Perry E. Jones, M.D.
Family Practice
Anesthesiology
Residency Education Director
Anesthesiology Residency
Brooke Army Medical Center
Ft. Sam Houston, TX 78234-6200
fpgas@aol.com
Palliative medicine is a recent addition to the
list of medical subspecialties. In late 1987, the Royal College
of Physicians of London recognized palliative medicine as a
specialty within general internal medicine.1
Palliative care arose out of the change from acute to chronic
causes of death. Currently the emphasis of health care is on
improving the quality of life. Palliative care has received
increasingattention in the United States as the debate over
euthanasia and AIDS have become political "hot button" issues.
It is now well established that a primary cause for a chronically
ill patient to consider euthanasia involves the lack of adequate
pain control, especially if the patient is already suffering
from a terminal disease process. As the current generation ages,
there will likely be an increase in the numbers of people dying
from cancer. There is an anticipated 20 percent increase in
men and a 12 percent increase in women dying from cancer between
1980 and the turn of the century. A study by Cartwright found
that 84 percent of surviving relatives reported that cancer
patients suffered pain in the last year of life.2
The World Health Organization (WHO) has also realized the efficacy
of palliative care. In 1990, a WHO expert committee on cancer
pain relief and palliative care suggested that 30-50 percent
of cancer patients are experiencing pain or being treated for
it. In an effort to advance the cause, the WHO provides this
definition of palliative care:3
- Affirms life and regards dying as a normal process
- Neither hastens nor postpones death
- Provides relief from pain and other distressing symptoms
- Integrates the psychological and spiritual aspects of patient
care
- Offers a support system to help the family cope during the
patientâs illness and in their own bereavement.
In short, palliative medicine is the active total care of patients
whose disease is not responsive to curative treatment. This
requires a multidisciplinary approach to treat symptoms, control
pain and address the psychological, social and spiritual needs
of the patient. Palliative care can be provided with less expense
and can provide more satisfaction to the patients and their
families.4
The anesthesiologist, especially the anesthesiologist trained
in pain management, should be a member of the multidisciplinary
palliative care team. Given the fact that the primary complaint
of terminal patients is pain, the anesthesiologist should be
central in the palliative medicine model. There is no other
medical/surgical specialty that can provide the medical and
procedural expertise allowing a patient to remain functional
until they die.
Cancer pain may be somatic or visceral due to tumor invasion.
Terminal patients may also present with neuropathic, sympathetically
mediated and centrally mediated pain either due to their end-stage
disease or the treatment of the diseases. The anesthesiologist
is uniquely trained to differentiate and treat these differing
pain entities.
Providing medical management for pain to include non-narcotic
analgesics, narcotics (with all their modes of administration),
anticonvulsants, local anesthetics, steroids and sympathetic
nervous system antagonists may not be the sole purview of anesthesiologists;
members of other specialties may be well trained in all of these
medical regimens. On the other hand, many medical specialists
may not feel comfortable using narcotics in the doses sometimes
required to ease the pain of the terminal patient.
After defining the pain syndromes of the palliative care patient,
there are procedural skills the anesthesiologist possesses that
aid in pain control, including epidural and/or intrathecal administration
of narcotics via implantable pumps, chemical neurolysis of nerve
roots and sympathetic ganglia, cryoanalgesia, radiofrequency
ablation, TENS units and dorsal column stimulators. Many of
these interventions provide long term, patient-controlled analgesia,
thereby allowing the patient to continue to function and perform
their activities of daily living.
There is little research that specifically addresses the utility
of the anesthesiologist in palliative care. Future work in this
area will be vital in expanding the role of the anesthesiologist
as a perioperative physician.
References:
- Doyle D. Palliative medicine: A UK specialty.
J Palliat Care. 1994; 10(1):8-9.
- Cartwright A. Social class differences
in health and care in the year before death. J Epidemiol
Community Health. 1992; 46(1):54-57.
- Goodlin SJ. What is palliative care? Hospital
Pract (Off Ed). 1997; 32(2):13-14.
- Parkes CM. Terminal care: Evaluation of
an advisory domiciliary service at St. Christopherâs Hospice.
Postgrad Med J. 1980; 56:685-689.
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