TREATMENT OF PAIN AND SUFFERING IN THE TERMINALLY ILL
          
by Alan D. Lieberson, M.D., J.D.

           Alan D. Lieberson, M.D., J.D., author of the text completed its production in 1999 with help and suggestions from others including:
1.     Dr. Hans-Martin Fuchs, Gastroenterologist, Norwalk, CT.
2.     Dr. Robert Levine, Neurologist, Norwalk, CT.
3.     Mary Ellen Loncto, RN, Chief of Oncology Nursing, Norwalk Hospital, Norwalk, CT.
4.     Dr. John Pool, retired surgeon, Wilton, CT.
5.     Mal Warshaw, Certified Grief Therapist and former Chairman of the Hospice Counsel of Connecticut, Westport, CT.
6.     Rev. Thomas Hughart, S.T.D., Ethicist, Bedford, N.Y.
           The opinions expressed in the text are purely those of the author and are not officially sanctioned by Norwalk Hospital or any other organization. The text has purposely not been copywriten. The author welcomes its use, downloading, and reproduction but requests that he and "preciouslegacy.com" be cited in any reproduction thereof.



INTRODUCTION

Introduction/Personal
Introduction/Outline
Introduction/Highlights

 

SECTION I -- PAIN

 

CHAPTER 1. PAIN IN THE TERMINALLY ILL

1.01 Pain in Cancer and Other Terminal Illnesses; Introduction

1.02 The Nature of Pain

1.03 Common Sites and Types of Non-Local Cancer Pain

A. Pain of Neurological Origin

B. Bone Pain

C. Abdominal Pain

D. Lesions of the Mouth

1.04 Pain as a Consequence of Surgery and Diagnostic Procedures

1.05 Pain in Patients With AIDS

1.06 Pain in Other Conditions

1.07 Pain in Special Populations

A. The Elderly

B. Children

C. Minorities

1.08 Early Discussion of Pain Management with Family

1.09 Basic Information About Pain Therapy

1.10 Measuring Pain

1.11 Evaluating Pain; Form

1.12 The Pain Treatment Plan; Form

1.13 Overall Success of Pain Therapy

1.14 AHCPR (DHHS) Guidelines

1.15 AHCPR (DHHS) Statement on Patient Education

CHAPTER 2. PAIN THERAPY USING DRUGS

2.01 Drug Therapy of Pain; Introduction

2.02 The Ladder Approach

2.03 Non-Narcotics

A. Aspirin and Acetaminophen

B. Newer NSAIDs

2.04 Narcotics: In General

2.05 Routes of Administration

A. Intravenous Injections

B. Subcutaneous Infusion under the Skin

C. Intramuscular Injections

D. Oral Administration

E. Buccal Mucosal Administration

F. Rectal Administration

G. Transdermal Administration

H. Nasal Administration

I. Administration into the Central Nervous System

