Care of the Dying Patient: Volume 1 - Softcover

Softcover

ISBN 10: 0826218903 ISBN 13: 9780826218902

Verlag: University of Missouri Press, 2010

Inhaltsangabe

Although the need for improved care for dying patients is widely recognized and frequently discussed, few books address the needs of the physicians, nurses, social workers, therapists, hospice team members, and pastoral counselors involved in care. Care of the Dying Patient contains material not found in other sources, offering advice and solutions to anyone—professional caregiver or family member—confronted with incurable illness and death. Its authors have lectured and published extensively on care of the dying patient and here review a wide range of topics to show that relief of physical suffering is not the only concern in providing care.

This collection encompasses diverse aspects of end-of-life care across multiple disciplines, offering a broad perspective on such central issues as control of pain and other symptoms, spirituality, the needs of caregivers, and special concerns regarding the elderly. In its pages, readers will find out how to:

• effectively utilize palliative-care services and activate timely referral to hospice,
• arrange for care that takes into account patients’ cultural beliefs, and
• respond to spiritual and psychological distress, including the loss of hope that often overshadows physical suffering.

The authors especially emphasize palliative care and hospice, since some physicians fear that such referrals may be viewed by patients and families as abandonment. They also address ethical and legal risks in pain management and warn that fear of overprescribing pain medication may inadvertently lead to ineffective pain relief and even place the treating team at risk of liability for undertreatment of pain.

While physicians have the ability to treat disease, they also help to determine the time and place of death, and they must recognize that end-of-life choices are made more complex than ever before by advances in medicine and at the same time increasingly important. Care of the Dying Patient addresses some of the challenges frequently confronted in terminal care and points the way toward a more compassionate way of death.

Über diesen Titel

Über die Autorin bzw. den Autor

David A. Fleming, M.D., MA, FACP is Professor and Chairman of the Department of Internal Medicine and Director of the Center for Health Ethics at the University of Missouri School of Medicine and Governor of the Missouri Chapter of the American College of Physicians.

John C. Hagan III, M.D., is Editor of the journal Missouri Medicine and practices in Kansas City.

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Care of the Dying Patient

University of Missouri Press

Copyright © 2010 The Curators of the University of Missouri
All right reserved.
ISBN: 978-0-8262-1890-2

Contents

Foreword, Edmund D. Pellegrino.........................................................................................................ixAcknowledgments........................................................................................................................xiiiIntroduction, David A. Fleming and John C. Hagan III...................................................................................11. Pain Management at the End of Life Clay M. Anderson................................................................................92. Relieving Pain: Today's Legal and Ethical Risks David A. Fleming...................................................................173. Relieving Non-pain Suffering at the End of Life Clay M. Anderson...................................................................304. Questions and Answers about Hospice: A Guide for Physicians Steven Zweig and Paul Tatum............................................455. The Burden of Caregiving at the End of Life David A. Fleming.......................................................................586. Helping Older Patients and Their Families Make Decisions about End-of-Life Care Steven Zweig and David R. Mehr.....................687. Cultural Sensitivity in End-of-Life Discussions David A. Fleming...................................................................848. Redefining Hope for the Terminally Ill Debra Parker Oliver.........................................................................1019. Spirituality and End-of-Life Care Scott E. Shannon and Paul Tatum..................................................................11510. The Path Ahead: Difficult Lessons for Physicians and Society David A. Fleming.....................................................128Notes on the Contributors..............................................................................................................145Index..................................................................................................................................151

Chapter One

Pain Management at the End of Life Clay M. Anderson

Pain is a universal aspect of life and part of our sensory experience. It is necessary and adaptive. At the same time, it is a form of suffering that can affect the duration and detract from the quality of human life. Currently, there are both pharmacologic and nonpharmacologic tools that allow us to modify pain in such a way as to minimize its impact on quality of life. This is a miracle of modern medicine. Still, around the world as well as in the United States, most pain sufferers are inadequately treated, for a variety of reasons. In other countries, the necessary medications may not be available. In the United States, the barriers to adequate pain modification include regulatory burdens, cost, myths about pain and pain medicines, and lack of education for the public and for medical professionals.

