Pain and Ethics in the Terminally Ill
Gonzalo Herranz, department of Bioethics, University of Navarra
Ongoing Session on Advances in Clinical Pathophysiology
University of Navarra, School of Medicine/University Clinic
auditorium, March 23, 1995, 7:35 PM
grade: development Semi-schematic
Study. skill in diagnosis and treatment of pain
B. Barriers to the patient or family
C. Barriers from health systems
Properly assess the patient and pain
Determine the pathophysiological mechanisms of each pain and the implications for its treatment.
There is no need to ponder the importance of the topic: the threat of euthanasia and medically assisted suicide hangs over him. The dilemma that will define the identity of the medicine of the future.
Lack of skill palliative, exacerbation of the internship euthanasia. The Netherlands: medical acts around the end of life, 40% of deaths from non-acute illnesses.
Dealing with skill Terminal pain is not just a matter of skill professional. It is also, and above all, an ethical question.
It is amply demonstrated that, with the general exception of physicians and nurses who are engaged in pain management, oncology or palliative medicine for a wide variety of diseases, few have adequate knowledge of the pathophysiology and pharmacology of pain and that put them in a position to treat pain. internship. I would like to thank this course on the pathophysiology of pain.
It is said that part of this professional insufficiency is linked to the survival of culturally and religiously based traditions or to professional prejudices linked to the fear of inducing addiction.
None of those counter-reasons are tenable. Doctors who treat pain badly, who mistreat their patients, leaving them plunged either into coma or overdose-induced death or into the permanent crisis of unbearable pain, have neither in medical science nor in religion the slightest support.
And that is an ethical-deontological problem.
Two years ago, before the reform of the legislation in Spain on the new prescription of narcotics, (narcotics, Alloza's letter: inappropriate word: used by police, people, jurists, politicians and toxicologists in a context of criminality: Narcotics Restriction Service in the Ministry of Health and Consumer Affairs) in a study by Zenz and Willweber-Strumpf, published in the Lancet analysed opiophobia and the treatment of cancer pain among doctors in certain European nations. The average consumption of DDD (defined daily doses, 30 mg) of morphine per million inhabitants per day ranged from a high of 3048 in Denmark, to 1438 in the UK, to 605 in Switzerland, to a low of 39 in Greece, 91 in Italy and 168 in Spain.
This was blamed on legal regulations, which were very restrictive in southern European countries and in Germany and Austria, and very liberal in the Nordic countries. In some places, there was a need for special prescriptions, a special card for patients in need of opioids, prescriptions that were valid for a short time and could not be reused. The regulations, in many cases prior to 1950, sought to prevent the underground market or the development of addiction. The value of oral opioids in treating cancer pain had not been discovered at the time. The consequence is that the pain of cancer patients was not adequately treated.
Why this opiophobia?
Fear of drug addiction
But the study of opioid use in recent times, following the WHO standards on the treatment of pain in cancer, shows that there is no relationship between the prevalence of drug addiction and opioid prescription.
Religious Prejudice
A letter from Josep Eladi Baños and Félix Bosh from the Department of Pharmacology and Psychiatry of the Autonomous University of Barcelona, in Bellaterra, suggested that the Catholic Church could constitute an important cultural element in the restriction of the use of morphine in some societies.
In any case, a lack of ethics
Overcoming scientific-professional ignorance and pseudo-religious ignorance are ethical operations of the first magnitude.
Study. skill in diagnosis and treatment of pain
Thus speaks the committee American Society of Clinical Oncology Ad Hoc on Cancer Pain:
More than 70% of cancer patients experience significant pain at some point in the course of their disease.
The general consensus is that cancer pain can be treated properly and effectively.
The good work Diagnosis makes it possible to determine the causes of cancer-related pain.
The list of effective pharmacological agents is long and growing.
And despite all that, most patients are poorly treated for their pain.
A major factor in that failure is the ignorance of doctors. They have neither been taught nor wanted to learn how to deal with cancer pain.
It is deontologically obligatory to deal with skill and good compassion for the pain of the cancerous
ASCO proclaims that patients have the right to such effective treatment.
And that the assessment and cancer pain management is integral to the responsibilities of physicians in general and oncologists in particular.
