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This chapter discusses pain control. The phenomenon of pain is found at the juncture of human biology and culture, and the prevailing theory—the gate control theory—of how pain operates allows for a modifying role for culture in one's experience of pain. The chapter shows that modern palliative care cannot function without effective pain control.

Pain is a significant cause of suffering for cancer patients. The onset of pain can herald a host of fears of death, disability, disfigurement, dependence, and distress. The role of healthcare professionals is to offer competent pain management with compassion and commitment to excellence, central to which is facilitating communication with the patient. Pain is not an event in isolation. It occurs in a personal and physical environment influenced by the social, cultural, spiritual, and biological inheritance of the patient. Thus, the experience of pain has a unique impact on, and meaning for, each individual. At the time of assessment, factors such as associated fatigue, depression, and anxiety may result in the pain becoming overwhelming. Assessing the pain involves not only measuring the level of pain and determining the nature of the pain, so as to diagnose the aetiology and mechanism of pain, but also exploring the ‘deeper level of pain experience’. Failure to do so can result in poor pain control and a lost opportunity for transformation of the experience and healing of the individual.

This chapter discusses the implications of the palliative care models on the quality of life and psychological well being of terminally ill patients. Experimental and descriptive studies that evaluated the model of palliative care and used quality of life as an outcome are considered. The term ‘quality of life’ includes the measures to assess the quality of life as well as the measures of pain control, symptom control, and general well being. The chapter does not include discussions on the development of research instruments geared to measure the quality of life, or the impact of palliative care on the quality of life and bereavement of relatives and families, or the implications of palliative care for non-terminally ill patients. However, it does include reviews of assessment tools, the concept of quality of life and its methods of assessment, and the role of care-givers in assessing the quality of life of the patients. Included as well are comparative studies of the palliative care practices and their impact on the quality of life of patients in the US and UK.

Pain is a common symptom in patients with disease arising from, or affecting, the respiratory system. The capacity for pain sensation is found in many of the tissues of the thorax. The most important areas to consider are: the skeletal system, the pleura, the intercostal nerves, and the brachial plexus. This chapter discusses types of pain, the biological basis of pain, a rational approach to pharmacological pain management, non-pharmacological therapies, and future developments in pain control.

This chapter discusses the difficult case of Miriam Lambert, which is as interesting as it is rare in the field of palliative care. Despite the best efforts of the palliative care team to ease and manage pain, the pain she felt remained uncontrollable and unmanageable. Ms Lambert's difficult life and emotional issues compounded her situation. In the hopes to alleviate her unmanageable pain, the palliative care team devised a pain control management using a full spectrum of medications including anesthetic blocks. Supportive nonmedical and psychological interventions such as art therapy, music therapy, and massage were tried; however, the pain persisted.

Cancer is often perceived as a life-threatening illness associated with severe and intractable pain. For most patients, pain is a powerful reminder of his or her disease, which in the latter stages will become more threatening and harder to bear if the symptoms become worse. Adding to the pain is the emotional and spiritual distress brought about by the disease. Pain can be managed; however, controlling pain requires proper administration of analgesics and adjuvant drugs, and therapeutic approaches that addressed the underlying cause of pain. This chapter offers an overview of the ways in which pain is caused by malignant diseases and their treatments. It discusses tumour-associated problems, with particular emphasis on pain. Discussions include the incidence of pain at the onset and at the latter stage of the disease, the mechanisms of pain, the pains caused by cancer treatment, and different forms of pain management.

This chapter discusses the causes, assessment, and management of pain in advanced local breast cancer. The World Health Organization analgesic ladder is used as a basis for cancer-pain management. The authors also provide a description of other methods – non-pharmacological and pharmacological – of pain control. These methods can be used in specific pain syndromes in patients who have advanced local disease.

This chapter examines the use of analgesics for the control of terminal pain. Though there is no need to resort automatically to strong analgesics when a patient approaches the terminal stages of his illness, pain must be relieved as soon as it becomes a matter of complaint. The criteria for giving analgesia, particularly opioids, should be the presence of pain and not the expected length of life. The chapter provides recommended treatment for different levels of terminal pain.

Oregon's Death with Dignity Act was a citizen's initiative passed by the voters in November 1994. After surviving a series of legal challenges, the law allowing physician-assisted suicide became effective on October 27, 1997. Adult residents of Oregon who are terminally ill can make a request to a physician for a lethal medication for the purpose of ending their lives “in a humane and dignified manner.” The physician must determine that the patient has an incurable illness and is competent. The Oregon Department of Human Services collects information regarding compliance with the provisions of the law. This chapter presents demographic data on the 341 patients who have died under the law between 1998 and 2007. Contrary to fears expressed by opponents of the legislation, those who chose assisted death were not the poor or uneducated but the better educated and those with higher incomes. Inadequate pain control was cited only by about one third of those who made use of the law. Instead of concern about good end-of-life care, the fear of losing control and dignity was one of the primary reasons for choosing assisted death. As a result of rapid expansion of palliative care, by 2007 a full 88% of those who chose assisted death were being cared for by a hospice. Despite some remaining problems such as the difficulty of recognizing psychiatric disorders, experience with the law has on the whole been positive and safeguards against abuse appear to be working.

