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