Palliative Care

Transforming the Care of Serious Illness

Diane E. Meier, Stephen L. Isaacs, Robert Hughes

• Publisher: Jossey-Bass
• Year: 2011
• ISBN:
  9781118039649
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Palliative Care is the first book to provide a comprehensive understanding of the new field that is transforming the way Americans deal with serious illness.

Diane E. Meier, M.D., one of the field's leaders and a recipient of a MacArthur Foundation "genius award" in 2009, opens the volume with a sweeping overview of the field. In her essay, Dr. Meier examines the roots of palliative care, explores the key legal and ethical issues, discusses the development of palliative care, and presents ideas on policies that can improve access to palliative care.

Dr. Meier's essay is followed by reprints of twenty-five of the most important articles in the field. They range from classic pieces by some of the field's pioneers, such as Eric Cassel, Balfour Mount, and Elizabeth Kübler-Ross, to influential newer articles on topics such as caregiving and cost savings of palliative care. The reprints cover a wide range of topics including:

• Why the care of the seriously ill is so important
  
  

• Efforts to cope with advanced illness
  
  

• Legal and ethical issues
  
  

• Pain management
  
  

• Cross-cultural issues
  
  

• Philosophical perspective
  
  

The demand for palliative care has been nothing short of stunning—largely because of palliative care's positive impact on both the quality and the cost of care provided to seriously ill individuals. By providing a wide-ranging perspective on this growing field, this book will serve as a guide for developing meaningful approaches that will lead to better health care for all Americans.

PALLIATIVE CARE

PAIN AND MEDICAL DECISION MAKING

Kathleen M. Foley, “The Treatment of Cancer Pain”

Timothy E. Quill and Ira R. Byock, for the ACP-ASIM End-of-Life Care Consensus Panel, “Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids”

Daniel P. Sulmasy, Wayne A. Ury, Judith C. Ahronheim, Mark Siegler, Leon Kass, John Lantos, Robert A. Burt, Kathleen Foley, Richard Payne, Carlos Gomez, Thomas J. Krizek, Edmund D. Pellegrino, and Russell K. Portenoy, “Response to Quill and Byock, ‘Responding to Intractable Suffering’”

14

THE TREATMENT OF CANCER PAIN

KATHLEEN M. FOLEY, M.D.

This article originally appeared as Foley, KM. The treatment of cancer pain. N Engl J Med. 1985;313(2):84-95. Copyright © 1985, Massachusetts Medical Society. All rights reserved. Reprinted with permission.

EDITORS’ INTRODUCTION

Kathleen Foley is the nation’s most prominent leader in pain research and palliative medicine. This 1985 article identifies untreated pain as a major public health problem and describes the science and the safety of appropriate pain management with narcotic analgesics. Twenty-three years later, progress in adhering to Foley’s recommendations remains too slow, but this article was influential in the effort to change physicians’ attitudes and behaviors towards pain management.

Advances in the diagnosis and treatment of cancer, coupled with an expanded understanding of the physiology, pharmacology, and psychology of pain perception, have led to improved care of the patient with pain from cancer.¹ Improved methods of cancer diagnosis and treatment provide the best approach to managing pain by treating its cause. Before the start of antitumor therapy, or when such therapy is unsuccessful or irreversible injury to bone, soft tissue, or nerve has occurred, however, adequate pain control is essential.

Management of pain in patients with cancer requires specific expertise that includes a knowledge of the clinical pain syndromes that are common in cancer and their pathophysiologic mechanisms, the psychological state of the patient, and the indications and limitations of the available therapeutic approaches. Clinical experience suggests that patients with cancer pain are treated most effectively with a multidisciplinary approach that includes adequate analgesic drug therapy, neurological and anesthetic procedures, behavioral methods, and supportive care.²,³,⁴,^-5

The goal of pain therapy for patients receiving active treatment is to provide them with sufficient relief to tolerate the diagnostic and therapeutic approaches required to treat the cancer. For patients with advanced disease, pain control should be sufficient to allow the patients to function at a level that they choose and to die relatively free of pain.^6,7 Critical to the management of cancer pain is the establishment of a trusting relationship between the patient and a physician who takes the pain seriously and assesses its nature and severity.