Pain control is a primary goal of palliative care. The World Health Organization (WHO) guidelines for pain control specify an escalating series of therapies, but the ultimate resource for the control of severe pain remains the opioids. Forty to forty-five percent of patients presenting for hospice care complain of constipation on admission. Work is needed to define the mechanisms by which opioids produce constipation. The secondary effects of opioid receptor activation also may be further defined and present new opportunities for pharmacological intervention. Those developing opioid alternatives, especially opioids with differing receptor affinities, have been unable to separate the analgesic properties from the side effects of opioids. Methods to optimize opioid use and traditional bowel care methods are being examined, but it is difficult at times to compare the results of interventions as the model and definition of success vary widely between publications.

In this 2000 article, Cicely Saunders likens the evolution of palliative care to that of assembling a kaleidoscope — ‘the putting together of many demands which were not previously related, giving a shake and finding that they come down in a new pattern or synthesis’. An encounter with one patient in 1948 was the catalyst for the Hospice Movement. The challenge to undertake appropriate pain and symptom control together with experience in further listening to patients in the small number of homes especially planned for dying people finally came together during the 1960s as the impetus for the first modern hospice which opened in 1967. Since then, palliative care has been developing worldwide and has shown that the basic principles demonstrated in those early years can be interpreted in various cultures and with different levels of resources.

The World Health Organization (WHO) defines palliative care as the active total care of patients whose disease is not responsive to curative treatment. Control of pain, other symptoms, and psychological, social, and spiritual problems is paramount. Multiple perspectives, obtained through a variety of research methods, are necessary to provide a greater understanding of the whole person. The goal of palliative care is to achieve the best quality of life for patients and their families. In pediatric palliative care, where systematic knowledge development is only in its infancy, such perspectives become even more critical. This chapter identifies extant research in pediatric palliative care and suggests additional methods or approaches for gaining multiple perspectives.

This chapter presents lessons that can be learned from the four regimes of assisted death examined in this study. The number of individuals who have sought aid in dying has been relatively small and for the most part has been limited to cases of intractable suffering in terminal illness. As knowledge of this remedy spreads, the idea of assisted death becomes more acceptable to both doctors and the public and the number of cases increases. Hence, the number has ranged from 0.19% of all deaths in Oregon to 2.2% in the Netherlands. Contrary to earlier concerns, the enactment of legislation allowing assisted death has everywhere given to a boost to palliative care. Assisted death thus has functioned not as an alternative to the best end-of-life care available, but as a way out for those who suffer inordinately despite all efforts to palliate. The scope of these laws varies. The three European regimes require merely the presence of lasting and unbearable suffering, while Oregon insists that patients be in the terminal phase of their illness. The chapter examines the downside of each approach. It also presents a model statute for the regulation of physician-assisted suicide prepared by specialists in the fields of law and medicine. It concludes that the prolonged experience with assisted death in the four national entities examined makes it possible to develop a regime that will satisfy the need for dignity in dying, assure accountability, and provide adequate safeguards against abuse.

The argument in this chapter examines two accepted palliative care measures that may have the capacity to hasten death: pain control by means of high doses of opioids and terminal sedation. The standard defence of these measures through the Doctrine of Double Effect is then explored and three conclusions are drawn: (1) the Doctrine has no application to these end‐of‐life cases since it assumes that death is invariably a harm; (2) the concept of intention does not allow a bright line to be drawn between permissible and impermissible measures; and (3) in these end‐of‐life contexts the intending/foreseeing distinction makes no ethical difference.

Vincent Shing Cheng’s chapter is based on interviews with Chinese former incarcerated drug users, documenting the painful experience of inmates in the laojiao, or ‘reform through education’, detention centres. Instead of ‘rehabilitation’, the detention centre’s brutal treatment seems to echo a general experience of pain and humiliation aimed at socializing and ‘prisonizing’ the new inmates. This combination of informal and formal violence represents a double-edged sword of pain with its own specific rationality in a Chinese philosophy of pain and control. While criminologists suggest that ‘pain’ is counterproductive to offender rehabilitation, the Chinese prison authority has actively used ‘pain to train’ new inmates for the purpose of control. These experiences stand in stark contrast to the official narratives of education. This contradiction has created a system of hypocrisy as counterproductive for the inmates as the ‘pain’ involved in it.

This chapter argues that progress in the debate requires confronting scientific ideology, the set of basic, uncriticized assumptions presuppositional to twentieth-century science—in particular, that science is “ethics-free.” It contends that failing to treat invasive animal studies as constrained by ethical standards is detrimental to animal welfare, and leads to bad science. This chapter indicates that the denial of the relevance of ethics to science was taught both explicitly and implicitly. It addresses the moral issues in animal research. It presents two paradigmatic examples: pain control and housing in animals.