Patientcontrolled Analgesia

The attractions of enabling patients to manage their own analgesics rather than be dependent on others are obvious. In mild and moderate pain it is easy to provide tablets for this purpose, but in severe chronic and acute recurrent pain, e.g. terminal illness, postsurgical, obstetric, other routes are needed to provide speedy relief just when it is needed. Drug delivery systems range from inhalation devices to patient-controlled pumps for i.v., i.m., s.c. and epidural routes.

Despite the obvious problems, e.g. training patients, supervision, preventing overdose, these can achieve the objectives of satisfying the patient while reducing demand on nurses' time, especially when the aim is to allow the patient to die comfortably at home.

Inhalation via a demand valve of nitrous oxide and oxygen, as in obstetrics, may be used temporarily in other situations: e.g. urinary lithiasis, trigeminal neuralgia, during postoperative chest physiotherapy, for changing painful dressings and in emergency ambulances.

Drugs in palliative care

It is a general truth that we are all dying; the difference between individuals is the length and quality of the time that remains.17 Terminal illness means that period (generally weeks) when active treatment of disease is no longer appropriate and the emphasis of care is palliative, i.e. to provide the maximum quality of life during these final weeks. This means that symptom control becomes the priority because,

One cannot adequately help a man to come to accept his impending death if he remains in severe pain, one cannot give spiritual counsel to a woman who is vomiting, or help a wife and children say their goodbyes to a father who is so drugged that he cannot respond.18

As the scope of life contracts, so the quality of what remains becomes more precious. Symptoms should not be allowed to destroy it. Drugs are preeminent in symptom control. An illustrative instance of success in palliative care is provided here by:

17 Mack R M 1984 Lessons from living with cancer. New England Journal of Medicine 311:1640. Recommended reading: a personal account by a surgeon who had lung cancer with metastases.

18 Dr Mary Baines, St Christopher's Hospice, London.

An elderly gentleman with obstructing carcinoma of the oesophagus who was a keen gardener. He remained at home, free from pain, attended a garden show on Saturday, worked in his garden on Sunday, and died on Monday.19

He was treated with continuous subcutaneous heroin (diamorphine) infusion. Whilst the randomised controlled trial provides a major basis for therapeutic advance, telling us what generally does happen, the clinical anecdote yet has value, telling us what can happen, and providing examples for us to emulate. With intelligent use of drugs, which follows from informed analyses of objectives, doctors can enable their patients to depart from life in peace20 and with dignity, i.e. true euthanasia.21

Whilst the skilful use of drugs can provide incalculable relief and deserves careful study, this must not hide the fact that the manner, attentive-ness and human feeling of the attendants are dominant factors once drugs have controlled any grosser physical and mental aberrations.22 The needs of the dying have been summarised as security, companionship, symptomatic treatment, and medical nursing

19 Russell P S B 1984 New England Journal of Medicine 311: 1634.

I have been half in love with easeful Death, Call'd him soft names in many a mused rhyme, To take into the air my quiet breath;

Now more than ever seems it rich to die, To cease upon the midnight with no pain.' (John Keats: 1795-1821).

21 Euthanasia (Greek: eu: gentle, easy; thanatos: death) is the objective of all. It does not mean deliberately killing people peacefully, which is voluntary euthanasia. That giving increasing doses of opioids and sedative drugs may also shorten life (the 'double effect') 'is not in our view a reason for withholding treatment that would give relief, as long as a doctor acts in accordance with responsible medical practice with the objective of relieving pain or distress, and with no intention to kill'. Report of the select committee on medical ethics. House of Lords, January 1994. HMSO, London.

22 Give me the doctor partridge plump, Short in the leg and broad in the rump, An endomorph with gentle hands, Who never makes absurd demands That I abandon all my vices,

Nor pulls a long face in a crisis, But with a twinkle in his eye Will tell me that I have to die.

(WHAuden 1907-73)

Symptom control and domestic care. Nearly half of the deaths in England and Wales occur in the patient's own home.

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