Introduction

In considering the topic of this chapter, I have decided to restrict myself to the problems encountered in the management of patients in hospital-based continuing care and the major assumption that underlies all my reasoning for treatment decisions in this setting is that a doctor is not always obliged to seek to prolong life when a patient is in a condition of underlying decline. Similar patients will be encountered in other settings, in which case the same assumption is relevant.

One point that is important to emphasise at the outset is that we are not dealing with a homogeneous group, but with a group of individuals with one thing in common; they require considerable skilled nursing care owing to severe physical disabilities, often with super-added dementia. The common need of such patients is social insofar as they are heavily dependent on others for many or all activities of daily life. Whether such a person who so wishes can be maintained at home will depend on the degree of physical and economic support that can be marshalled. The lack of willing and able family and friends or of the necessary finance to pay for the support required may remove all options other than institutional care.