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