The hospice movement has been receiving
a great deal of attention lately. Care of the dying has become the
byline for any professional as well as non-professional writers. You
are sure to find at least one article in any current journal for
health professionals devoted to the care of the terminally ill.
Television has presented news miniseries and specials on the needs of
the dying, and syndicated columnists, such as Sylvia Porter, have
written on the subject. Why all this interest in the dying? 4hy all
this interest by the health professionals who have been dealing with
dying clients for centuries? One answer has been to attribute this
recent attention to the fact that people are now living longer than
even a half-century ago. However, the answer is quite likely much more
complex than that. There is currently an internal evaluation process
being carried out in most health related facilities. These evaluation
procedures have evolved from government and consumer demands over
recent years. It has become a recognized fact that within the medical
and nursing professions not enough attention has been given to the
care of the dying and/or the handling of the dying client.
Attempts are made to correct this dilemma. Medical and nurai1:,;
schools are now offering courses and recommending them to their
students on such topics as "Perspectives on Death and Dying." They
have not reached a required status in most college curricula; however,
death and dying is at least accepted as a topic to be discussed in
the professional preparation of the future health care practitioners
in this country.
When considering the health care needs
of the dying today, many think of the work of Dr. Elisabeth Kubler-Ross
with her theory of the Stages of Death and Dying, and the work of
other thanatologists, and most recently the hospice movement. This
work will focus on hospice. Just what is the Hospice concept and what
are its roots?
The term "Hospice" comes from the Latin
root Hospes which means both host and guest. It implies, therefore, a
mutual caring between practitioner and recipient. The first Hospice in
modern times is the well-known St. Christopher's in London from which
the American Hospice movement grew. However, the original hospices
date back to medieval times. They were way stations established by
religious communities to provide care and personal attention to those
who became sick or wounded on their travels to the Holy Land. They became famous for the excellence and compassion of the care
given in them. They were the historical institutions from which more
specialized modern institutions such as hotels and hospitals have
evolved. Thus, Hospices have come to be remembered as a community for
sojourners along the way, a place of replenishment, refreshment, and
care. The reigning moral theme at the time of the medieval hospices
was "as long as you do it for the least of my brothers that you do
unto me." Whatever the moral tone of our contemporary society, the
Hospice movement seems to be catching on. We will have to face the
inevitable one day -- our own death. We can deny it, cry about it,
worry about it, laugh it off, or we can be prepared for it. Realizing
that no one has found a "way out" throughout the centuries, many today
are trying to insure that they will die with dignity and with others
around who genuinely care for them. That is what Hospice workers have
been trying to accomplish.
For anyone who has ever had a loved one
die in the cold, sterile atmosphere of a hospital, it isn't easy or
necessarily dignified. It is not entirely the fault of the medical and
nursing staff either. I believe that I can say that as a nurse who has
been in life and death situations throughout my career. Knowing
someone is going to die and knowing all that you have been trained to
do is useless in terms of prolonging that person's life, is not only
the most frustrating and helpless feeling, but also one of the saddest
that a nurse has to face. Nurses must deal with those feelings early
in their careers to be of any benefit to the dying clients entrusted
to their care.
Today, Hospice can be equated to a
special way of caring for those incurably ill, and its goal is to
blend the best of professional care with the most personal service
possible so as to meet ongoing client needs for comfort and relief
even when a cure is no longer possible. Hospice was developed to
supplement, not replace, existing medical facilities or
services. The staffing of the Hospices is primarily volunteers who are
carefully selected and trained, and made up of both professionals and
non-professionals.
The purposes of the Hospice approach,
an interdisciplinary total care approach to the care of the dying,
are as follows: to establish a community of caring for
clients diagnosed as having
an incurable chronic illness with a life expectancy of six
months or less and for their families; to help ease the physical and
psychological discomforts inherent in such illness and death;
and to assist families during the bereavement period
which includes follow-up care after the death of
the loved one. The Hospice approach is family oriented, with
the family as the unit of care. It is a highly people-oriented
approach also, i.e., an interaction and caring between humans.
