The Law Commission of India has recently taken up the study of legal issues relating to 'limiting life support' in patients in Intensive care units. Physicians, particularly, those dealing with critical care, feel that a debate on these issues is necessary towards the creation of appropriate legal provisions. This article summarises the existing international legal position.

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The absence of guidelines for withdrawal and withholding of life support in Indian law is perceived to be the most important obstacle to the practice of appropriate end of life care. In addition, physicians appear to be apprehensive about their civil or criminal liability when called upon to make decisions to limit life-supporting therapies. The following account explores the existing Constitutional and legal provisions that can reasonably be used by physicians in their defence. The article provides illustrative case histories that bring to focus the ethical dilemmas commonly faced by the physician .It also spells out the need for new legislation specifically addressing end-of-life issues.

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Consideration of end-of-life issues is a relatively new phenomenon in the Indian context. It is difficult to assess the magnitude of the problem except the certainty that these issues will affect more patients and their families in the future. The approaches used in the West to prepare patients and public in general such as living will and durable power of attorney have not always been useful. The religious and social attitudes have an effect on facing end-of-life issues and yet these attitudes are in transition. The lack of education in bioethics and paucity of case law is reviewed. New approaches to the end-of-life issues in the light of experience gained in the West are suggested.

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Acute colonic pseudo-obstruction is managed with bolus neostigmine as shown in a recent prospective, double blind, placebo-controlled study. Parasympathetic stimulation with neostigmine leads to abdominal pain, salivation, and symptomatic bradycardia. We submit a more effective method may involve use of neostigmine infusion to reduce complications and improve efficacy.

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We present three cases of iatrogenic tracheal injury. Two patients suffered acute tracheal injuries during anesthesia/surgery, one was managed surgically and the other conservatively. The third case is a delayed tracheal injury presenting as a fistula. The reasons for surgical vs conservative management of tracheal injuries and preventive measures are discussed.

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We present a rare case of unexpected sudden death in a young woman with undiagnosed sickle disease. The provocative factors for the terminal events were excessive exercise in the form of trekking, urinary infection, and emotional stress .the sudden cardiovascular collapse could have resulted from acute pulmonary hypertension resulting from severe hemolysis or acute chest syndrome .

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Mechanical ventilation is a life-saving therapy used in children in PICU. These critically ill children are usually extensively investigated in PICU. Chest radiograph is an irreplaceable investigation in these patients prior to ventilation. AIM: We studied the impact of initial chest radiograph on the final outcome of ventilated children. DESIGN: Retrospective. SETTING: Tertiary care teaching hospital. METHOD: One hundred and forty-one children were included in the study. Initial chest radiograph of all the ventilated children was evaluated and outcome of these children was correlated with the initial radiograph at admission. RESULTS: Abnormal initial radiograph was recorded in 60% (n = 84) ventilated children. Overall mortality in ventilated children was 24% (n = 34). Ventilated children with abnormal initial radiograph had significantly greater mortality (28/84) than those with initial normal chest radiograph (6/57) (P < 0.05). CONCLUSION: Initial chest radiograph at the beginning of ventilation may be useful to predict the outcome of these children

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