Scientific Relieving Non-Pain Suffering at the End-of-life by David D. Cravens, MD, Clay M. Anderson, MDWe 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 Missouri Medicine January/February 2003 Vol. 100 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 Vol. 100 No. 1 Missouri Medicine 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 Missouri Medicine January/February 2003 Vol. 100 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 Vol. 100 No. 1 Missouri Medicine 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 Missouri Medicine January/February 2003 Vol. 100 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 forPhysicians 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: www.ahcpr.gov/clinic/cpgsix.htm).
Morissette MR, Cameron R, Bally GA, eds.
Module 4: Palliative care. In: A ComprehensiveGuide for the Care of Persons With HIV Disease.
Toronto, Ontario: Mount Sinai Hospital and
Storey P, Knight CF. UNIPAC Four: Managementof 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.
com/mayjune95/5no3terminaldyspnea.html.
January/February 2003 Vol. 100 No. 1 Missouri Medicine 79
Randomized-block and randomized complete-block designs (Chapters 21 and 25)Randomized block designs. In a randomized block (RB) design, experimental units are grouped into \blocks" thatare thought to be similar. The random assignment of units to treatments is done separately within each block. Therationale for doing this is that, in the resulting dataset, the proportion of units receiving e
SECTION 1 IDENTIFICATION OF THE PRODUCT AND OF THE SUPPLIER Product Name Lithium Iodide Solution OtherName Manufacturer Scancia IN CASE OF EMERGENCY 955 av. St-Jean-Baptiste Call CANUTEC at 613-996-6666 (24h) Québec, Qc G2E 5J5 SECTION 2 HAZARD IDENTIFICATION May be irritating to eyes, respiratory system and skin. SECTION 3 COMPOSITION/INFORMATION ON INGRE
Scientific
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.
Table 2. Dopamine Agonist for Nausea & Vomiting
hydroxyzine. Doses of 25—50 mg p.o.
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.
usually signifies significant dehydration
symptoms for patients at end-of-life.
of-life and their families or caregivers.