Hospice is not a place, but a concept or program of health
care. The Hospice approach is dedicated to removing the
stigma of death and isolation that accompanies the institutionalized
way of dying. Dr. Leigner, a specialist in radiation therapy at
St. Luke's Hospital, N.Y.C., states hospice "teaches the realization
and acceptance (consciously of dying and death as part of being
born and part of the struggle of life."
The hospice goals vary within each
institutional setting. The general or overall goals would include the
following: to help the client live as fully as possible, conscious and
free of pain, and in control; to support the family as the unit of
care; to keep the client at home as long as appropriate; to educate
health professionals as well as lay people, to supplement, not
duplicate, existing services; and to keep costs down. The concept of
remaining home is the “ideal” Hospice approach.
Dr. Cicely Saunders
made the Hospice synonymous with more humane care of the dying and
good medical practice. In
1967,
Dr. Saunders founded St. Christopher's Hospice in
London, England. It is indeed a way station for the dying -a place
where people can go in the final stages of degenerative
diseases. It is a place of warmth and support. St.
Christopher's has a charitable foundation; it is funded by
friends and families. A client, however, is never turned
away because of financial inadequacy.
Dr. Sylvia Lack
began the United States hospice Movement after working at St.
Christopher's and St. Joseph's in London. The design of the New Haven
Hospice accommodates the primitive fear of and revulsion
for the dead body. This hospice is the first here in the
United States
to be closely modeled after St. Christopher's. The Federal
government's attitude toward the
birth of the Hospice movement in the
United States has been
one that is cautious and investigatory by nature, but finally
approving. There are at this time 300 operating Hospices
in the United States, with more than 125 planned.
In the United States, death has finally
come out of the closet. In the past, we did not know when to
let go. Our society, including trained physicians, denied death. We
still have a need to keep clients "biologically alive" with
modern technology. Medical and nursing staffs haven't looked at dying
clients realistically. All they saw in the death and
dying around them was failure and the terror of their own
inescapable death -- their mortality. The only
health care deemed acceptable was successful care -- care that
saved a life.
The group best suited and motivated to
take the lead in the provision of care and comfort for the
dying seems to have been religious communities or religious lay
groups. An example of an earlier undetected "Hospice" in the United
States is Calvary Hospital in the Bronx. It was founded in 1899 by
Mrs. Annie Storrs and a group of Irish Catholic laid women for the
care of the destitute, dying of cancer. It is now owned
by the New York Archdiocese, and it is the only hospital in
New York State exclusively for the terminally ill. This recently
modernized hospital can house up to 200 clients. It is a voluntary,
non-profit facility. Although a pioneer in the care of the dying, it
still remains a Hospice experience within a hospital setting.
Philosophically little has changed in 82 years at Calvary. V. Dunigan,
5 C.M. referred to Calvary Hospital in the May, 1980 Catholic
Digest as a place "where the dies come.
None of the New York area Hospice
programs at present fulfill the "ideal." The Hospice program that is
closest to the "ideal" is the one in Riverside, New Jersey. It was set
up in January of 1977. It is a program of medical, spiritual, and
social support services established to enable terminally ill cancer
clients to die at home. Its philosophy is to provide humane,
compassionate, palliative medical and social care to clients with
cancer and their families. Its primary goals are to provide support
necessary to help the client die with dignity and minimize the
destructive impact of the cancer death on the surviving family
members. The Riverside Hospice has a back-up in-patient unit with the
home care program receiving the primary emphasis. This particular
hospice is funded through the National Cancer Institute. The dying
clients and their families meet with the hospice team initially
to identify the problems, set goals, and make any necessary referrals,
and then meet as often as necessary.
There are a variety of programs
markedly diversified that have been labeled as Hospices. The American
Hospice Movement recognizes several variations from the "ideal"
home-based set-up. St. Luke's in New York City was organized in 1975;
it was the first hospice program incorporated into a United States
medical center, and it was the second hospice established in this
country (New Haven being the first). It is open only to adults; it has
an in-patient and an outpatient approach. Influenced by Dr. Saunders,
pain management with medications is geared toward maintaining an
alert and rational client for as long as possible. This is a
voluntary, non-profit hospital. The goal of this integrated,
consultative Hospice team within the hospital medical center is to
improve the quality of life that remains for their clients.
