by James E. Cimino, M.D.

(Presented at the CAMS 1999 Semiannual Scientific Meeting)

Palliative Care (WHO definition)

1. Affirms life and regards dying as a normal process.
2. Neither hastens nor postpones death.
3. Provides relief from pain and other distressing symptoms.
4. Integrates the psychological and spiritual aspects of patient care.
5. Offers a support system to help patients live as actively as possible until death,
6. Offers a support system to help the family cope during the patient’s illness and in their own bereavement.
7. Radiotherapy, chemotherapy, and surgery have a place in palliative care, provided that the symptomatic benefits of treatment outweigh the dis-advantages.

Prevalence of symptoms: Of 1592 hospice patients, over 70% complain-ed about problems of eating or anorexia, weight loss and dry mouth. Over 40% experienced constipation, shortness of breath, bone pain, nausea and difficulty of swallowing.

Principles of pain management:

1. Pain is only one of many symptoms contributing to the suffering.
2. Believe the patient.
3. Identify cause.
4. Can cause be removed?
5. Assessment of the severity- patient knows best.
6. Description of pain by the patient- nature and duration. What makes pain worse or better?
7. Any other symptoms present?
8. Identify the role of loneliness, abandonment, despair, depression, misunderstanding.
9. Know the technical management of pain.
10. The goal is to achieve a maximally oriented and functional patient.

Know the technical management of pain:

1. The use of analgesics- weak to strong.
2. Around the clock dosing.
3. The place of breakthrough analgesics.
4. Anticipate and treat side effects.
5. The use of adjuvant therapy: tricyclics, anticonvulsants, neuroleptics, anti-spasmotics, anxiolytics.
6. Understand physical dependence versus addiction.
7. The dilemma of minimizing pain versus shortening of life.
8. Terminal sedation versus Euthanasia - the difference is intent. A better term is "Sedation therapy".

1. Nonopioid ± adjuvant.

2. Weak opioid (has analgesic ceiling) ± adjuvant.

Barriers to opioid use:

a. Knowledge deficits.

b. Cultural and attitudinal - re addiction.

c. Regulatory authorities.

When patient becomes poorly responsive - opioids may need to be continued in order to avoid withdrawal symptoms. PCA pumps may be used.

1. Cancer cachexia
2. "Food is more than nutrition."
3. TPN? Enteral?

1. Inconsistent definitions.
2. Establish goals.
3. Is there a real chance of achieving these goals?
4. If relief of suffering is the goal - it is different than preservation of life.

Sedation therapy:

Terminal sedation is an ill chosen phrase. Although it may have been intended to describe sedation in a terminal patient, it is often misunderstood to mean sedation that brings about the terminal event. Death is neither the intention nor the expected outcome.

Dame Cicely Saunders, the founder of the modern hospice movement, prefers "aggressive palliation." We would like to substitute the term "sedation therapy." After all, treatment of refractory symptoms is the sole purpose.

1. Voluntarily stopping eating and drinking.
2. Physician assisted suicide.
3. Terminal sedation.
4. Sedation therapy.

Death wish - the issues:

1. Sanctity of life.
2. Intolerable suffering.
3. Reliability of decision- depression, other psychiatric abnormalities.
4. Risk of abuse - patients vulnerability to:

a. Outside encouragement;

Risk of abuse - patients vulnerability to:

a. Outside encouragement;

b. Absence of an advocate.

c. Lack of capacity.

Physicians are not ethically obligated to deliver care that, in their best professional judgement, will not have a reasonable chance of bene-fitting their patients. Patients should not be given treatments simply because they demand them. Denial of treatment should be justified by reliance on ethical principles and acceptable standards of care, not on the concept of "futility", which can not be meaningfully defined. ðP

Dr. Cimino is Clinical Professor of Medicine, New York Medical College, and Medical Director of Palliative Care Unit, The Calvary Hospital.