2.06 Opioids in the Ladder Approach

2.07 Opioid Narcotics; Method of Action

2.08 Different Opioid Narcotics

2.09 Different "Potent" Opioid Narcotics

A. Morphine

B. Hydromorphone (Dilaudid)

C. Methadone (Dolophine)

D. Fentanyl (Duragesic or TDS-Fentanyl)

E. Levorphanol (Levo-Dromoran)

F. Meperidine (Demerol)

2.10 Patient-Controlled Analgesia (PCA)

2.11 General Principles of Narcotic Use

2.12 Dose and Choice of Narcotics

2.13 Side Effects of Narcotic Administration

2.14 Treatment of Narcotic Side Effects

A. Constipation

B. Nausea and Vomiting

C. Sedation

D. Mental Clouding

E. Respiratory Depression (decreased breathing)

F. Subacute Overdose

2.15 Influence of Concurrent Medical Conditions on Pharmacotherapy

2.16 Narcotic Tolerance and Addiction

2.17 Adjuvant Drug Therapies

A. Corticosteroids

B. Anticonvulsants

C. Antidepressants

D. Other Drugs

2.18 Reversible Medication Failures

2.19 Inadequate Pain Therapy/Health Care Providers

A. Educational Failures

B. Inadequate Pain Assessment

2.20 Inadequate Pain Therapy/Social Problems/Patients

A. Under-Reporting of Pain by Patients

B. Inappropriate Administration of Pain Medication

2.21 Inadequate Pain Therapy/Social Problems/Cultural and Religious

A. Misunderstanding of Religious Principles

B. Problems of Communication

2.22 Inadequate Pain Therapy/Social Problems/Cost-Containment

2.23 Inadequate Pain Therapy/Social Problems/Poor Communications

2.24 Inadequate Pain Therapy/Legal Problems

A. Threatened Recriminations

B. Practical Difficulties

2.25 Summary

APPENDIX

Table 1 NSAIDs

Table 2 Opioid Narcotics, Comparison of Methods of Administration

Table 3 Table of Dose Equivalents for Opioid Analgesics

Table 4 Table of Adjuvant Drugs for Treatment of Pain

CHAPTER 3. MECHANICAL TREATMENT OF PAIN

3.01 Mechanical Treatment of Pain; Introduction

3.02 Tumor Surgery

3.03 Surgical Nerve Intervention and Anesthetic Blocks

3.04 Radiation

CHAPTER 4. ALTERNATIVE THERAPIES FOR PAIN

4.01 Physical and Psychological Modalities in Pain Relief; In General

4.02 Slow Rhythmic Breathing For Relaxation

4.03 Psychosocial Intervention

4.04 Cutaneous Stimulation

4.05 Exercise/Positioning

4.06 Massage Therapy

4.07 Acupuncture

4.08 Relaxation and Imagery

4.09 Distraction and Reframing

4.10 Hypnosis

4.11 Pastoral Counseling

4.12 TENS Therapy

4.13 Peer Support Groups

 

SECTION II -- SUFFERING

 