Twenty-six Hospice programs had been
selected initially by the Health Care Financing Administration of HEW
as two year demonstration projects for reimbursement through
Medicaid and Medicare. One of the fifteen in New York State
participating; in this project has been the Brooklyn Hospice,
sponsored by the Metropolitan Jewish Geriatric Center. It is a 50 bed
in-patient facility with out-patient services too. Its goal is to
foster the spiritual, emotional, and physical well-being of dying
clients and their families.
North Shore Hospital in Manhasset in
Nassau County has an H.O.M.E. (Home
Oncology Medical Extension) approach for advanced cancer clients
wanting to be treated at home. They have a mobile van equipped with
lab and medical supplies. Their outreach program offers chemotherapy.
This program was one of the pioneers in alternatives to
hospitalization for dying clients.
Another Hospice program is St. Rose’s
free home for incurable cancer run by the Hawthorne Dominicans which
was built in 1912. It houses 60 clients. There are no lab or work-up
facilities on the premises. Their goal at St. Rose's is to keep the
client pain-free and alert. Pain medications when needed are given
before the patient has to request them as it is done in St.
Christopher's. This facility will accept anyone who is unable to pay
for care anywhere else. St. Rose's was founded by Rose Hawthorne,
daughter of Nathaniel. It relies on the donations of the sympathetic
public. It is one of many homes run by these Sisters in this country.
Mercy Hospital Hospice in Rockville
Center in Suffolk County is family centered with volunteers an
integral part of the program. It is part of the general hospital
setting, i.e., a unit with its own staff.
The first Hospice in the world planned
for children is St. Mary's Hospice in Bayside, Queens. It emphasizes
the concept, more than the institution. St. Mary's program will have
ten beds, and 60-70 out-patient department clients. There will be active
in-service education programs. There will be a cost of $125/day.
However, at the outset it will be a funded project; therefore, there
will be no charge to clients. There will be continuous outcome,
process, and structure evaluations done in the program. The approach
taken with the children will be one characterized by honesty.
Thus, one can see the "variations on
the theme" concept applied to the set-up of a few Hospice programs in
the New York City vicinity. The main similarity is a caring community
of people trained in their various skills and offering a service and
fellowship, not only to the client, but to the entire family unit.
There are no prejudices in the Hospice Movement as to race, creed, or
financial abilities. Since all of us will one day die, all of us are
entitled to the same care and concern from our fellows. This caring
community operates on its own principles, autonomous in terms of its
professional procedure (Stoddard,
1980). The major difference perhaps from this way of caring for
the dying from the well-known hospital approach is that the Hospice
is planned as a therapeutic environment designed from the client's
point of view. What makes Hospice a better way of dying and a "good
death" is the insistence upon fitting care to the client, rather than
forcing the client into the relentless routine of some institutions,
that are basically designed and run for other purposes. "The Hospice
provides individuals with the process of pure being, as it is acted
out in giving and receiving of human love" (Stoddard). This is the
key to the Hospice movement and the Hospice success.
There has long been a need to talk
about death and dying and that need continues even today, but we also
need to begin to take action on those thins that will enable us to
improve the care of the terminally ill. Death need not, nor should it,
he experienced alone.
The future of Hospice is bound up in
the growing awareness that this is a better and more humane attitude
than that which has preceded it.
Hospice has developed much recognition
these days, so much so that there is a National Hospice Organization
in McLean, Virginia, 22101. There is also a Hospice Institute for
education, training, and research, in
New Haven, Connecticut, 06511.
Hospice Inc. in Connecticut is a non-profit corporation with
voluntary members. The institute has been able to estimate the cost of
the hospice care to be $450 over a 3 month period for home care, which
is far cheaper than hospital care.
