Pgs 5378

Relieving Non-Pain Suffering
at the End-of-life

by David D. Cravens, MD, Clay M. Anderson, MD We discuss non-pain
problems at end-of-life in this
paper. Management of these
problems is key to ensuring relief of
suffering. Much of this paper is a
reiteration of the material on
common physical symptoms, which
is presented in module 10 of the
Education for Physicians on End-
of-life Care (EPEC) project of the
American Medical Association in
conjunction with the Robert Wood
Johnson Foundation.
their goals and values are just asimportant as specific symptom-focused practice of this care are discussed in this Suffering at the End-of-life,” and pain management is discussed in “Pain Relief advisable, or not desired by the patient, 74 Š Missouri Medicine Š January/February 2003 Š Vol. 100 Š No. 1 q 15min until effect, then continuous SQ or IV manage any illness: an accurate history, a as reliable or helpful as is the patient’s or hypnotic therapy may be beneficial.
patient’s face may eliminate dyspnea as pain control are often successful. While anticipatory nausea associated with diagnosing” in these circumstances.
of as the “Eleven M’s”: metastases, opioids. See Table 1 for suggested doses dopamine antagonists, prokinetic nausea is probably dopamine-mediated.
and can be effective as the sole therapy.
January/February 2003 Š Vol. 100 Š No. 1 Š Missouri Medicine Š 75 Table 2. Dopamine Agonist for Nausea & Vomiting hydroxyzine. Doses of 25—50 mg p.o.
therapy to prevent the inevitable opioid- increase peristalsis are helpful. Osmotic content and overall volume of stool.
that facilitate the dissolution of fat in include: dexamethasone 6—20 mg p.o.
effective but are extremely expensive.
lubricate the stool and irritate the bowel lorazepam 0.5—2.0 mg p.o. q 4—6hrs.
stress, or lack of absorptive surface may regular toileting based on the patient’s 76 Š Missouri Medicine Š January/February 2003 Š Vol. 100 Š No. 1 P.O.-titrate to effect (9 or more per day) P.O.-titrate to effect (9 or more per day) in juice or water P.O. then titrate to effect usually help, even if it is only partial.
Treatment options are listed in Table 4.
may be adding to the patient’s suffering support if necessary and appropriate.
enjoyment of food is the primary goal.
January/February 2003 Š Vol. 100 Š No. 1 Š Missouri Medicine Š 77 usually signifies significant dehydration symptoms for patients at end-of-life.
patients and caregivers alter activities to course of illness can be beneficial.
be told it is normal to lose thirst in the provide appropriate assistive devices.
be treated appropriately. Judicious use of patients, and can worsen edema states.
maintain normal intravascular volume.
78 Š Missouri Medicine Š January/February 2003 Š Vol. 100 Š No. 1 of-life and their families or caregivers.
be covered with hydrocolloid dressings.
A primary source for this material is theEducation for Physicians on End-of-life Care Fragile skin at risk for breakdown can be project of the American Medical Association in mattresses, gel mattress, or air-flotation pressure points on cachectic patients.
Emanuel LL, von Gunten CF, Ferris FD, eds.
The Education for Physicians on End-of-life Care (EPEC) Curriculum: The EPEC Project, The Robert Wood Johnson Foundation, 1999.
Doyle D, Hanks GWC, MacDonald N, eds.
Oxford Textbook of Palliative Medicine. 2nd ed.
Oxford, England: Oxford University Press; Quality:
Morissette MR, Cameron R, Bally GA, eds.
Module 4: Palliative care. In: A Comprehensive Guide for the Care of Persons With HIV Disease.
Toronto, Ontario: Mount Sinai Hospital and Storey P, Knight CF. UNIPAC Four: Management of Selected Nonpain Symptoms in the Terminally-ill. Hospice/Palliative Care Training for Physicians: A Self- study Program. Gainesville, FL: American Academy of Hospice and Palliative Medicine; alleviating suffering is rewarding, albeit Storey P. Primer of Palliative Care. 2nd ed.
Gainesville, FL: American Academy of Hospice treatment as end-of-life approaches.
dyspnea. Available at: http://www.grandrounds.
January/February 2003 Š Vol. 100 Š No. 1 Š Missouri Medicine Š 79



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