The Surgical clinics of North America
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The key points of this article are: Spirituality gives meaning and purpose to life. Spiritual issues that may lie dormant for many years often surface at the end of life. Not all people are religious, but all are spiritual. ⋯ Redefining hope: hospice can help the dying patient to redefine hope in terms of realistic goals-from a hope for cure to a hope for good symptom relief. Reconciliation is the work of the dying. Empathy is the opportunity for those who care for the dying.
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Pharmacologic therapy for neuropathic pain is based on an evolving understanding of its underlying mechanisms, and often requires a patient,methodical sequence of trials that include the "four As": analgesics,antidepressants, anticonvulsants, and antiarrhythmics. Critical for success is a willingness to stay engaged with the patient to evolve a mutually acceptable plan and goals of care with realistic outcomes that emphasize symptom control and maximization of function. Such management is within the capabilities of surgeons for most patients, whereas the use of consultation and interdisciplinary supportive interventions from comprehensive pain management centers, if available, is helpful in more difficult cases.
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Surg. Clin. North Am. · Apr 2005
ReviewEthical issues in surgical palliative care: am I killing the patient by "letting him go"?
Recent medical advances have complicated decisions regarding terminal care. Surgeons should be familiar with the ethical issues that contribute to end-of-life decision-making. ⋯ Artificial ethical distinctions between withholding versus withdrawing care or ordinary versus extraordinary treatments can confuse clinical decision-making at the end of life. An ethics of death and dying requires that the intent and the action of the moral agent be considered.
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Palliative care for the critically ill has become an increasingly important component of care in the SICU. As the population ages, medical technology continues to offer new treatments that can prolong life, and more and more Americans die in the hospital in critical care settings, the appropriate management of the end-of-life must be part of the clinical expertise of surgeons and intensivists. ⋯ Attention to the principles of good pain management, communication with patient and family, and discussion of goals of care are not just for patients who are at the end-of-life, but are appropriate care for all critically ill patients, regardless of prognosis. In this framework, "intensive care"encompasses palliative and curative care.
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The primary intent of surgical procedures traditionally has been the achievement of cure. Palliative surgery is emerging as an equally legitimate strategy of care; its goals are symptom relief and enhanced quality of life based on the patient's preferences. The key to successful palliative surgery is understanding patient and family dynamics, interdisciplinary team approaches, and producing a consistent and rational treatment plan. Far from condemning a patient, palliative surgery has a potential place in many treatment plans for enhanced quality of life and longevity.