The basic principles of the diagnosis and management of pain syndromes are similar across all clinical settings. Details of the application of these principles, however, can vary significantly depending on the clinical context. One context that is especially important is the care of patients with incurable, progressive, and ultimately fatal illnesses who are in or approaching the terminal phase. This is sometimes referred to in the context of “palliative care,” and this term, although not fully satisfactory,1 is used throughout most of the discussions in this chapter. The range of pain syndromes that arise in these situations includes most of the acute and chronic pain syndromes addressed in detail in other chapters in this text, and their management primarily involves the same diagnostic and therapeutic strategies and skills. Nonetheless, pain management in the palliative care setting often raises clinical and ethical issues that are at least somewhat different from those in other settings. This chapter focuses primarily on those differences.
PAIN MANAGEMENT AND PALLIATIVE CARE: OVERVIEW
“Life cannot simply be put on hold while treatment is endured.” —Ira Byock, MD
The Task Force on Palliative Care of the Last Acts Campaign,2 formulated by representatives of many leading U.S. professional organizations, states: “Palliative care refers to the comprehensive management of physical, social, spiritual, and existential needs of patients, particularly those with incurable, progressive illnesses. Palliative care affirms life and regards dying as a natural process that is a profoundly personal experience for the individual and family. The goal of palliative care is to achieve the best possible quality of life through relief of suffering, control of symptoms, and restoration of functional capacity while remaining sensitive to personal, cultural and religious values, beliefs, and practices.” The Task Force identified five “core precepts” of the evolving field of palliative care:
Respecting patient goals, preferences, and choices: Identifies and honors the preferences of the patient and family through careful attention to their values, goals, and priorities, as well as their cultural and spiritual perspectives and assists patients in establishing goals of care by facilitating their understanding of their diagnosis and prognosis, clarifying priorities, promoting informed choices, and providing an opportunity for negotiating a care plan with providers
Comprehensive caring: Places a high priority on physical comfort and functional capacity, including management of pain and other symptoms; diagnosis and treatment of psychological distress and assistance in remaining as independent as possible or desired; and provides physical, psychological, social and spiritual support to help the patient and family adapt to the anticipated decline associated with advanced, progressive, incurable disease
Using the strengths of interdisciplinary resources: Requires an interdisciplinary approach drawing on the expertise of, among others, physicians, nurses, psychologists, pharmacists, pastoral caregivers, social workers, ancillary staff, volunteers, and family members to address the multidimensional aspects of care; incorporates the full array of interinstitutional and community resources (hospitals, home care, hospice, long-term ...