Ethical considerations in the treatment of pain in a hospice environment
Introduction
The vast majority of patients treated in hospices throughout the world suffer pain due to advanced disease; most being cancer or AIDS sufferers. Not having cancer or AIDS, however, is from the hospice perspective, not a guarantee of being luckier. Untreatable cancer causes death within weeks or months, non-cancer diseases may do this in months or years and the pain may be even more difficult to control. Hospices form a specific environment for dying people and their families in providing several important aspects of care. For those people who are about to complete their life’s journey, a hospice is a place where they will not only get rest and be autonomous in making their own informed decisions, but also where they may feel safe and find shelter. Hospices were designed to address many problems dying people normally encounter on the busy wards of modern hospitals or at home. Undoubtedly hospices helped to set up new standards in the field. By doing this, however, they could not avoid creating new problems and ethical dilemmas. This paper deals with both ‘old’ and ‘new’ problems.
Section snippets
The needs of patients
Hospices are institutions for the care of the dying and terminally ill, however, the term terminally ill may be defined very widely. Palliative medicine as practiced in hospices and palliative care units is usually defined as total and continuous care for the patient and his family when the disease does not react to curative treatment and death becomes inevitable [1]. The specific feature of the hospice environment is recognition of different levels of patient’s needs. At the ‘foundations’ of
The pain analysis
The treatment of pain in hospices, which is usually a very complex process, begins from a thorough analysis and listening to what the patient has to say. Pain, although frequent, is nearly never the only symptom the patient is talking about. Pain is usually interconnected with many other symptoms and it has an emotional meaning to the patient. The pain may remind patient about the losses he/she experienced in the past or will experience in the near future. It is only occasionally a new symptom,
Myths about opioids
Relying only on the ‘objective’ methods of pain diagnosis and measurement and postponing thorough analysis, as described above, may lead to the origin of new myths. In the past, the fears of addiction and drug tolerance were the reasons for their underprescription [2]. The old myths have faded now, nearly away helped by enormous pressure of the pharmaceutical industry, but new myths emerge and become dominant. Opioids used without proper initial analysis are thought to be the panacea for all
Goals of pain therapy
Imagine the following model. The patients’ physical activity is being measured by a wrist actometer. This simple device, which is increasingly popular in physiological research [4], registers the movements of the patients’ arm, which is proportional to the patients’ activity. The dose–activity obtained by the continuous measurements will be bell-shaped (Fig. 2). By increasing the dose of opioid in a situation where this drug is well-chosen analgesic, better analgesia is being obtained. This may
Experimenting versus extrapolating
Many pain therapies are first developed and proven in a safe clinical environment. The patients who are treated in the double-blind trials are usually young(er) and in much better conditions than those patients in the last stage of their diseases that we meet in hospices. The organ functions of terminally ill may change in a day and this is the reason why certain treatments may become more toxic even if they were well tolerated previously. Unusual adverse events, never described for this type
Taking risks in pain therapy
Occasionally another problem with choosing the right treatment may be encountered. The cancer patient with severe neuropathic pain may be reasonably expected to respond to tricyclic antidepressants (TCAs). However, his physician refuses to prescribe these drugs because of the risk of cardiac arrhythmia. As all other drugs have been found to be ineffective, the patient’s prognosis is limited to several weeks and his pain appears to be intractable. Administering the TCAs gives a chance to control
Patients’ autonomy
Hospices were designed in order to increase patients’ autonomy. These should be the places where the patients are really listened to and where they may really participate in making the treatment decisions. Although broader, the autonomy in hospices is also not unlimited. Each patient may refuse treatment, but what do we do with the patient who refuses reasonable pain treatment and screams from pain the whole night keeping all fellow patients awaken? The hospice physician should, of course, ask
Life prolongation and shortening
Many decisions taken at the end of life have directly or indirectly to do with life shortening or prolongation. The subject of opioids and the influence on the survival has been discussed above. When the dose of opioids is too high, the side-effects will be sedation that may result in dehydration and death. An opposing problem is created when the patient suffers from headache, nausea and vomiting due to brain tumor. Usually there are two possible treatments. One of them is symptomatic treatment
Intractable pain
Despite all what we know and can do in palliative medicine, some pain symptoms may appear intractable. In terminal care, many physicians would say that there are no intractable pain conditions, as increasing the dose of opioids, sometimes combined with other drugs, like sedatives, will always result in pain control even if they would make patient comatose and speed patients’ death. However, many intractable conditions are due not to the paucity of treatment modalities, but to the patients’
Patients who request assisted death
Many patients admitted to the hospices, not only in The Netherlands, due to the comfortable feeling of increased autonomy, discuss with their physicians issues of assisted death. Approximately 25% of our patients do so [7]. Usually these discussions take place before admission. Very few refuse to be admitted to the hospice because it does not provide euthanasia. Many others, however, express the wish that assisted death is dictated by the feeling of hopelessness. Many are afraid of something.
Conclusion
Hospices are expected to affirm life but also accept death. Accepting death means that many decisions concerning pain and symptom treatment may be different, sometimes even opposite to those that may be expected in the earlier stages of disease. Accepting death does not mean that the carers should passively wait for death but actively, with a dose of creativity, search for the best means of pain and symptom control. The specific way how palliative care physicians look at the problem of complex
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2017, Medycyna Paliatywna w PraktyceAlzheimer disease and euthanasia
2010, Ethical Foundations of Palliative Care for Alzheimer DiseaseEuthanasia - The illusion of autonomy
2006, Medicine and Law