Nurses are
interested in the people-oriented type of care in the Hospice setting,
which attracts capable, caring nurses. The nurse's role in the Hospice
is as diversified as it is in other nursing settings. The nurse is
responsible for pain and symptom management, teaches the family basic
nursing care, lends emotional support to client and family through
close of life and through bereavement, and makes home visits. The
nurse, in this type of care, needs to listen, touch, and hear, be
thoughtful and competent, open and willing, use silence and be honest.
Since Hospice is a way of life - a commitment--those attracted to
this special caring usually have some commitment to spiritual values,
and are outgoing individuals who enjoy helping and caring for others.
As in most nursing services, hospice clients require 24 hour a day, 7
days a week coverage. The nurse needs to be accessible to the client,
and have a kind of candor and conscience in filling the information
gap.
As for physicians,
Dr. Twycross at :sir Michael Sobell House in Oxford, England drew up
what he called the Ten Commandments for doctors dealing with the pain
of cancer.
I previously
mentioned as part of the nurse's responsibility symptom and pain
management. Let me expound on that statement in this section. Symptom
control can be divided into three main categories: 1) physical, e.g.,
pain, nausea, vomiting, etc.; 2) emotional, e.g., helping the client
and family cope with the distress accompanying impending death; and 3)
spiritual, an integral part of the program, with attention to human
spiritual concerns a priority. Pain control varies as follows: 1)
narcotics, 2) precision dosage and timing, 3) morphine, 4) the
"American Hospice Mix" which contains morphine 5-90 ms's-, cherry
syrup to 10 mls, and Compazine 5 mgs. (This is derived from the "Brompton's
Cocktail" used in
Britain,
which is a liquid formal-: of herein, cocaine, alcohol, syrup, and
chloroform water), and 5) hypnotics, and 6) adjuvant drugs (e.g.,
phenothiazines). Addiction is not an issue in a Hospice; the quality
of the life remaining for the client is the key and real issue. Since
the major concern of the Hospice is to keep the client alert and
responsive at the same time pain and nausea free, the prescribed drugs
are not given prn (whenever necessary) as is the usual method of
dispensing pain medications. The proper time to give a dying client
pain medication is before the client feels any pain, eliminating,
therefore, the anxiety of the expectation of the pain. This requires
close monitoring and continuity of care and personnel. The client will
usually then remains as comfortable and peaceful as possible until he
or she dies. For many clients “it is not death they fear, but
unspecified, unlimited pain” (Lowell). Thus, how the pain medication
is given is far more important than what is actually given.
Another key to the success of the
Hospice movement is the lack of restriction in the area of visiting
clients confined to the "non-ideal" Hospice outside the home. No
restrictions are placed on the volume of visitors, as long as the
client can tolerate it, nor the age of visitors including infants and
small children; even pets are allowed to visit if that will add to the
client's peace and comfort, and no restrictions are placed on
visitors as to time, since time is very precious to the dying person.
Recent studies have shown that survivors who do not view the
body at the close of their loved one's life have difficulty in
separating from the dead and can become long-term, chronic grievers,
making them susceptible to higher morbidity and mortality rates.
Moreover, there is much to be learned from the dying that would be
lost if they are kept isolated. It is the dying who teaches us the
real meanings of life.
Hopefully, the Hospice movement is an
alternative method of care for dying clients that is more positive and
more humane. The hospice accepts the client's death as a natural end
to the client's life. The hospice team assists the client and family
through the various stages of dying and the experiences associated
with death, after first coming to grips with their own attitudes,
concepts, and fears of death. The caring community helps and supports
the client through their psychological and emotional reactions to
dying, e.g., anger, guilt, shame, grief, depression, and acceptance;
they recognize the client's coping mechanisms, e.g., denial,
regression, and intellectualization as part of that dying client's
death process. They enforce guidelines for interacting with a dying
client such as: maintaining the
client's dignity (respect as a person), helping the client feel secure
(a need for trust), and maintaining the client's hope (short-term
goals). The Hospice team preserves the dying person's bill of rights
which was established back in 1975. The Hospice approach eliminates
the "living dead" syndrome so frequently seen in hospital settings
(the dying client who waits alone, isolated, and already mourned by
the family members in an emotionally and physically sterile
environment). The control over one's life is important even if one
knows that death is near and inevitable. The Hospice approach has
added new dimensions to the nurse-dying client relationship.
