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Trends in hospice care

"It is better to die living than to live dying." Mitchell’s personalview that the needs of the dying are very much those of the living1closely reflects the philosophy of the hospice movement-thatterminally ill patients should be able to live fully and with dignityand comfort until death. The idea is that a hospice should cater forthe social, physical, emotional, and spiritual needs of patients andtheir families in a relaxed atmosphere. But is this what hospicesactually do? In a survey by postal questionnaire of 111 hospices inthe British Isles, Johnson and colleagues2 found, from the 98 replies,that all 17 National Health Service hospices had either full-time orpart-time consultants, whereas in 12 of the 81 independent hospicessenior medical cover was provided by local general practitioners.Ways in which patients were cared for varied so much that, sayJohnson et al, the title of hospice was the only factor these unitsseemed to have in common. For example, throughput varied from17 to 31-8 deaths and discharges per bed per year, and dischargerates ranged from 1 to 76%. Nevertheless, the median values forthese measures indicate that many patients are discharged from ahospice, thus dispelling the misconception of the public and somehealth professionals that the sole purpose of such an institution is toprovide "tender loving care" in the last few days of life. Johnson et alalso found that many patients were managed with a range ofinvestigations and procedures usually associated with acute hospitalcare; whether such procedures were done seemed to be associatedwith type of medical input. For example, in units with a full-timeconsultant or medical director, throughput was greater, invasiveprocedures were more likely to be done, and patients were morelikely to be referred for palliative surgery and organ donation.Moreover, there was a trend for units with such medical support todescribe themselves in technical terms ("a specialist medical/nursing unit") rather than the non-technical terms ("a peacefulhaven", "home from home") favoured by units without suchsupport. Johnson and colleagues conclude that these differences arelikely to increase with the appointment of more consultants fullytrained in palliative medicine following the Royal College ofPhysicians’ recognition of palliative medicine as a new specialty.

1. Mitchell W. Care of the dying: local government services. Br Med J 1973; i: 39-40.2. Johnson IS, Rogers C, Biswas B, Ahmedzai S. What do hospices do? A survey of

hospices in the United Kingdom and Republic of Ireland. Br Med J 1990; 300:791-93.

Acres of antibodies

Ever thought of growing antibodies in your own back garden? Theidea may not be as far-fetched as it seems, for genetically engineeredantibodies may one day be harvested by the acre, rather than by thegram in the laboratory, if experiments with tobacco plants cansuccessfully be turned to large-scale production. Indeed, a productreview in Nature speculates that agricultural production couldprovide virtually unlimited quantities of any mammalian antibody. 1Last year Hiatt et al reported the expression of immunoglobulinsderived from a mouse hybridoma in transgenic tobacco plants,using a soil bacterium Agrobacterium tumefaciens as vector.2Transformed tobacco leaf segments expressing single gamma orkappa immunoglobulin chains were regenerated to maturity, andthe adult plants were then crossed to yield progeny in which bothchains were expressed. In some of the progeny functional antibodyaccounted for 1-3% of the total leaf protein, and the yield, saysHiatt, could probably be increased by using promoters to enhancetranscription. Tobacco is not the only candidate plant-alfalfa,soybean, tomato, and potato would probably do just as well. Oneuntested feature of plant-derived antibodies is their

immunogenicity in man. The terminal residues of the carbohydrateon the heavy chain will be different from those of mammals. Howthese changes in carbohydrate composition would affect the

antibody’s biodistribution and serum clearance has yet to bedetermined.The main advantage of producing antibodies in plants is the low

cost-perhaps as little as US$100 per kilogram for one grown insoybeans, according to Hiatt. Genetically stable seed stocks fromantibody-producing plants could be stored indefinitely andconverted into a bumper crop of immunoglobulin in one growing

season. The antibody harvested could easily be purified fromhomogenised leaves.

’

The therapeutic and diagnostic potential of antibody agricultureis obvious, but the impermeability of plant cell walls to largemolecules suggests a further possible application of plant-producedantibodies-as biofilters to clean up the atmosphere. The feasibilityof using antibodies locked inside the cells of growing plants toabsorb environmental pollutants of smaller molecular weight is nowbeing explored.

1. Hiatt A. Antibodies produced in plants. Nature 1990; 344: 469-70.2. Hiatt A, Cafferkey R, Bowdish K. Production of antibodies in transgenic plants.

Nature 1990; 342: 76-78.

Three-quarters true

Unlike many other US agencies, the Center for the Absorption ofFederal Funds "has never failed to deliver its promised work". Whosays so? None other than the Center’s near-legendary director,Grant Swinger, recipient of numerous honours including theSegmentation Prize (awarded annually for the most publicationsfrom a single piece of research) and originator of the Swinger index(numbers of papers produced, miles travelled, and conferencesattended). For the uninitiated we can reveal that Dr Swinger is thealter ego of our Washington correspondent, Dan Greenberg, towhom he regularly imparts the choicest snippets from the federalscene in general and the Center’s activities in particular. The firsthometruths from Dr Swinger’s prodigious output appeared in 1983and, as Greenberg comments, should have served as a stem warningagainst "naive faith in the skills and disinterest of heavilycredentialed ’experts’, especially that thriving new breed of pressconference virtuosos who clamor for our attention". Grant Swingernow returns with an expanded second edition; the collectedwisdom encompasses the earlier material plus five interviewsrecorded from 1983 to 1989.Dr Swinger must be heartened by the fact that the intervening

years have witnessed the further "spread of the Swinger spirit in theculture of science". As Greenberg himself also admits, "Never did Iexpect that high bodies within the scientific community wouldcorroborate the substantial existence of the Swingerian style withintheir profession. But so they have, in a succession of doleful reports,issuing from committees assigned to study the debris after oneethical crash or another in the affairs of science". Dr Swinger’sCenter has flourished by a combination of foresight and nimbleness.He astutely identified the key ingredients for surviving the troughsand peaks of federal funding: the need, always, for further study; thecyclical rediscovery of discarded issues such as poverty,malnutrition, and unemployment ; and due deference to the federalresearch agency ethos "never move without surveys, literature

surveys, conferences, and workshops, which lead to publishedproceedings, and followup conferences and workshops".

In 1982 he triumphed with the 200 lb all light meat mega-chicken, developed for the fast-food industry but sufficientlyaggressive for the Defense department, with an eye to newanti-Soviet weapons, to award a grant for helmets and body armour.In 1987 he was despairing about American scientific illiteracy "amajority think a mammogram is a Mother’s Day greeting ... andreverse transcriptase is a Japanese method of shorthand". But let thegreat man speak on his favourite theme: "We have a solid base ofongoing activities at the Center. Overhead and Underhand: TheGrant S’winger Guide to Academic Finance is now in its third edition.We also prepare material on various issues: For and against theSuper Collider, on the justice and the injustice of the peer-reviewsystem-take your choice. We’ve got papers saying the biguniversities are shortchanged on federal research money, and we’vegot papers saying they get too much. On scientific fraud, we’ve gotpapers that argue that the problem happens one in a million,though, of course, we have no idea how often it happens. Ourposition is that even idiotic notions merit a respectful hearing, aconference, and a report."

1. Greenberg DS. The Grant Swinger papers. 2nd ed. Published by Science andGovernment Report, 3736 Kanawha Street Northwest, Washington, DC 20015,USA. Pp 40. $8.95 (add $2.00) for overseas airmail).