EPIDEMIOLOGY

Large-scale epidemiologic studies of the incidence and severity of cancer pain are lacking, but numerous studies in specialized medical care settings have demonstrated that the prevalence of pain increases with the progression of disease. Patients with cancer frequently have multiple causes of pain.⁸ Some 15 percent of patients with nonmetastatic cancer have pain.⁹ One-third of adults and children with metastatic cancer report pain that interferes with and reduces their activity level and requires the use of analgesics.¹⁰ With advanced disease, 60 to 90 percent of patients report substantial pain.^3,11,12 It is postulated that 25 percent of all patients with cancer throughout the world die without relief from severe pain.⁹ To remedy this situation, and as part of a broader cancer program, the Cancer Unit of the World Health Organization has formulated a pain-relief program to conduct an epidemiologic investigation of cancer pain throughout the world, to provide guidelines for pain management, particularly in patients with advanced disease, and to encourage national governments to help make therapeutic approaches available, specifically oral narcotic drug therapy.¹³

TYPES OF PAIN

Patients with cancer have two types of pain: acute and chronic. This division is based on an increased understanding of the mechanisms of pain transmission and the recognition that the central modulation of acute and chronic pain states may differ, along with their clinical management and response to treatment. ^14,15 For this discussion the definition of pain proposed by the International Association for the Study of Pain is most useful: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”¹⁶ Because pain is a subjective experience, evaluation of it is difficult. The physician has limited objective signs to confirm the severity of reported pain. The patient and physician are best served if the physician believes the patient’s report.

Acute pain is characterized by a well-defined temporal pattern of onset. It is generally associated with subjective and objective physical signs and hyperactivity of the autonomic nervous system. These signs serve as objective evidence to the physician, substantiating the patient’s report of pain. In contrast, chronic pain is pain that persists longer than six months, in which adaptation of the autonomic nervous system occurs. Patients with chronic pain lack the objective signs common to acute pain. Chronic pain leads to marked changes in personality, life style, and functional ability. Such pain requires an approach that encompasses not only treatment of the cause of the pain but also treatment of its psychological and social consequences.^15,17

Patients with chronic or acute pain from cancer can be further subdivided, providing the physician with a useful classification when considering therapeutic approaches (Table 14.1).

Group I comprises patients with acute cancer-related pain. A subgroup of this category includes patients in whom pain is the major symptom leading to the diagnosis of cancer. For this group, pain has a special meaning as the harbinger of their illness. The occurrence of pain during the course of the illness or after successful therapy has the immediate implication of recurrent disease. Determination of the cause of the pain may present a diagnostic problem, but effective treatment of the cause—for example, irradiation of bone metastases—is usually possible and is associated with dramatic pain relief in the majority of patients.

TABLE 14.1. Types of Patients with Pain from Cancer

I.	Patients with acute cancer-related pain
	a.	Associated with the diagnosis of cancer
	b.	Associated with cancer therapy (surgery, chemotherapy, or radiation)
II.	Patients with chronic cancer-related pain
	a.	Associated with cancer progression
	b.	Associated with cancer therapy (surgery, chemotherapy, or radiation)
III.	Patients with preexisting chronic pain and cancer-related pain
IV.	Patients with a history of drug addiction and cancer-related pain
	a.	Actively involved in illicit drug use
	b.	In methadone maintenance programs
	c.	With a history of drug abuse
V.	Dying patients with cancer-related pain

The second subgroup includes patients who have acute pain associated with cancer therapy—for example, pain after surgery or secondary to the acute effects of chemotherapy. The cause of the pain is readily identified, and its course is predictable and self-limited. Such patients endure pain for the promise of a successful outcome.

Group II, which consists of patients with chronic cancer-related pain, represents difficult diagnostic and therapeutic problems. This group can be subdivided into patients with chronic pain from tumor progression and those with chronic pain related to cancer treatment. Both subgroups have pain that has persisted for more than six months.

In patients with chronic pain associated with the progression of disease—for example, those with carcinoma of the pancreas—the pain escalates in intensity, and combinations of antitumor therapy, analgesic drug therapy, anesthetic blocks, and behavioral approaches to pain control are all attempted with varying degrees of success.

Psychological factors play an important part in this group of patients, in whom palliative therapy may be of little value and is physically debilitating.¹¹,¹⁸ The sense of hopelessness and fear of impending death may add to and exaggerate the pain, which in turn contributes to the overall suffering of the patient. Identification of both the pain and the suffering component is essential to the provision of adequate therapy. Saunders has used the phrase “total pain” to describe the etiologic components other than the noxious physical stimulus, including emotional, social, bureaucratic, financial, and spiritual pain.⁴ Those caring for this group of patients...

Table of contents

• Title Page
• Copyright Page
• Foreword
• Introduction
• Acknowledgments
• REVIEW OF THE PALLIATIVE CARE FIELD - THE DEVELOPMENT, STATUS, AND FUTURE OF ...
• CARE OF THE SERIOUSLY ILL: WHY IS IT AN IMPORTANT ISSUE?
• EFFORTS TO COPE WITH DEATH AND PROVIDE CARE FOR THE DYING
• SOCIAL, LEGAL, AND ETHICAL ISSUES
• RESEARCH INTO END-OF-LIFE CARE
• PALLIATIVE CARE
• THE ENDS OF MEDICINE AND SOCIETY
• THE EDITORS
• Index