Text 18 Palliative Care and Pain Managemet

The focus of palliative care is to improve symptoms and quality of life at any stage of illness. At the end of life, palliative care often becomes the only focus of care, but a palliative care approach is applicable throughout the course of both serious chronic and terminal illnesses.

Whether the goal is to cure disease or manage chronic illness, clinicians have a responsibility to help ameliorate patients’ suffering. “To cure sometimes, to relieve often, to comfort always” is the crux of palliative care.

The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Palliative care commonly involves management of pain, but treatment of all symptoms is pursued, including physical symptoms, such dyspnea, nausea and vomiting, constipation, and agitation; emotional distress, such as depression, anxiety, and interpersonal strain; and existential distress, such as spiritual crisis. While palliative care has been recognized formally as a medical specialty by the American Board of Medical Specialties, all clinicians should possess the basic skills to be able to manage pain, treat dyspnea, identify possible depression, communicate about important issues (such as prognosis and patient preferences for care), and help address spiritual distress. While palliative care experts are increasingly available in hospital and outpatient settings and while expert consultation may be helpful for many patients, recognizing the importance of symptom management and quality of life is a necessary step for all clinicians in helping patients face serious illness.

Symptoms that cause significant suffering can be considered a type of medical emergency and managed aggressively by frequent elicitation, continuous reassessment, and individualized treatment. While patients at the end of life may experience a host of distressing symptoms, pain, dyspnea, and delirium are reported to be among the most feared and burdensome. The principles of excellent palliative care dictate that comfort is the main focus of care and that properly informed patients or their surrogates may decide to pursue aggressive symptom relief even if, as a known but unintended consequence, the treatments preclude further curative interventions or even hasten death. That said, there is a growing awareness that scrupulous symptom control for patients with end-stage illness may actually prolong life.