Journal of palliative medicine
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The principle of double effect is used to justify the administration of medication to relieve pain even though it may lead to the unintended, although foreseen, consequence of hastening death by causing respiratory depression. Although a review of the medical literature reveals that the risk of respiratory depression from opioid analgesic is more myth than fact and that there is little evidence that the use of medication to control pain hastens death, the belief in the double effect of pain medication remains widespread. Applying the principle of double effect to end-of-life issues perpetuates this myth and results in the undertreatment of physical suffering at the end of life. The concept of double effect of opioids also has been used in support of legalization of physician-assisted suicide and euthanasia.
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The physiochemical characteristics of the potent synthetic opioid agonist fentanyl make it ideal for noninvasive transmucosal delivery. Studies of oral transmucosal fentanyl citrate (OTFC), a candied matrix formulation administered orally as a palatable lozenge on a stick, have investigated and determined this analgesic's pharmacokinetics and pharmacodynamics in a number of clinical settings, including premedication before surgery, acute analgesia for painful medical procedures, and, most recently, for the control of breakthrough cancer pain. The onset to meaningful pain relief in patients with acute pain from surgery or breakthrough pain from cancer is between 5 and 10 minutes after initiating OTFC use, equivalent to intravenous morphine. ⋯ Side effects from OTFC are similar in character and frequency to other opioids, including sedation, nausea, and pruritus. These effects appear to wane rapidly with repeated use of this medication. To date there have been no reported serious adverse events in any of the population groups studied or treated with OTFC.
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Too few cancer patients have optimal care at the end of life, as measured by unrelieved pain, death in a setting other than home, and uncoordinated care. The American Society of Clinical Oncology (ASCO), as the largest professional society whose members care for most cancer patients in the United States, has begun an initiative to improve end-of-life care. Educational programs for ASCO members have been started at the national level. ⋯ Specific sections of the Task Force will address hospice care, physician- assisted suicide, clinical barriers, economic barriers, research initiatives, educational deficiencies, and quality of care at the end of life. Improvements in end-of-life care can be made if the current deficiencies are noted, barriers ascertained, and specific solutions found. Professional societies have both the interest and responsibility to improve end-of-life care.
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There is growing recognition of the reciprocity of suffering by patients and families experiencing terminal illness and the need to improve the quality of their lives as the patient's illness progresses. Research is presented that addresses the importance of a dyadic perspective in recognizing patients' and families' stress and adjustment and the related physical, emotional, social, spiritual and financial needs at the end-of-life. ⋯ This article addresses the importance of assessing the dynamics of the family caregiving system and potential palliative care interventions to enhance the quality of life of family caregivers. Implications for research are also discussed.