CHAPTER 5. INTRODUCTION: SUFFERING IN THE TERMINALLY ILL

5.01 Suffering in the Terminally Ill; In General

5.02 Definition: What is Suffering?

5.03 Treating Suffering Related to Pain

5.04 On Death and Dying/Adapting to the Reality of Death

5.05 Suffering in the Terminal Illness and End-Stage Disease

A. End-Stage Physical Suffering

B. Mental Suffering

C. Existential Suffering

5.06 Effects of Suffering on Others

CHAPTER 6. SUFFERING FROM PHYSICAL SYMPTOMS OTHER THAN PAIN

6.01 Physical Symptoms Other than Pain; In General

6.02 Symptoms Related to Digestion

A. Nausea and Vomiting

B. Constipation

C. Diarrhea

D. Loss of Appetite and Weight Loss

E. Trouble Swallowing

F. Dry Mouth

G. Nutrition and Hydration

6.03 Problems with Breathing and the Lungs

A. Shortness of Breath

B. Cough

C. Hiccough

D. Secretions

6.04 Neurologic Problems

A. Insomnia

B. Confusion, Delirium and Dementia

C. Terminal Restlessness

D. Seizures

E. Headache

6.05 Conditions of the Skin

A. Itching

B. Bedsores

C. Edema

D. Odors

6.06 Bladder Problems

6.07 Weakness and Other General Symptoms

CHAPTER 7. MENTAL SUFFERING IN THE TERMINALLY ILL

7.01 Frequency of True Mental Illness in the Terminally Ill

7.02 Specific Mental Conditions Related to Terminal Illness

A. Anxiety

B. Depression

C. Therapy of Depression

(i) Drug Therapy

(ii) Psychiatric Care

(iii) Family Care

7.03 Existential Suffering

A. Definition

B. Factors in Existential Suffering

C. Applicability of Medical Treatment to Existential Suffering

7.04 Specific Fears

A. Pain

B. Death

C. Physical Symptoms Other Than Pain

D. Being a Burden on Others

E. Family Desertion

F. Abandonment by Physicians

G. Loss of Standing or Status Within One,s Profession, Family, and/or Community

H. Losing Mental Ability

I. Narcotic Addiction

J. Loss of Dignity During the Process of Dying

K. Being, Or Being Considered, A Worthless Individual

7.05 Other Causes of Existential Suffering

A. Inability to Obtain, Evaluate and Use Information

B. Loss of Ability to Control One,s Bodily Functions/Loss of Dignity

C. Loss of Ability to Maintain Access to One,s Family or Society

D. Loss of Ability to Control People Formerly Controlled by the Patient

E. Hopelessness

7.06 Stressing Past Accomplishments

7.07 Helping Establish Closure

7.08 Helping Patient with Unfinished Family Business

7.09 Being There

7.10 On Showing Compassion

7.11 Choosing Appropriate Caregivers to Question the Patient

7.12 Working Through Problems/The Physician,s Role

7.13 Specific Suggestions

A. Maintaining Appearance

B. Helping Maintain Function

C. Adding Meaningfullness to Life

D. Stressing Pleasure

E. Honoring Privacy

CHAPTER 8. SUFFERING AND THE PROVISION OF ARTIFICIAL

NUTRITION AND HYDRATION

8.01 Employment of Artificial Sustenance; Introduction

8.02 Nutrition and Hydration as Part of Dying Naturally

8.03 Methods of Artificial Nutrition and Hydration

8.04 Do Terminally Ill Patients Suffer Starvation and Thirst?

8.05 Considering Artificial Sustenance

A. Benefits of Forsaking

B. Emotional Aspects

C. Societal Aspects

D. Religious Aspects

E. Ethical Aspects

F. Legal Aspects

G. Traditional Medical Practice

H. Palliative Care Medicine

I. Feeding Tubes

8.06 Author,s Opinion

8.07 Reaching a Decision

CHAPTER 9. ADDITIONAL ISSUES/SUFFERING AND THE TERMINALLY ILL

9.01 Family Issues/Family Suffering

A. Caregiver Burden

B. Family Showing of Compassion and Respect

C. Family Pressures and Dying at Home

D. Family Concerns Regarding Patient Suffering

E. Family Demands for Futile Therapy

F. Family Concerns in Stopping Aggressive Therapy

G. Family Requests for Assisted Suicide

9.02 The Signs of Dying

9.03 Physician Issues/Physician Suffering

A. Inadequate Training

B. Palliative Care as Non-Traditional Care

C. Death as a Failure

D. Recurrent Need to Deal with Death

E. Time Considerations

F. Specialization and Costs

G. Variability in Desired Treatment Philosophies

H. Dealing with Families in Conflict

I. Dealing with the Law

J. Miscommunications

K. Physicians Facing Their Own Mortality

9.04 Telling Patients the Truth

9.05 Desirability of Working with Patients, Not Surrogates

9.06 Balancing Symptom Relief and Sedation

9.07 Financial Issues

 

SECTION III -- HOSPICE AND ALTERNATIVES TO PAS

 