The United States
is on the verge of a Hospice proliferation. As the American health
care system progresses away from the renowned hospital setting and
moves back into a community-based system, as it is predicted, the
Hospice movement will probably be strengthened. With or without the
passage of the National Health Insurance Program, Hospice bills will
still be paid for in part by such plans as Blue Cross/Blue Shield,
Medicare, and Medicaid as it is currently being covered.
The scope of this
paper thus far has been the Hospice as the future hope of the dying
client's right to die with dignity. Drawbacks and imperfections in
this system are also evident to the probing mind. One prime example is
the setting up of the Hospice program as yet another specialty in the
medical world. Nurses and physicians have departmentalized themselves
into these specialties at the expense of the holistic approach to
health care. Individual practitioners tend to remain in one chosen
aspect of the field until burn-out occurs. Burn-out has also been
experienced as a recurrent theme, especially in Hospice care. How long
can one work with only the dying before depression or frustration sets
in? An apparent solution to this problem would be a rotation schedule
for medical and nursing staffs to prevent one from becoming too
specialized or burnt-out. However, this would defeat the purpose of
the commitment and continuity needed for Hospice care. As in every
other area of the medical/nursing professions, the skills utilized
can also become mechanical and rote in the Hospice movement. In
Hospice care the need for hope, freshness, and diversity is apparent.
Another possible drawback of this type of health care is an emotional
over-involvement with the clients with the resultant: "each man's
death diminishes me." How much can one give to another without paying a
price? It is very draining to continually be supportive, accept the
anger of others, and constantly face one's mortality. The caring
required in Hospice care involves the willingness to do the
unlovely -- a chief ingredient in this type of commitment
(Hoskovec,8 Administrator of St. Mary's Hospital, Bayside,
Queens.) How long can this
willingness thrive in a selfish society?
Another potential problem is the
exploitation by commercial interests who would convert nursing homes,
geriatric centers, and wards into "nominal" hospices in order to take
advantage of a trend without any real preparation for, knowledge of,
or commitment to the ideals of the hospice movement.
In summary, there has been change in
the approach of the health care practitioners in the care of the
terminally ill clients. The Hospice approach has been offered as an
alternative to the existing pattern of avoidance and denial in the
care of the dying. This approach is still in its formative years and
has a long way to go before it is a widely accepted, preferred
approach with minimal drawbacks that realizes the ideals of the
Hospice movement as expressed by Dr. Saunders (1967): "You matter
because you are you. You matter to the last moment of your life, and
we will do all we can not only to help you die peacefully, but also to
live until you die."
PHYSICIAN'S
ATTITUDES
The physician's task as stated by
Edward Trudeau many years ago "to cure sometimes, to relieve often, to
comfort always" seems to be the basis for care at Hospice. While the
health team at Hospice consists of doctors, nurses, clergymen, social
workers, psychiatrists, and volunteers, the most important person is
still the physician. Too often the dying client feels abandoned by the
doctor, that one has been written off as incurable -- therefore to be
ignored as frequently as is possible by that one person whom they
have come to trust and depend on. The Hospice doctors do not shun
their clients or try to avoid "uncomfortable discussions" concerning
their illness. The client knows the illness, prognosis, and what can
be expected in the future. The client is not treated as a child but as
an intelligent adult (assuming, of course, the client is an adult).
The client is given functions to
perform for and by himself for as long as possible. The client is also
consulted in regards to the type and amount of pain reducing
medication needed, the foods the client wants to eat, and when the
client wants to sleep. The physicians sit down with the other members
of the health care team on a regular basis to work out a plan of care
for the client/family.
Taking care of the
dying client has been part of medical treatment down through the ages.
Maybe even now it should n_-It been excluded from the
mainstream of medicine, since it has always been the responsibility of
compassionate family physicians. Clients welcome continuity of care
until their last breath (this
is the "rule rather than the
exception in Hosp- ice" S. Lack), This editorial comment of John P.
