system that typifies daily general
practice.
If we can truly deliver either choice to a level approaching either
unity or zero then happily a decade of my opposition to the concept of
medical consumerism can come to an end.
To whom do we apply?
Competing interests:
None declared
Competing interests: No competing interests
I agree with Dr. Stone.
The peculiar patterning of this depigmentation indicates to me that
there is/was an exogenous cause, and suggests that it is probably related
to some component of the mask itself (it looks like a perfect match) or is
possibly due to a compound used to disinfect/clean the mask (especially if
it had phenols or antibacterial chemicals in it).
Facial depigmentation, incidentally, often responds to the use of
topical steroids alone, or in combination with topical immunomodulators
such as tacrolimus. I have found this combination very useful in patients
with vitiligo, and I suspect this patient would do well. Care must be
used when treating patients with topical steroids on the face, of course.
Competing interests:
None declared
Competing interests: No competing interests
Editor – Mohammed et al described an interesting case of a patient
developing perioral vitiligo in the exact distribution of her facemask1.
The patient had no vitiligo elsewhere and had no autoimmune disease. They
propose trauma and the Koebner phenomenon as the cause.
Vitiligo is indeed recognised to Koebnerise, however I would like to
propose a second possibility. If the facemask was made of rubber, this
could be a case of ‘rubber depigmentation’.
Hydroquinone and its derivatives were traditionally used as rubber
antioxidants and stabilizers. These are recognised as potent skin
lightening agents and have been reported to cause depigmentation over the
dorsum of the hands due to rubber gloves2. Hydroquinone is no longer
commonly used however cases of rubber depigmentation continue to be
reported, such as peri-orbital depigmentation due to rubber swimming
goggles3, wrist depigmentation due to a rubber wrist splint4 and neck
depigmentation due to rubber stethoscope ear pieces5. Rubber chemical
additives in current use can also therefore cause ‘rubber depigmentation’
thought to be due to a direct chemical inhibition of melanocytes.
I would be interested to know what material the culprit facemask was
made from!
Natalie Stone consultant dermatologist
natal@kaloo.freeserve.co.uk
Royal Gwent Hospital, Newport, Wales
1. Mohammed A, Whitehead M, Miller E. Vitiligo in distribution of
face mask BMJ 2004;328:1326 (29 May)
2. Oliver EA, Schwartz L, Warren LH. Occupational leucoderma. JAMA
1939;113:927.
3. Goette DK. Raccoon-like periorbital leukoderma from contact with swim
goggles. Contact Dermatitis 1984;10:129.
4. Nabai H, Mehregan AH. Rubber-induced depigmentation secondary to a
wrist splint. Cutis 1994; 53(6);295-6.
5. Srinivas CR, Mukhi SV. Stethoscope earpiece-induced chemical
depigmentation. Contact Dermatitis 2003; 49(2):110-1.
Competing interests:
None declared
Competing interests: No competing interests
It is important to realise the inevitability of death. I reckon life
as a journey through time with different persons getting off at different
times. So, if at all possibe I would like to travel in comfort till the
very end. If the final leg of the journey is troublesome and tiresome, I
think, I will jump off at the penultimate stop with equanimity. The living
may grieve my departing but I will never know!
Competing interests:
None declared
Competing interests: No competing interests
An interesting clinical picture but surely this was caused by
nebulised steroid used chronically with prolonged contact between the mask
and the face? - It would be interesting to know if the patient was on long
term nebulised budesonide
Competing interests:
None declared
Competing interests: No competing interests
The thing is, it isn't mine to trade. Anyone who thinks he can
control such things is a deluded fool.
The underlying question is, "How much do you want an extra six months
of good health at the end of your life? Is it worth suffering for?"
Because no treatment outcome is guaranteed, it is always a matter of
playing the odds. Each must make his own decision, but neutropenic sepsis
may still forestall the most favourable karyotype and even the direst
survival curve has a confounding 2% tail.
To a doctor, oblivion is always available at the end of a needle; but
as Hamlet put it, "What dreams may come when we have shuffled off this
mortal coil, must give us pause."
For those who choose the bare bodkin over the fardels and the
thousand natural shocks, my question would be, "Are you ready for the
undiscover'd country?"
Competing interests:
None declared
Competing interests: No competing interests
My final hour is decided and the last one month is immaterialto me as
I am not going to be aware of it.I would rather live six months healthy
life and inform the people concerned that my life may terminated one month
early and given smooth take off.
Any attempt for a better care will not extend my term,it is waste of
resources and agony to family and friends.May be useful for organ donation
if terminated early with the consent.
Competing interests:
None declared
Competing interests: No competing interests
Would I trade six months of healthy life to ensure better care in my
final month?
We could get caught in the 'concrete aspect' of this question and
debate endlessly on issues like is it possible to barter as proposed
above,how do we know that we will not have a swift death and therefore not
require being cared for etcetra.
The abstract aspect is all about mans'need to be in control of what
happens to him and the fear of losing that control.
One's attention is drawn to the use of the term 'better care'in the
question which too would be open to lot of debate.
I like being in control of as many aspects of my life,health
included.If there was any way I could barter a small period of physical
health for better care in my final month,meaning emotional security about
the 'end',I would definitely say yes please!
Competing interests:
None declared
Competing interests: No competing interests
Trading six months of healthy life?
I assume the question is actually: Would you trade six months of
unhealthy life for a swift, painless and unexpected death?
The reason for my assumption is that the last six months of our lives are
usually the least healthy six months of our lives and take up
approximately 50% of the NHS health budget.
My impression is that many patients would opt for the swift demise rather
than a desperate and agonising struggle against the odds. I work on an
intensive care unit and frequently encounter patients who do not wish to
be readmitted. I also regularly encounter patients who refuse intensive
care because the have seen how unpleasant it has been for their loved
ones.
It would be a valuable exercise to conduct a survey and find out what the
general population actually wants in the way of treatment, since intensive
care treatment is normally issued by default to patients who have not
given consent and have no idea of what they are letting themselves in for!
Competing interests:
None declared
Competing interests: No competing interests