A great part of what we do as primary care physicians is palliative care. There are many people with chronic irreversible conditions that are incurable and they are often associated with a significant amount of pain and suffering. These patients do not all have cancer, although many do. A lot of them “just” have severe arthritis, severe cardiomyopathy, end-stage lung disease, chronic dementia, advanced age, or chronic pain from whatever cause that is unremitting and intolerable.
When we can’t cure the disease or get it into remission, we are left with only one treatment choice- palliate the symptoms. The end result of palliative therapy is either to try to make a nonfunctioning individual functional again, or, in the case of terminal illness, make the symptoms at least tolerable to help abate the suffering.
Pain control is a large part of palliative care. For terminally ill patients whose death is imminent and irreversible, the palliative care specialist will provide comfort and relief of pain, nausea or shortness of breath in whatever way it can be most effectively accomplished. Sometimes this means using increasingly higher doses of IV analgesics given via a PCA (patient controlled analgesia) pump. This is usually done in a hospital setting by supplying a low basal rate continuously with additional doses of analgesic that can be initiated by a button pushed by the patient whenever needed. This, of course requires that they are alert enough to know when to push the button. In some cases, it’s better to just provide a higher basal rate and not use the PCA button. In either case, this obviously requires close supervision, at least in the initial stages. Once the pain control is stable, it can continue to be used in the outpatient setting, monitored by home health nurses and supervised by a physician.
In the case of those patients who are not imminently terminal, the goal of palliative care is different than that of those who are in the process of dying. The goal here is get the individual to become more functional by controlling their pain. The use of oral medications are tried first, beginning with non-narcotics, along with physical therapy, steroid injections, nerve blocks or whatever other modality that can be used to safely control the pain. Some of these patients will have to move on to narcotic analgesics in order to attain some degree of functional status.
It is important to keep the goals in mind when treating non-terminal chronic pain patients. If the treatment you are giving is resulting in improved functionality, then you have done the right thing. If your treatment is making the individual less functional by increasing the risk of falling or by causing lethargy, nausea or severe fatigue, then you need to decrease medication doses until they become functional again.
Issues of addiction in palliative care are usually not concerning when treating terminally ill patients; however, they do become very significant when treating chronic pain patients who are still relatively young and have many years left during which there is plenty of time to build up tolerance to opiate therapy. For these patients, it is easy to get into a situation of lifelong chemical dependency, which should be avoided if at all possible. Sometimes there are no other options if all the alternative modalities of therapy have been exhausted and if the patient has been rendered nonfunctional due to pain. These patients ideally should be referred to a pain management clinic if one is available.
Depression and grief reactions are also frequent and serious problems in these patients with chronic pain and/or terminal illnesses. Family and church support are often helpful. Sometimes too much family support is stressful and confusing as multiple members of the family have different opinions about what should be done. Good communication between the health care team and the patient and family often help to allay fears and confusion. Some antidepressants are known to be helpful in controlling chronic pain as well as helping to reduce anxiety in some situations.
Many hospitals contain palliative care teams who can provide assistance in dealing with these issues of chronic pain and/or end-of-life situations. These are well-trained professionals who understand the problems these patients and their families are facing, can provide emotional support and counseling and are pharmacologic experts in the use of iv and po analgesics and titration of therapy. They are also well-versed in medical ethics, stages of dying, hospice care and comfort care. They can often make the difference between what could have been a miserable, suffering death into a peaceful, dignified passing. Families greatly appreciate this effort and the compassion associated with it.
Similarly, the support that patients and families receive from their primary care physician is often extremely helpful. S/he is often the only health professional the patient can really trust to be sincere and to communicate effectively about what is going on. The primary care doctor is usually the main listening ear that patients can turn to and explain how they feel and know that they are understood. This is a great source of relief for most of these patients and unfortunately, with the current tendency toward discontinuity of care, it is one source of great support that is not recognized as important by many in the profession. If you are able to provide this support, patients and families will be truly appreciative. In many cases, this form of palliative care is almost as effective if not more so than the pharmacologic support.