Continuum, December 2005, Volume 11, Issue 6

Palliative care has been defined as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illnesses, through the prevention and relief of suffering. Unfortunately, many neurologists have received inadequate training in its principles and practice. This chapter will provide an overview of palliative care, emphasizing first the critical communication skills necessary for physicians dealing with patients with very serious, often fatal, disorders. Ethical concerns will be introduced but discussed in greater detail in a subsequent chapter. Specific symptomatic management issues, including pain, fatigue, and dyspnea, will be addressed. Metastatic cord compression is a prototypical example of pain in the context of cancer and will serve as a focal point of the discussion of pain.(C) 2005 American Academy of Neurology

Ethics is the branch of philosophy that deals with distinctions between right and wrong and with the moral consequences of human actions. The ultimate purpose of ethical analysis is to help individuals do what is right and good in a particular situation. Although there are many approaches to ethical analysis, the most widely accepted approach is to begin by considering ethical theories, from which ethical principles may be derived, and guide the making of specific decisions in specific situations. An important first step in ethical decision making is to establish the goals of treatment. Advance care planning permits patients and families to begin the process of anticipating difficult decisions that may lie ahead. Because palliative care often involves decisions to discontinue life-prolonging treatment, including medically administered hydration and nutrition, understanding the ethical rationale for making such decisions is an essential part of providing palliative care. Although palliative sedation remains controversial, it is not equivalent to euthanasia or physician-assisted suicide and is ethical in appropriate circumstances.(C) 2005 American Academy of Neurology

Pain is treated ineffectively. Routine pharmacological measures can provide adequate relief in 85% to 90% of patients with pain related to cancer, yet 40% of patients with cancer die in pain ( Foley, 1996). Appropriate assessment of pain syndromes coupled with a judicious selection of analgesic medications can improve pain management dramatically ( Jacox et al, 1994). Opioid analgesics are the mainstay of the treatment of severe pain at the end of life, but their use is often limited by their side effects. Physicians' concerns about tolerance, dependence and addiction, and patient-related factors further limit their use. This chapter offers specific guidelines on assessing pain syndromes, appropriately managing the difficult side effects of constipation, somnolence, and nausea, and recognizing and understanding tolerance, dependence, and addiction. The end-of-life issue of "double effect" is also addressed. Patients must be assured that they will not die alone and that they will not die in pain. Case studies illustrate each of the principles discussed.(C) 2005 American Academy of Neurology