The first obligation is to overcome complexes and eliminate prejudices that prevent or inhibit righteous conduct. They come from various places.
to. Acknowledging one's own ignorance. Learn how to assess pain and how to treat it.
b. To believe that only terminals are dependent on maximum analgesic treatment.
c. Believing that patients are not good judges of pain intensity.
d. Not knowing how to distinguish between tolerance, physical dependence, and psychological dependence or addiction.
and. Unfounded and excessive fear of opioid toxicity.
f. Excessive fear of the risk of iatrogenic opioid addiction.
g. Excessive fear of health authorities' control over consumption and prescriptions.
h. Ignorance or misinformation about the multimodal approach to pain management.
B. Barriers to the patient or family
to. Ignorance that pain can be treated and relieved
b. Do not accuse pain so as not to give the impression that the disease is progressing.
c. Fear of the effect of opiates: risk of addiction, confusion, personality change.
d. Cost of pain treatment. Slow-release morphine.
C. Barriers from health systems
to. Lack of interest
b. Fragmentation of care among several specialists
c. Unfriendly pharmaceutical services.
Properly assess the patient and pain
Take a good medical history of pain. It is the best cure against prejudice. Listen to the sick. Overcoming preconceptions and feelings aroused by the sick: I will not allow my feelings to come between my patient and the services I provide. Listen to the patient, listen to him, ask him, to make a good diagnosis of pain.
History is taken by the day: you have to change your ideas and treatment because the pain, and the patient, change. Evaluate what is done, maintain it, modify it, or change it. Follow the changing story of pain.
Know the instruments for assessing pain: assessment Scales of variation, inventory: they are useful. They are not pure American activism and an obsession with justifying one's own performance in front of the judges: it is careful attention to the needs of the patient. Learn to handle at least one quantitative scale. Assess pain in patients who have difficulty expressing themselves.
Determinants of pain: Direct effect of the tumor, pain from interventions, intercurrent diseases.
Determine the pathophysiological mechanisms of each pain and the implications for its treatment.
Nociceptive, somatic or visceral pain due to tumor infiltration, compression, infection, muscle spasm, ureteral or intestinal obstruction, hepatomegaly.
Neuropathic pain: by nerve section, by polyneuropathies, paraneoplastic or induced by chemotherapy, sympathetic pain, afferentation pain.
Pain from psychological factors
Chronology of pain, decisive for dosage: continuous, intermittent, intermittent acute on a continuous background.
Evaluate other factors that influence pain: depression, tiredness, social and economic problems, prognosis, metabolic disorders (hypercalcemia), nausea, cough, etc.
Education of the patient and family about the pain and its treatment.
Know a lot of therapeutics
Know that there are not only medications: there are human, spiritual factors that need support, activation, encouragement. Respect dignity, activity, self-care whenever possible.
Palliative medicine, better as a team.
That there are specific problems: of the elderly and children, for example.
Analgesics are the fundamental pillar, but it cannot be ignored that there are other supports: multimodal treatment. There is palliative radiotherapy and surgery, and adjuvant pharmacology (antibiotics, hormones, palliative chemotherapy, radionuclides: beta, for example). Neurostimulatory and neurosurgical procedures, anesthesia (due to permanent or temporary block of nerve trunks), physiotherapy, psychological support.
Be aware of the cost: careful use of expensive medications, they fatigue the pocket or cause a tendency to ration.
Know the pharmacology and dosage of analgesics: the entire analgesic ladder. From non-narcotic analgesics, from acetaminophen to non-steroidal anti-inflammatory drugs. How they can be combined with opioids. Of the properties, advantages, disadvantages of opioids to treat moderate or severe pain: those that are enhanced, those that accumulate, those that lose potency, those that are not useful for much. of the routes of administration, of the need to adapt the dose to the needs, which may be fixed or changing. About the use of the right intervals, about how to combine background treatments with attack treatments for painful crises. Know the side effects and how to treat them: gastrointestinal, alertness, affectivity, mood depression and respiratory depression, urinary retention.
You have to master concepts of equianalgesic doses in order to switch from one opioid to another.
It is important to be attentive to the problem of tolerance to analgesics and recognize its importance in the treatment of cancer pain, lest, due to a lack of understanding of a biological phenomenon, we make an inoperative treatment and the injustice of placing the label of drug addict on an innocent person.
