SiR,—Your Round the World correspondent (Dec 2, p 1325) cites a 103-year-old poem welcoming the "huddled masses" to America and then laments that the Department of Justice in 1987 extended the clause restricting entry into the US of some foreigners with "deadly infectious or contagious disease" to include those who are HIV-positive. The Department is complying with a policy established by the US Congress in 1929 requiring the limitation of entrants into the US who were "likely to become a public charge". The economic load of over ten million illegal immigrants and about half a million legal immigrants annually to the USA is staggering. Many of the newcomers quickly receive free health care, welfare, public housing, social, legal, and penal services, and education. Since 1984, counties in Calfifornia have been obliged by law to provide free routine inpatient services to illegal aliens, even when they could safely return for care to their home countries. I have observed that tourists use several ways to defray medical as proof that their health insurance coverages visits abroad, or purchase of travel or automobile insurance that includes coverage for health services abroad until a person can safely return to their home country. Your correspondent calls for "a highly visible protest and cancelling the San Francisco conference". A more mature approach would have been to see how many attendants at the conference, who, one assumes, belong to well-established institutions and organisations in other countries, are already covered under the health insurance of their home country for visits abroad, and for the organisers of the conference to offer umbrella coverage for the few who are not so covered. The Justice Department is to be applauded for its efforts to comply with the law and to minimise further strain on our health system at a time when the need for rationing health care is spreading from Oregon to other states in the USA because of the enormous cost.
SURVIVAL BY CHANGE IN KARNOFSKY RATING
4770 North Cedar Avenue, Fresno, California 93726-1091, USA
ANDRE N. MINUTH
Financial help for terminally ill patients SIR,-In the UK people who need "a lot of help from another person because of physical or mental disability" and who are so severely disabled that they need "frequent attention in connection with their bodily functions" or "continual supervision throughout the day to avoid substantial dangers to themselves or others" receive financial help (attendance allowance) from the state, after a qualifying period of six months.l Because of this delay terminally ill patients are often excluded from receiving this benefit. The UK Government is proposing to waive this qualifying period for patients with terminal illness. To define this category of patient has proved difficult, however: the Department of Health’s definition in the new Social Security Bill,2 "a person is terminally ill at any time if at that time he suffers from a progressive disease and his death in consequence of that disease can reasonably be expected within 6 months", we think includes an unnecessary reminder of the short prognosis. Moreover, clinicians are usually over optimistic about patients’ survivaland may thus underestimate the appropriate period for receiving benefits. We have analysed data from a consecutive series of 487 cancer patients’ to establish whether survival was shortened in those with disability sufficient for attendance allowance. The Karnofsky index of mobility, which ranges from 100 (normal) to 0 (dead)/ was assessed at referral, and then every week. We believe that people with a score of 60 (requires occasional assistance, but can care for most needs) would not usually qualify for attendance allowance, whereas a score of 50 (needs considerable assistance and frequent care) would do so. 207 (43%) patients had Karnofsky ratings of 50 or below at referral, and the number of days until death was recorded for 189 (91%): the mean and median survivals were 33-9 and 19 days, respectively (SD 40-4, range 1-204). In 167 (34%) patients with ratings over 50 at referral, the ratings fell during the study. The table shows the mean and median days to death according to Karnofsky
*80= normal activity with effort, process
signs and symptoms;
10= moribund, fatal
ratings. There is a clear trend of shorter survival with reducing mobility. Where ratings fell to 50 or below, 92-8% died within 3 months and 98-8% within 6 months. With a cut-off point at 60 or below, we found only a slightly higher proportion of patients lived longer: 91-7% died within 3 months and 97-7% within 6 months. 100 patients (21 %) did not have ratings below 50 at any stage: for most the average weekly rating did not fall below 50 until death. 13 patients were lost to follow-up. In a series of 42 cancer patients Evans and McCarthy3 showed that those with a score of 50 had a predicted survival of 24 days, and those with scores of 50 or less had survivals ranging between 3 and 70 days. In the USA Yates et aP showed that 104 cancer patients with reduced mobility had shortened survivals: only 1 patient with a score of 50 or less lived for longer than 6 months. Of our patients fewer than 2% who were sufficiently disabled to claim attendance allowance survived for more than 6 months. We welcome the Government’s recognition of the financial needs of terminally ill patients but we suggest that the prognosis estimate of 6 months should be removed from the definition of eligibility for attendance allowance. We thank the members of the support teams at Basingstoke Hospital, Bloomsbury, Charing Cross Hospital, St Thomas’ Hospital, and South Bromley Hospiscare. Help the Hospices provided financial support.
Department of Community Medicine, University College and Middlesex School of Medicine, London WC1 E 6EA, UK
IRENE HIGGINSON ANGELA WADE MARK MCCARTHY
1. Attendance allowance application form. London: Department of Health and Social Security, NI 205/July 1984. (Revisions m 1985 and 1986). 2. Social Security Bill 1990 (Bill 51). Clause 1, para 1. 3. Evans C, McCarthy M. Prognostic uncertainty in terminal care: can the Karnofsky index help? Lancet 1985; i: 1204-06. 4. Higginson I, McCarthy M. Evaluation of palliative care: steps to quality assurance. Palliative Med 1989; 3: 267-74. 5. Yates JW, Chalmer B, McKegney P. Evaluation of patients with cancer using the Karnofsky performance status. Cancer 1980; 45: 2220-24.
colleagues’ article (Dec 23/30, p 1509) and accompanying editorial both clearly attack the idea of psychiatric care in the community and the associated closure of large psychiatric hospitals. Weller et al examine destitute people in London and show that 40% of them are seriously mentally ill. Other surveys have given similar results, including that by Priest in the late 1960soHow many of these destitute psychotic individuals had been discharged from psychiatric hospitals as part of the closure programme is not clear. It should be remembered that mentally ill people have always roamed the streets and, in the past, many spent SIR,-Dr Weller and
much of their lives in workhouses. I would not suggest that this is a satisfactory situation, but keeping mental hospitals intact is no better a solution than reopening the old workhouses. In your editorial you cite Penrose2 and claim that the increase in our prison population is directly related to the run-down of psychiatric hospitals. There is ample evidence that this is not a true picture. More offenders who are not mentally ill are being imprisoned and longer sentences are dispensed by the courts. I would also suggest that those who advocate a slowing down or halting of the programme of psychiatric hospital closures should carefully look at what they want to keep open. An examination of