End-of-Life Care and Palliative Medicine
Palliative care is geared toward the relief of pain and suffering when there is no attainable cure. Palliative care physicians must not only be skilled in the administration of powerful opioids, which are the standard medication to treat the physical pain of terminal illness; they must maintain the ability to treat the emotional pain and suffering of dying patients and their loved ones without offering false hope or making promises that cannot be kept. Most importantly, it is the job of the palliative care physician to maintain a sense of dignity amid the physical and emotion insults that come with loss of independence.
One of the most important tasks for a physician caring for a dying patient is to determine when the time for curative care has ceased. It is only then that palliative care can begin. Ideally, physicians should strive to extend life and decrease suffering; at the same time, they must accept death as a defining characteristic of life. Some physicians, however, have developed dysfunctional attitudes about death, which have been reinforced throughout their lives by their experiences and training. It has been postulated that doctors are more frightened of death than members of other professional group and that many enter the study of medicine so they may gain control of their own mortality using the defense mechanism of intellectualization.
Physicians able to deal with death and dying are able to communicate effectively in several areas, including diagnosis and prognosis, the nature of terminal illness, advance directives about life-sustaining treatment, hospice care, legal and ethical issues, grief and bereavement, and psychiatric care. In 1991, the American Board of Pain Medicine was established to ensure that physicians treating patients in pain were both qualified to do so and were kept up to date on the latest advances in the field.
Students should study the questions and answers below for a useful review of this field.
Helpful Hints
Students should know and define the following terms.
advance directives
DNI
DNR
end-of-life symptoms
euthanasia (active, passive, involuntary, voluntary)
health care proxies
hospice
hydromorphone
living wills
morphine
neuropathic pain
opioids
pain suppression pathways
Patient Self-Determination Act
physician-assisted suicide
psychogenic pain
psychotoxicity
somatic pain
Uniform Rights of the Terminally Ill Act
visceral pain
Questions
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
56.1 A risk factor for the development of aversive reactions in physicians is when
A. the physician identifies the patient with someone in his or her own life
B. the physician is dealing with a sick family member
C. the physician feels professionally insecure
D. the physician is fearful of death and disability
E. all of the above
View Answer
56.1 The answer is E (all)
All people are equal in the face of death, yet physicians are expected to put aside their personal reactions and to remain attentively focused on the care of any dying patient. There is evidence that doctors have more death anxiety than other professionals and may have become physicians to conquer that fear. In addition, long exposure to disease and death breeds anxiety despite the appearance of familiarity. The practice of medicine requires and reinforces intellectual coping skills, teaches that disease must be conquered, and expects that doctors function effectively under any circumstance. However, confrontation with death arouses threatening emotions, the deepest being an inchoate fear that is so rapidly submerged that it is barely experienced, much less explored. Beyond that, all health professionals are at risk for feeling frustrated, helpless, or defeated. Lowered self-assurance is transmuted into rescue fantasies, cynicism, or anger. Hardest of all is the grief when a familiar patient dies, a pain they repeatedly steel themselves to control. Table 56.1 lists risk factors for the development of aversive reactions in physicians.
56.2 The most common cause of undertreatment in patients is
A. noncompliance
B. patients with a high pain threshold
C. lack of knowledge or resources
D. when inexperienced doctors are overanxious
E. lack of communication between the doctor and patient
View Answer
56.2 The answer is C
The most concrete causes of undertreatment are lack of knowledge or resources. Patients in pain require aggressive use of analgesics, and doctors should not be intimidated by criticism about addicting patients. Lack of communication between the doctor and patient, a patient with a high threshold for pain, and overanxious doctors are not concrete causes of undertreatment in patients. Noncompliance can be a source of undertreatment but not to the extent that a lack of resources account for this phenomenon.
56.3 Of the following drugs, the least likely to cause psychotoxicity is
A. hydromorphone (Dilaudid)
B. levorphanol (Levo-Dromoran)
C. methadone (Dolophine)
D. morphine
E. none of the above
View Answer
56.3 The answer is A
Opioids commonly cause delirium and hallucinosis. A frequent mechanism of psychotoxicity is the accumulation of drugs or metabolites whose durations of analgesia are shorter than their plasma half-lives (morphine, levorphanol [Levo-Dromoran], and methadone [Dolophine]). Use of drugs such as hydromorphone (Dilaudid), with half-lives closer to their analgesic duration, can relieve the problem without loss of pain control. Cross-tolerance is incomplete between opiates; hence, several may be tried in any patient, with the dosage lowered when switching drugs. Table 56.2 lists opioid analgesics used in the management of pain.
Table 56.1 Risk Factors for the Development of Aversive Reactions in Physicians | ||
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Table 56.2 Opioid Analgesics for Management of Pain | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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56.4 Which of the following is not true regarding patients with strong religious beliefs?
A. Patients with strong religious beliefs may be strengthened by their illness.
B. Patients with strong religious beliefs have a higher pain threshold.
C. Patients with strong religious beliefs may explain illness as a test of their faith.
D. Patients with strong religious beliefs are often better able to deal with end-of-life issues.
E. Patients with strong religious beliefs may see suffering as having redemptive values.
View Answer
56.4 The answer is B
Patients with well-elaborated faith, especially one that includes a reunion with God in the afterlife, tend to do better at the end of life. Some patients may experience illness as a test of their faith or may view suffering as having redemptive value, and others gain strength from the belief that God will not send them more than they can handle. However, they also often ask, “Why me?” and struggle with anger, a sense of betrayal or abandonment, disappointment, self-imposed guilt, and a loss of faith that leaves them truly desolate. Patients with strong religious beliefs do not have a higher pain threshold.
56.5 Advance directives
A. include living wills
B. include health care proxies
C. include DNR and DNI
D. are legally binding in all 50 states
E. all of the above
