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| Chapters from Pain Management at the End of Life |
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Why do people experience pain? By describing the pathways of pain, reviewing pain assessment techniques, and briefly discussing pain transmission and classification, Douglas Weschules, PharmD, and Joanne Reifsnyder, PhD, APRN, introduce readers to the phenomenon of pain.
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From the old idea of punitive pain to modern breakthroughs in palliation, William M. Lamers, Jr., MD , traces a history of pain and our attitudes towards it.
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Christine Puchalski, MD differentiates pain (physical) from suffering (spiritual). She then discusses how the two oftentimes combine at the end of life.
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According to Kenneth Doka, PhD, pain management must consider all the factors—physical, emotional, cultural—that affect how pain is experienced and treated.
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In this chapter, John Mulder, MD, gives an overview of the most important part of pain management—assessment. He outlines and briefly evaluates several aspects of pain assessment, including the physical exam, history, diagnostic testing, and psychosocial considerations.
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Pain is inadequately assessed and treated in those with cognitive impairments. Keela Herr, PhD, RN, and Sheila Decker, PhD, describe some methods for breaking this unfortunate trend: the use of surrogate reporters, direct observation of potential pain indicators, monitoring baseline activity patterns, and using analgesic and nondrug trials.
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In chapter seven, Rebecca Selove, PhD, Dianne Cochran, BSRN, and Ira Todd Cohen, MD, discuss the challenges of and best approaches to treating pain in infants, toddlers, children, and adolescents.
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Arthur G. Lipman, PharmD, considers pharmaceutical methods for end-of-life pain management. This chapter servers as a primer on pain management and discusses current debates about how best to treat end-of-life pain.
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By emphasizing an experimental orientation—one that stresses constant re-evaluation of treatment plans— Janet L. Abrahm, MD, uses a case study approach to examine pharmaceutical and nonpharmaceutical approaches to complex pain management.
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Even as helpful data regarding complementary therapies are incomplete, Donna Kalauokalani, MD, discusses the known benefits of "alternative" treatments: improved patient/provider communication, more culturally sensitive treatment options, stress reduction, and a greater perception of family control.
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Samira Beckwith, CEO of Hope Hospice and CSW, outlines how the hospice approach is distinct from other forms of palliation. By utilizing a team-based approach, hospice is able to alleviate pain on multiple fronts: physical, spiritual, psychological, familial, and financial. By treating other forms of discomfort along with physical pain, hospice appropriately treats end-of-life distress in all its forms.
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W.A. Drew Edmondson, attorney general of the State of Oklahoma, examines how the need for effective pain management intersects with the need to reduce illegal opiod diversion. After outlining the conclusions drawn by the National Association of Attorneys General, he stresses the need for greater communication between the end-of-life care community, state attorneys general, medical licensure boards, and the DEA.
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Timothy Keay, MD, describes current deficiencies in medical curricula regarding pain management. He discusses how some current initiatives are improving the situation (including recognition of pain as the "fifth vital sign," and new fellowships in palliative care) and then outlines some helpful efforts in danger from lack of funding.
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Ben Rich, PhD, begins his chapter by recounting the end-of-life physician's dilemma: the ethical obligation to alleviate pain and the regulatory risks involved with possible over-prescription of opiods. He goes on to examine other ethical issues involved in end-of-life care: total sedation, terminal sedation, and physician-assisted suicide.
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