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“Pain is a more terrible master than Death itself.”


Dr. Albert Schweitzer


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 as the context of “palliative care,” and that term, while not fully satisfactory,1 is used throughout most of the discussions in this chapter. The range of pain syndromes that arise in these situations include 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 “end-of-life” or “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.


The World Health Organization (WHO) has defined palliative care as: “The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families . . Palliative care . . affirms life and regards dying as a normal process . . neither hastens nor postpones death . . provides relief from pain and other distressing symptoms . . and integrates the psychological and the spiritual aspects of care, . . [including helping] the family cope during the patients illness and in their own bereavement.”2


A more recent statement developed by the Task Force on Palliative Care of the Last Acts Campaign,3 formulated by representatives of many leading U.S. professional organizations, states that “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 goes on to specify five “core precepts” of the evolving field of palliative care:


  • 1. Respecting patient goals, preferences, and choices
  • 2. Comprehensive caring of the patient
  • 3. Utilizing the strengths of interdisciplinary resources
  • 4. Acknowledging and addressing needs and concerns of family caregivers
  • 5. Building systems and mechanisms of support for the field.


While it is clear that the field of palliative care encompasses a far broader range of issues than the narrower field of pain management, it is also clear from these definitions that the two fields overlap in important ...

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