Primary care
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Regular assessment for the presence of pain and response to pain management strategies should be high priority in terminally ill patients. Pain management interventions are most effective when treatments are individualized based on the various physical and nonphysical components of pain at the end of life, and patients and family are educated and involved in the decision making. Opioids remain the cornerstone of pain management, and adjuvant analgesics and nonpharmacologic options are usually considered after relative stabilization of pain. This article describes the various issues that are pertinent to the assessment and treatment of pain in terminally ill patients.
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Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems: physical, psychosocial, and spiritual. This article discusses illness trajectories and prognostic estimates, prognostic tools, educating physicians and nurses in palliative care, research in palliative medicine, and palliative care in hospitals and the community.
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Dementia is a progressive and noncurable illness, and its management in late stages should follow a palliative care approach. However, many patients with advanced dementia sustain aggressive interventions that do not improve their survival and might hinder their comfort and quality of life. This is likely explained by a lack of research on this population; a lack of knowledge from health care providers, patients, and family members; and lack of communication between those caring for these patients. There is therefore an urgent need for research and education on this topic, as well as palliative care services devoted to this population.
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Progress in pediatric palliative care has gained momentum, but there remain significant barriers to the appropriate provision of palliative care to ill and dying children, including the lack of properly trained health care professionals, resources to finance such care, and scientific research, as well as a continued cultural denial of death in children. This article reviews the epidemiology of pediatric palliative care, special communication concerns, decision making, ethical and legal considerations, symptom assessment and management, psychosocial issues, provision of care across settings, end-of-life care, and bereavement. Educational and supportive resources for health care practitioners and families, respectively, are included.
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The basic elements of palliative care can be translated into practice for patients with HIV/AIDS. More than half of clinical events and deaths occurring among patients on highly active antiretroviral therapy are classified as non-AIDS illnesses. Thus, end-of-life care for patients with late-stage AIDS needs to include any palliative measures that are used for patients without AIDS. This article reviews the epidemiology of HIV/AIDS, prognostic indicators, opportunistic infections, specific AIDS-defining and non-AIDS-defining malignancies, substance abuse/liver disease, and highly active antiretroviral therapy and comfort measures for late-stage AIDS patients.