Clinical Guidelines for Voluntarily Stopping Eating and Drinking (VSED).

As the care of patients with serious illness increasingly emphasizes clarifying goals of care, exploring quality of life, and minimizing patients' symptom burden, voluntarily stopping eating and drinking (VSED) has emerged as a topic of increasing interest for patients who face a diminishing quality of life. It is an option for those with serious illness that is legal in every state in the country, but for which there are few published comprehensive guidelines-and none specific to the American medical system-even as public awareness and the number of inquiries regarding this action increase. In addition to the ethical questions raised by the practice and support of VSED, there are also clinical, logistical, institutional, social, religious, spiritual, and administrative considerations for clinicians who are asked to respond to patients' inquiries about VSED and who discuss this option in end-of-life care. With these clinical guidelines, we seek to provide practical recommendations for clinicians who consider providing support to their patients who contemplate and/or undertake this effort to hasten death.

Early surgical intervention as definitive treatment for ocular adnexal capillary haemangioma.

BACKGROUND: Capillary haemangioma is the most common orbital and eyelid tumour of childhood, with a prevalence ranging from 1 to 3%. Periorbital haemangiomas can cause amblyopia secondary to anisometropia, induced astigmatism, strabismus or occlusion of the visual axis. Oral and intralesional steroids are considered to be the most accepted form of primary treatment. The authors have been performing early surgery as definitive treatment in selected lesions and believe it has an important role. METHODS: A retrospective chart review of 17 infants (2-20 months old) seen between 1996 and 2002 was carried out. Indications for surgery in the present series were astigmatism, rapid growth, anisometropic amblyopia and obscuration of the visual axis. Thirteen were treated primarily with surgery and the other four were treated with other methods prior to considering surgery. Preoperative computed tomography scans were obtained when indicated. RESULTS: Fourteen lesions were completely excised; residual tissue was deliberately left in order to preserve vital structures in three cases. No major surgical complications were noted. One child with residual tissue after surgery, who had proliferation of the remaining tissue, developed anisometropic amblyopia and ptosis. One child had a mild ptosis postoperatively that resolved after 6 months. Follow up was for an average 11.1 months. CONCLUSIONS: Early surgical intervention should be considered in a multidisciplinary team approach as a primary treatment option with selected, isolated haemangiomas, without a significant cutaneous component. Surgery is a safe, effective treatment for selected lesions, provides a definitive early treatment, and prevents astigmatism and occlusion-related amblyopia.