Pain Control in Terminal Care
Pain is a common and feared symptom in the dying.
It is not inevitable. It occurs in up to 70% of patients with advanced cancer and about 65% of patients dying of non-malignant disease. Much can now be done medically to make their last few weeks or months relatively pain-free. An average GP will have 10 patients receiving terminal care each year, 5 of them dying of cancer, and good palliative care can make a huge difference to the quality of an individual's end of life.
Terminally ill patients often report that they fear intractable pain more than they do dying. Patients frequently express the desire to have open and honest dialogue with medical carers about pain and want to be involved fully in planning their pain management. A doctor must be able to get alongside the patient and their family and to spend time presenting options, answering questions and quelling fears. Having promised to keep the patient relatively pain-free, it is paramount to meet this promise to preserve trust. Pain is easier to prevent than it is to relieve and drugs should be prescribed on a prophylactic basis with no other consideration than maintaining the patient's quality of life.
Pain is a complex subjective phenomenon and is affected by the emotional context in which it is endured. Adequate psychological support is critical as removing the fear of pain in itself will help to optimise pain control. A patient who is fearful, withdrawn and depressed often appears to have a lower pain threshold than one who is still actively engaged in enjoying what is left of their lives, even though they may have same stage disease. Non-drug measures to help psychological or spiritual distress may be as important as medication in relieving pain and suffering.
Whilst pain relief is vital, good palliative care encompasses far more. Within primary health care teams, improving the quality of palliative care can be facilitated by the Gold Standard Framework. Similarly, good practice is outlined in the Liverpool Care Pathway for the Dying, which provides an important resource for those caring for those at the end of life. Good communication within and between teams is vital, eg between primary and secondary care and between usual daytime GP and out-of-hours provision, to avoid unnecessary problems during this period.
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