Dismantling the Barriers: Providing Palliative and Pain Care

KEYWORDS:
• chronic disease
• narcotics
• opioids
• pain
• palliative care
• terminal care

In 1997, the Institute of Medicine (IOM) published a report, Approaching Death, that called for the need to improve care of patients at the end of life.¹ The IOM report identified serious deficiencies in the current provision of palliative care in the United States. Among its 7 recommendations, health care professionals were asked to commit themselves to use existing knowledge to reduce pain and manage symptoms in patients facing death. The report also recommended that medical training programs educate practitioners in the care of dying patients.

For patients whose disease is not responsive to curative therapies, palliative care offers pain control, symptom management, and psychological and existential support to maximize patients' quality of life.² Historically, cancer has served as the model disease in the development of hospice and palliative care services, but importantly, the IOM report calls for the expansion of such services to patients with noncancerous chronic illnesses.

Providing compassionate and competent care to dying patients and families is an enormous challenge for the medical profession. Major attitudinal, behavioral, educational, and institutional barriers have been described that prevent physicians from delivering and patients from receiving the desired humane and compassionate treatment.^1-3 Pain is one of the most common complaints of patients seeking medical attention. Among the general population surveyed in 1997, 72% feared dying in pain.⁴ In an earlier survey of cancer patients, 57% endorsed the statement that a painful death can be expected with cancer; 69% reported that they would consider suicide if their pain was not adequately treated.⁵ Prevalence studies reveal that one third of adult and pediatric cancer patients in active therapy and two thirds of those with advanced disease require analgesic drugs.⁶ Studies from the World Health Organization Cancer and Palliative Care Unit show that 4.5 million patients from developing and industrialized countries die each year in uncontrolled pain.²

In a landmark study of 1308 oncology patients, 56% reported moderate to severe pain, and 72% of physicians expressed their lack of knowledge concerning pain management.⁷ Pain is also prominent in seriously ill patients with noncancer diagnoses; moderate to severe pain has been identified as a major symptom in 50% of seriously ill patients who were conscious during the last 3 days of life.⁸ These and other data support the concept that pain is a serious public health problem.

Impediments to adequate pain treatment include health care providers' fear of inducing physical or psychological addiction, misconceptions about pain tolerance, and assessment biases. A strict drug regulatory environment that closely monitors physicians' prescribing practices further contributes to patients' undertreatment. Major medical and nursing textbooks devote a few pages to current pain and symptom control guidelines.⁹ This inadequacy has been most evident in the care of dying patients in cases where physicians' ignorance of the proper use of opioids has led to needless suffering.^{3, 10} The recent Supreme Court decision against a constitutional right to physician-assisted suicide endorsed the need for pain control and palliative care.¹¹ More importantly, it supported the aggressive use of opioids to manage symptoms as distinct from physician-assisted suicide.^{10, 12}

Advances in pain research have redefined our understanding of tolerance and neuropathic pain, offering new therapies to maximize pain relief and minimize side effects. Protocols, such as the WHO Three Step Analgesic Ladder,² provide detailed methods to facilitate pain relief for patients.

These efforts, coupled with the IOM's call to action, are signs that improving pain and palliative care is becoming a priority for medicine. Medical students can participate in curriculum electives that incorporate didactic and experiential learning in pain management and palliative care. Increased attention to pain and palliative care education by each medical school is critical if we are to reduce the barriers to patient undertreatment that education, clinical experience, and role modeling can readily change.