Callan, i•'1.D.~l was refuted a few months later in the same journal
by Sylvia A. Lack and William Fischer from the New Haven Hospice. In
response, they commented that the ultimate goal of the hospice
movement is reincorporation of timeless values and accepted methods
into general medical care, and not to exclude the care of the dying
from the mainstream of medicine. Technologically specialized curative
medicine has catalyzed the growth of the hospice Medical care as a
natural balance. Part of our responsibility and commitment is to
educate health professionals that a "care system" can coexist with a
"cure system". This requires fundamental changes in attitude. Until
these ultimate goals are realized, hospice care remains the only way
to get competent and compassionate terminal medical care from a
multidisciplinary team on a continuously available basis for care in
the home and for bereavement follow-up.
Most hospices
require the primary physician to remain responsible for the client's
on-going plan of care.
Dr. Grebin, St.
Mary's Hospice, said that one continuing uncertainty was the attitude
of the profession and whether medical authorities would be prepared to
make referrals. Some physicians "stand back from the idea that they
cannot do anything" for the dying client, h°_ declared, adding; that
it was even more difficult for the physician to accept the fact that
he had reached the end-point of treatment for a child.
Although the majority of practicing physicians
may believe that it is better for them to be reticent with the dying,
this opinion must be reconsidered in the light of the fact that an
equally large proportion of lay people say that they would like to be
told. On the surface, it seems quite perverse that 80 or
90% of physicians say that
they rarely, if ever, tell clients that their illness is mortal (Oken
1961)13 whereas about 80p of clients say they would like to be told (Gilbertsen
& Wangensteen, 1961).1
If a physician sees the question in rather unreal black and
white terms of either pressing unpleasant news of impending death upon
a client or keeping the client in happy ignorance of one's fate, this
will sway the physician towards expressing an opinion against
telling. This travesties the usual situation, however, where the
dying person, with gathering doubts and clues, becomes increasingly
suspicious that the end is near.
While physicians are trying to judge
their clients' capacity to stand unpleasant news, many clients are
equally making their intuitive judgments of whether their physician
can bear sincere but difficult questions. (Hinton
1967).15
"Medicine tries to deny the need for
pain, suffering, and death. So when they do appear, their victims,
deprived of cultural support, have to face them unprepared. With the
belief that the physician's task is to struggle against death, man has
lost control over his own destiny. The medical profession has
undermined the ability of people to manage their own lives" (Downie
1974).16
In a
1979 New York Times article, Hugh O'Haire17 stated physicians agree that community-based treatment is not
only more convenient but also welcome to clients because of some of
the immediate but short-lived side effects of chemotherapy which make
travel arduous. According to Dr. Roger Winn, chairman of a
community-based outreach program of Memorial Sloan-Kettering Cancer
Center, "doctors trained at large city-based medical centers are now
able to carry out complex treatment regimens at the community level.”
In the St. Luke's Hospice Pilot
Project, the physician’s role is summed up as follows:
1) To see referred
clients and decide if they are hospice candidates;
2) To discuss with
the client's physician if the client is to be picked up by the Team;
3) To prescribe a
plan of care in coordination with the client's physician;
4) To see clients
at least once a week and more frequently as needed;
5) To discuss the
client's condition and plan of care with the Team once a week;
6) To see clients
in the clinic;
7) To function as
a consultant to other physicians who desire help in managing the
symptoms of advanced cancer;
8) To assist with
the writing of a research proposal related to the care of clients with
advanced carcinoma.
PAIN CONTROL
Mindful that not all pain suffered by the
cancer client is due to the cancer, the hospice team seeks to control
the pain so that it will not return. They strive for constant pain
control! The client who experiences pain quickly learns to
fear it. Most physicians in most conventional hospitals would prescribe
pain relief medications every three to four hours whenever necessary (prn).
By the time the client's pain medication arrives, the client is anxious,
fearful, and probably angry. It then takes approximately one half hour
for the medication to work and become effective, and even longer for the
client to calm down. The client may get an hour worth of peace and then
the vicious cycle begins again -- anticipation of the expected pain,
the wait again, and the short-term relief.
