Therapeutic Guidelines: Palliative care
- Peter Keppel
- Aust Prescr 2002;25:18
- 1 January 2002
- DOI: 10.18773/austprescr.2002.011
'Palliative care is active care.'
This statement rings true to me, having worked in a small rural town for over 16 years, in which the care of the dying is a large part of my practice. Whether it is severe chronic obstructive pulmonary disease, intractable congestive cardiac failure (less often seen now with newer drugs) or cancer, the process always involves a brief introduction, then breaking bad news, then a terminal phase in which shifting goals are negotiated and renegotiated.
The book attempts a lot more than a list of pharmacological options. It opens with general chapters covering principles of palliative care, ethical issues, communication, loss and grief, and analgesic guidelines. It makes the point that general practitioners are by default the co-ordinators of care, as well as being the gatekeepers to the health system. The place of self-care among providers is recognised.
With regard to pain management, the approach is one of identifying different types of pain, e.g. nociceptive (superficial somatic, deep somatic, skeletal muscle, visceral colicky, visceral constant) or neuropathic, rather than the traditional three stage 'ladder' approach.
The emotional, spiritual and social aspects of pain are not ignored. I particularly found useful the approach to delirium and confusion. The problems of the elderly demented patient are dealt with rather briefly, given the large cohort of these people now ageing. No mention is made of the practical problems accessing the newer antipsychotics because of the Pharmaceutical Benefits Scheme prescribing restrictions. The dose of morphine in terminal severe chronic obstructive pulmonary disease patients is stated to be 1 mg 4 hourly, increasing as needed. In my experience this is usually nowhere near enough.
There are useful chapters on medical oncology describing some newer regimens for particular cancers.
The book has been found useful by our active and busy palliative care team. It would not be sufficient on its own to answer all questions on the subject, but is written in a compassionate style, showing the wisdom of experience. There is extensive cross-referencing within the text. There is no list of other texts for reference that I could find.
General Practitioner, Yarrawonga, Vic.