Stable disease does not require escalation of opioid doses. When patients need dose escalation, it is because significant progression, recurrence, or spread is likely occurring.
It is important, therefore, to have a clear concept of the existence of physical dependence. Addiction, on the other hand, is a psychological, behavioral phenomenon. Iatrogenic addiction is an exceptionally rare phenomenon in the course of treating cancerous pain in patients of any age.
Know the indications, pharmacological properties and dosage standards of adjuvant analgesic therapy. It is a chapter that promises a lot, but already gives a lot. Nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, corticosteroids, neuroleptics, antihistamines, analeptics, benzodiazepines, and others: diphosphonates, local anesthetics, cannabinoids, calcitonin, baclofen.
Finally, don't forget iatrogenic pain, induced by bone marrow punctures, lumbar punctures, venipunctures, cannulations, etc. Every time they have to be done, prevent anxiety, pain, discomfort. Accumulate them in short periods of time: don't be frequently bothering for one thing, for another.
This requires knowing how to answer the syllabus on assessment and cancer pain treatment committee ad hoc of the Soc. Amer de Oncol Clín. is published in the J Clin Oncol 1992;10:1976-1982.
The conclusion of a splendid article on the treatment of pain in cancer (Cancer 1993; 72:3393-3415) is this: there is a modern strategy for treating cancer pain that, when applied correctly, is ordinarily effective. Unfortunately, many oncologists are not well prepared for the task of assessing and treating pain, so the results achieved in the internship are often less than optimal.
An essential element of that strategy, as well as the right one assessment Of the types and components of each patient's pain, is the use of primary therapies with systematic administration of non-opioid analgesics and opioids. It is of the utmost importance internship In opioid pharmacotherapy, the selection and dosage of the drug, determining the route of administration, determining the dose, and treating side effects. It is necessary to strike a wise balance between pain relief and unwanted effects. To this end, it is necessary to take into account the possibilities contained in the use of adjuvant analgesics, psychological therapy, psychiatric techniques, among non-invasive interventions, and among invasive interventions intraspinal opioids, nerve stem block and neuroablative techniques. Finally, sedation can be used in the treatment of patients whose pain is refractory to all other interventions.
Expert application of this strategy can provide adequate relief to the vast majority of patients, most of whom will respond to systemic pharmacotherapy without further ado. Patients with refractory pain should be placed in the hands of pain management or palliative medicine specialists who can often successfully deal with these difficult problems.
With that, the ethical problem is simplified.
We will never fall into the trap of doing nothing about the evicted. There's a lot to do and a huge field to do well.
History of pain management progress.
The harshness of the old regime. Lurches from unbearable pain to extreme sedation, with serious disturbances of the sensorium and respiratory and digestive physiology. Indirect euthanasia.
Reaction to patients' pleas: Saunders, Bonica. Treat them as they ask.
Progress from comprehension to self-administered analgesic treatment.
The Catechism of the Catholic Church says in point 2279: "Even if death is considered imminent, the ordinary care due to a human person cannot be legitimately interrupted. The use of analgesics to alleviate the suffering of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not intended, neither as an end nor as a means, but only foreseen and tolerated as inevitable. Palliative care is a privileged form of selfless charity. That is why they should be encouraged.
In the letter of the health workers, published last November by the Pontifical committee of the Pastoral Care of Health Care Workers, what journalists like to call the Pope's Ministry of Health, an entire epigraph is delineated, in Chapter III: Dying, to the use of analgesics in the terminally ill patient.
I transcribe it in its entirety, for it clearly summarizes the Church's teaching on the subject. topic that interests us this afternoon. Ago reference letter as well as some previous documents of the Holy See on the subject, especially the Instruction on Euthanasia of the Congregation for the Doctrine of the Faith
122. Analgesics should be included among the treatments to be provided to the terminally ill patient. which, by favoring a less dramatic course of the disease, help to humanize and accept dying.
And yet, the use of painkillers does not constitute a rule behavior. (Says a grade At the bottom of the page: For the believer, "pain, especially that of the last moments of life, takes on a particular meaning in God's plan of salvation", as a "participation in the passion" and as a "union with the redemptive sacrifice" of Christ. To this end, the Christian can freely decide to accept this pain without relieving it or only reducing it by moderating the use of analgesics: SCDF: Declaration on Euthanasia, May 5, 1980). But no one can impose "heroic behavior" on another. But it often happens that "pain diminishes the moral strength" of the person: suffering "aggravates the state of physical weakness and exhaustion, hinders the decision of the soul and exhausts the moral forces instead of sustaining them. On the other hand, the suppression of pain provides a physical and mental tranquility that facilitates prayer and makes possible a more generous gift of self."