The Hospice Team tries to avoid the
waiting period for terminal clients. The client knows that there will
not be a wait for relief-medication is administered in anticipation
of the pain. If pain is eliminated, so is the fear of it. One
does not become depressed or angry and one is able to derive the maximum
relief from the drug given.
Non-narcotic drugs are used for as long
as they are effective for each individual client. When relief is no
longer attained, narcotic drugs are given. Fear of addiction is not
a concern of the Hospice Team. The
nurses will administer the smallest dose possible to accomplish the
desired results an alert, pain-free client. Narcotics are usually
administered with phenothiazines to potentiate the narcotic, to provide
an antiemetic effect, and to alleviate anxiety.
At the New Haven
Hospice, morphine dissolved in cherry syrup and phenothiazine is used
for their clients. This is referred to as the "Hospice Mixture".
Cocaine, alcohol, or chloroform water (components of the famous
Brompton’s Cocktail) is not deemed necessary. The Hospice staff also
considers the use of heroin unnecessary in almost all cases.
The current debate
about whether to permit the use of heroin or morphine by dying clients
is symptomatic of a larger problem: the lack of a humane approach to the
care of the incurably ill.
Dr. Robert Butler,
Director of the National Institute on Aging, editorialized in
1977
that there are several factors to consider in dealing with
the pain that characterizes the final days for many. Physicians must
change their present practice of prescribing analgesics "as needed" and
begin to prescribe small doses of effective painkillers, gradually
increasing the dose until the client is p infree. The next dose should
be given before the client may even think it is necessary. Thus, it is
possible to erase both the memory and the fear of pain and to enable the
client to review life and face death as serenely and comfortably as
possible. Relief from pain is essential, and physicians should be able
to prescribe the most effective drugs for their clients, including
morphine and heroin.
With the current
system of waiting for pain relief, clients actually require a higher
dosage of medication than would ordinarily be indicated. With lower
dosages required clients experienced less confusion and were afforded
more "quality time" to talk and share feelings with friends and loved
ones.
In another New
York Times editorial by Harold M. Schmeck, Jr., it was suggested
that the person dying of cancer usually needs protection from pain and
fear. The treatment for pain and nausea is sometimes so cautious as to suggest
that those in charge consider it either unimportant or immoral to deal
thoroughly with the client's final agony.
The attitude appears to be changing,
however; and the change was accelerated recently by the prodding of no
less an agency that the White House.
The current focus is on two drug-- heroin
and marijuana. The current attitude seems to be toward making these
drugs more easily available, at least through legitimate research
projects with clients. How far this will go
and soon is not yet clear.
Heroin proved to be no more effective
than morphine when administered orally at St. Christopher's Hospice as
part of the Brompton mixture, a cocktail of narcotics, tranquilizers
and alcohol given regularly to terminal cancer clients (Clark
1978).22
THC, the active ingredient in pot
(marijuana) was tried as an antiemetic on a small group of clients
receiving chemo therapy and found no better than conventional
anti-nausea drugs. Dr. Peter Bourne, a President's special assistant
health issues and an expert on narcotic abuse, and other experts believe
that questions about the usefulness of heroin and marijuana can be
resolved within the next few years.
The hospice at St. Luke's Hospital
Center, New York City controls severe pain with methadone by mouth,
giving it in initial doses of 5-10 mg. At 3-4 hour intervals. They have
also had good results controlling pain with an oral solution consisting
of morphine sulfate, 15 mg; cocaine hydrochloride, 10 mg.
951%
alcohol, 1.7 ml. cherry
syrup, 3.7 ml. and distilled
water, 10 ml. It is given to many clients around the clock instead of
prn (whenever necessary) because of the chronicity of their pain. Pain
that is not allowed to reach peak intensity is easier to control.
Tylenol or aspirin sometimes is given
with narcotics (though not all clients require narcotics) to potentiate
their effects. Some clients require only APL's with codeine.
Analgesics may not always be needed to
treat discomfort. What is essential is an assessment of the pain --
noting its site, duration, pattern, precipitating factors, and what
relieves it.