CHAPTER 10. HOSPICE

10.01 Hospice; Introduction

10.02 Hospice; History

A. England

B. America

C. Home v. Institutional Hospice Care

10.03 Hospice Philosophy

10.04 Hospice Approach

A. Primary Concern is Symptom Relief

B. Interdisciplinary Team and Plan of Care

C. Autonomy and Patient Communication

D. Working with Family Caregivers

E. Emphasis on Home Care

10.05 Hospice Experience

10.06 Medicare and Hospice

10.07 Hospice Cost

10.08 Problems with Hospice

10.09 Separation of Care

CHAPTER 11. DOUBLE-EFFECT AND PHYSICIAN ASSISTED SUICIDE

11.01 Double-Effect; Introduction

11.02 The Principle of Double-Effect

11.03 Historical/Religious Development

11.04 Ethical Considerations

11.05 Legal Considerations

11.06 Clinical Effects

11.07 Double-Effect Versus Euthanasia

CHAPTER 12. TERMINAL SEDATION

12.01 Terminal Sedation; Introduction

12.02 Frequency of Need

12.03 Symptoms for Which Employed

12.04 Medications Used

12.05 Usual Period of Sedation

12.06 Patient Choice/AMD

12.07 Ethics of Terminal Sedation

12.08 Legal Aspects of Terminal Sedation

12.09 Clinical Implications of Terminal Sedation

12.10 Clinical Use of Sedation When Discontinuing Life-Support

12.11 Terminal Sedation Versus Euthanasia

CHAPTER 13. VOLUNTARY TERMINAL DEHYDRATION

13.01 Voluntary Terminal Dehydration; Introduction

13.02 Historical Development

13.03 Case Histories

13.04 Thirst and Hunger

13.05 Medical Aspects

13.06 Ethical Aspects

13.07 Legal Aspects

13.08 Practical Undertaking

 

SECTION IV -- RELATED ISSUES

 

CHAPTER 14. ADVANCE MEDICAL DIRECTIVES IN THE TERMINALLY ILL PATIENT

14.01 Advance Medical Directives; Introduction

14.02 General Values of Writing a Living Will

14.03 Common Law Living Wills

14.03 Common Law Living Wills

14.05 The Patient Self-Determination Act

14.06 Living Will Form Declaration When Terminally Ill

14.07 Form Notice to Health Care Provider

14.08 Health Care Powers of Attorney: In General

14.09 Pros and Cons of Designated Health Care Agents

14.10 Choosing a Health Care Agent

14.11 Determination of Competency/Capacity

14.12 Other Concerns of the Physician

14.13 Decisions of a Health Care Agent

14.14 Advantage of a Combined Document

14.15 Form: Durable Power of Attorney for Health Care

14.16 Do-Not-Resuscitate Orders: In General

14.17 Do-Not-Resuscitate Orders/Difficulties

14.18 Do-Not-Resuscitate Orders/Principles Guiding Decision-Making

14.19 Do-Not-Resuscitate/Hospital Forms

14.20 Do-Not-Resuscitate Orders for Use at Home

14.21 Do-Not-Resuscitate Orders/Special Considerations

14.22 Anatomical Gifts: In General

14.23 Anatomical Gifts; Surrogate Decision-Making

14.24 Anatomical Gifts: Form

CHAPTER 15. GRIEF, MOURNING AND BEREAVEMENT

15.01 Grief, Mourning, and Bereavement; Introduction

15.02 Anticipatory Grief

15.03 Grieving as a Normal Process

15.04 Responsiveness to Understanding

15.05 Timing

15.06 Stages of Grief

15.07 Symptoms of Grief

15.08 Grief Versus Depression

15.09 Grief Therapy

15.10 Shadow Grief/Grieving by Others [Burn-out]

CHAPTER 16. GRIEVING FOR PATIENTS WITH ALZHEIMER'S DISEASE

16.01 Patients with Alzheimer,s Disease; Background

16.02 Natural History and Prognosis in Alzheimer,s Disease

16.03 One or Two Individuals

16.04 Artificial Nutrition and Hydration in Alzheimer,s Disease

16.05 Suffering and Grieving in Alzheimer,s Disease

16.06 Grief Therapy for Relatives of Patient,s Dying of Alzheimer,s Disease

16.07 Institutionalization of the Alzheimer Patient

CHAPTER 17. SPIRITUALITY AND TERMINAL ILLNESS

17.01 Spirituality; Introduction

17.02 Spirituality; Definition

17.03 Spirituality as Different Than Religion

17.04 Uniqueness of Spirituality

17.05 Reasons for Trying to Understand the Patient,s Spirituality

17.06 Promoting Spirituality

17.07 Efforts to Determine Spirituality

APPENDIX -- Issues Related to Spiritualism

I. Religion

II. Attitude Toward Self/Spirituality

III. Support Family/Friends

IV. Illness/Terminal Care


Table of Contents Introduction Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7
Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17

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