Liming Treatment

Preface

The first edition of the Royal College of Paediatrics and Child Health (RCPCH) document ‘Withholding or Withdrawing Life Saving Treatment in Children: A Framework for Practice’ was published in 1997 and was one of the first documents produced by the newly-formed College. The first edition followed a series of workshops, public meetings and discussions in the Ethics Advisory Committee. There was consultation with a wide range of clinicians, representatives of faith groups and parents’ groups and from individuals with disabilities themselves.

Given the difficult and emotive nature of the subject, and the significant number and differing views of those consulted, the original document acknowledged the impossibility of achieving total consensus, but did identify common ground on which a framework could be built. The framework document was widely used; it did inform constructive debate and provided clarification in this difficult and emotive area.

The second edition, published in 2004, reflected changes in practice and new legislation but retained the same ethical and legal principles as the first.1 Its title was changed from ‘life-saving treatment’ to ‘life-sustaining treatment’ to reflect the fact that the treatment that is often given in these circumstances is not curative but supportive.

The need for a revision of the document has been considered over the past 2 years by the Ethics and Law Advisory Committee of the RCPCH (ELAC-RCPCH). Once again, we have consulted those who have used the document and have incorporated comments from individuals and groups, both in the UK and elsewhere. As before we have attempted to synthesise differing views and values in reaching a consensus. We were also mindful of the change in emphasis in decision making with individuals with life-limiting conditions, as exemplified in the General Medical Council (GMC) document: ‘Treatment and care towards the end of life: good practice in decision making’.2 We have incorporated relevant case and statute law decided or enacted since the last edition. We have also taken into account developments in palliative care provision and the growing availability of ethical and other support in decision making, as well as issues that have arisen in response to the two previous documents. In particular, we have replaced the five criteria that were previously used to identify situations in which limitation of treatment might be discussed with a more formal classification based on quantity or quality of life. We have included a category that formally acknowledges the wishes and preferences of those young people who are able to make decisions for themselves, albeit with the support of their families and professionals.

We accept that decisions to withhold, withdraw or limit life-sustaining treatment in children with life-limiting or life-threatening illness may still prove contentious, difficult and emotive. Once again, we have attempted to provide a framework for practice that is not prescriptive and that attempts to recognise the interests of the child both in his or her own right but also as part of their family. We accept that determining the best interests of an individual child is complex; nevertheless it remains a fundamental consideration in the kind of situations to which this document refers.

We emphasise two important points so as to avoid confusion:

    This document sets out circumstances under which withholding or withdrawing life-sustaining treatment might be ethically permissible—NOT circumstances under which such treatment must certainly be withheld or withdrawn.

    The document describes situations in which individual children should be spared inappropriate invasive procedures—NOT types of children to whom appropriate procedures should be denied.

—Although they are largely covered by forests, soils extreme North of Tunisia have very high agronomic potentialities ; first because they are well preserved against the erosion and well enriched with organic matter, secondly, because they are well watered (annual rainfall greater than 1200 mm). However, they are constrained by the acidity which imposes a restriction in the root growth of the plantes. During the last decades, the walnut plantations were intensified in the forest clearings. However, their production is still very low compared to the optimum levels. The acidity seems to be the most limiting factor; it concentrates in the soil solution toxic elements and therefore provides a hostile environment for roots development. The removal of the soil acidity is fundamental to agricultural development in the forest clearings. The amendment of the acid soils with lime to eliminate the unwanted effects of the acidity is the solution if the goal is to improve the productivity of these soils and to increase the crop yield levels. This research aims to study the effect of the lime on the soil porosity, nutrition and he walnut yield cultivated on an acid soil. A field trial was conducted on a walnuts plantation situated in a forest clearing of the region of Aïn Draham. The experience is arranged in complete random blocks in three repetitions. Treatments are combinations of two rates of lime based on CaCO 3 and with three rates of ammonium nitrate. The results showed that soil liming improved soil porosity significantly, increased leave nitrogen content and leave total potassium. However, there are not significative effect total phosphorus concentration of the. It increased, on the other hand, the yield of walnut very significantly. The nitrogenous fertilization, from in its part improved the soil porosity and did not show impact on the mineral composition of leaves and the walnut yield, regardless of the dose of the lime application.