Significant pain is present in the majority of patients dying of chronic diseases such as cancer, heart disease, lung disease, and diabetes. End-of-life care entails treating patients with these chronic diseases when the diseases are in their final phase, with the focus on bringing about relief of suffering and aggressively treating symptoms caused by the diseases. The common complaint of pain at the end of life is usually eminently treatable now, yet most patients remain undertreated. Here I will describe the problem of pain at the end of life and then show a way to optimally manage pain in this vulnerable population.

The Problem: Pain and Its Pathophysiology

Pain, one of many forms of suffering, is common at the end of life and is usually accompanied by a plethora of other symptoms, including dyspnea, nausea, confusion, anxiety, and depression. Pain seems to be the predominant symptom and also the most feared form of suffering. Pain at the end of life is protean and complicated. No two patients are alike in terms of the pathophysiology of their pain complaints or the psychosocial contexts of their pain. Pain at the end of life is undertreated, which is completely preventable. There is an ethical obligation in medicine and nursing to relieve suffering, and it is this directive that should lead physicians and other providers, as well as society in general, to bring down barriers and optimize pain management throughout life, but particularly at the end of life.

The pathophysiology of pain is complex, with new scientific discoveries in this area occurring frequently. I will now explain the basic concepts of pain pathophysiology so as to inform the rationale for optimal pain-management strategies. Nociception, the most upstream signal in pain physiology, occurs when tissue damage results in the stimulation of peripheral neuroreceptors in tissues, which, in turn, transmit a signal to a peripheral nerve. Transmission is the traversing of a pain signal from the nociceptor to the peripheral nerve to the spinal cord to the brain stem to the midbrain to the sensory cortex to the association cortex. Next is modulation, when, at least at the levels from the spinal cord and above, descending and local signals serve to either dampen or accentuate the ascending pain signals from the periphery. After modulation comes cognition, the final, summed subjective sensation of pain and modifying influences as experienced by the patient. Finally, expression is the communication of this cognition to others, verbally or nonverbally. Although simplistic, this schema allows us to get from a painful site in the body to the point where the person suffering the pain tells the provider about the pain in the context of his or her life and illness, and also shows us the levels at which any intervention might have an impact upon the pain.

Assessment and Therapy

Thorough assessment of pain is absolutely vital in order to treat it optimally and manage the disease causing it appropriately. This is true for diseases in the end-of-life phase as well as eminently curable conditions. Important factors in the assessment of pain include determining the following: location—subjective and anatomic description of where the pain is situated; chronicity—the duration of the pain complaint; temporal pattern—how the pain changes over time; severity—the intensity of the pain complaint, often measured from 0 to 10 (ordinal scale) or on a visual analog scale; character—how the pain is described, as sharp, dull, stabbing, burning, etc.; and associated findings—at the end of life, many other findings may be present, including dyspnea, cachexia, fever, depression, etc. A comprehensive approach to treating pain, one that takes into account both its characteristics and the results of the workup indicating possible etiology and/or a unique pathophysiology, is most likely to be successful.

Assessment, workup, and therapy sometimes occur nearly simultaneously in the real-life situation, but in general, an initial assessment and treatment is usually followed as soon as possible by a thorough workup in the outpatient or inpatient setting. The workup includes a physical examination—a good general examination with special attention to the neurologic and musculoskeletal findings; laboratory examination—judicious use of laboratory tests to confirm or refute suspected conditions causing the pain complaint (for example, infection or bone metastasis); radiographic...

Details zur Ausgabe

• Verlag: University of Missouri Press
• Erscheinungsdatum: 2010
• Sprache: Englisch
• ISBN 10: 0826218903
• ISBN 13: 9780826218902
• Einband: Taschenbuch
• Auflage: 1
• Anzahl der Seiten: 154
• Herausgeber: Fleming David A., Hagan John C. III
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: Nicht verfügbar