"Human and Christian prudence suggests for the majority of patients the use of appropriate medicines to relieve or suppress pain, even if this results in hindering or diminishing lucidity as side effects. As for patients who are not in status If they do so, it may reasonably be assumed that they wish to receive such painkillers and should be given them on the advice of the physician."
The use of painkillers in the dying is not, however, without difficulties.
123. In the first place, its employment It can have the effect, in addition to relieving pain, of anticipating death.
When "proportionate reasons" are required, "it is permissible to use in moderation narcotics that alleviate suffering, but can also lead to a more rapid death." In such a case, "death is not willed or sought in any way, even if it is risked for a reasonable cause: it is simply intended to relieve pain in an effective way, using the analgesics available in medicine."
124. There is another eventuality: that of causing a suppression of the consciousness of the dying person with painkillers. Such status It deserves particular consideration.
"One cannot, without grave reasons, deprive the dying person of his conscience." Sometimes, the resource It is a systematic threat to narcotics that reduce the patient to unconsciousness, concealing the desire, often unconscious, of health workers not to have relations with the dying person. The aim is not so much to alleviate the suffering of the patient as to alleviate the discomfort of those around us. The dying person is deprived of the possibility of "living his own death", plunging him into an unconsciousness unworthy of a human being. Therefore, the administration of narcotics with the only purpose to spare the dying a conscious end is "a internship truly deplorable."
A different case is a serious clinical indication for the use of analgesics that suppress consciousness in the case of violent and excruciating pain. Therefore, anesthesia can be described as licit, but with the conditions mentioned above: that the dying person has satisfied or can still satisfy his moral, family and religious duties.
This is Catholic doctrine. He is not a bit intolerant of medical science: on the contrary, he demands skill when it comes to managing pain therapy. Let the patient choose. It creates an obligation to deal. But it imposes the limit of respecting life and the person, not sacrificing them to hedonism or the convenience of others. It bows to extreme situations, but requires rectitude of intention, for it does not tolerate deliberate harm.
I think that many of the ethical problems that arise are pseudo-problems. They depend more on professional insufficiency, i.e. lack of training internship And truly skill, than of the inconveniences that the Catholic religion may oppose.
It simply requires acting in accordance with sound reason. When it is invoked as a cause of the deficient treatment of pain – this happened recently among us – it is because the teaching of the church is as ignored by the people as the good internship of analgesia is ignored by doctors.
1. Treating pain as experts is the obligation of terminally ill care physicians.
They must have the humility to seriously and competently assess pain, as failure to do so is a major reason for poor treatment.
3. They need to know much more about the causes, mechanisms and treatments of the different types of pain, and learn to recognize that in the patient's suffering there may be several variants that must be specifically treated.
4. They must follow the changing evolution of pain day by day, in order to adapt the therapeutic behavior to the needs of each moment.
5. They must be flexible. Tolerate the involvement of the closest collaborators (residents, nurses) to deal with emerging crises. They can't tyrannize the status and impose gratuitous suffering. Any delay in the treatment of pain creates not only undue suffering, but also makes it difficult to master the pain. status. There's plenty bibliography in nursing journals that show the harshness and callousness of the doctor. Leriche used to say that there is no pain more tolerable than the pain of others.
7. Have confidence in people. Patient-controlled analgesia. Patient-controlled analgesia requires confidence, patience, looking for the spot, and moving it when necessary. Adapt it to situations. It can sometimes be entrusted to a relative: the father of a child, for example. Or a patient who is finally asleep and could rest if someone activated the pump before the pain woke them up. It is important to adjust the basal infusion rate and self-administered doses. It's not just the patient who can feel the pain. Sometimes patients with rheumatoid arthritis have difficulty pressing the button. The drug addict raises important questions when he or she is the patient of the PCA.
The seriousness of the problem to humanize terminal illness. Thank you to those who stay up late to ease pain and reject the black ghost of euthanasia.