Therapeutic ratio and defined phases: proposal of ethical framework for palliative care.

Abstract

radiation and surgical intervention and, in addition, resources are wasted. Large studies of children who have swallowed foreign bodies do not show that ingested coins that have passed beyond the cardia cause complications in children with a normal gastro? intestinal tract13; only one such case seems to have been described.4 Furthermore, the potential hazard of prolonged asymptomatic gastric retention of swallowed coins (more than two weeks) may have been exag? gerated. In our experience such coins eventually pass spontaneously and, under experimental conditions of gastric acidity, the dissolution of toxicologically significant quantities of metal is unlikely to occur (I M House, National Poisons Unit, Guy's Hospital, London, personal communication). The management of swallowed coins in children in the United Kingdom could be improved. Adopting the scheme outlined in the figure would reduce the radiation dose received by many children and produce a considerable financial saving. An initial single antero posterior radiograph of the neck and chest is advisable even in asymptomatic patients because of the dangers from silent oesophageal impaction.5 A lateral radio? graph may then be necessary to localise coins in the neck and upper chest. When the coin is below the cardia only symptomatic patients require further assessment. Searching of stools is both unpleasant and inaccurate.