Articles: palliative-care.
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Terminally ill patients often hope that death will come quickly. They may broach this wish with their physicians, and even request assistance in hastening death. Thoughts about accelerating death usually do not reflect a sustained desire for suicide or euthanasia, but have other important meanings that require exploration. ⋯ In all cases, patient requests for accelerated death require ongoing discussion and active efforts to palliate physical and psychological distress. In those infrequent instances when a patient with persistent, irremediable suffering seeks a prompt and comfortable death, the physician must confront the moral, legal, and professional ramifications of his or her response. Rarely, acceding to the patient's request for hastening death may be the least terrible therapeutic alternative.
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Fifteen patients with intractable pain received intrathecal morphine delivered via a programmable (Medtronic) device. In twelve patients the pain was due to cancer and three patients had pain of non malignant origin. All of the patients reported excellent or good relief. ⋯ One patient with pain of non malignant origin developed serious complications which required the removal of the infusion device. The results of this study show that chronic intrathecal infusion of morphine is superior to conventional forms of analgesia in patients with intractable pain of malignant origin. We would advise that it should remain a therapy of last resort in patients with intractable non malignant pain as the long term side effects are still unknown and the potential for serious side effects still exists.
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Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. Patients may develop bowel obstruction at any time in their clinical history, with a prevalence ranging from 5.5% to 42% in those with ovarian cancer and from 10% to 28.4% in those with colorectal cancer. The causes of the obstruction may be benign postoperative adhesions, a focal malignant or benign deposit, or relapse or diffuse carcinomatosis. ⋯ Although surgery should be the primary treatment for malignant obstruction, it is now recognized that some patients with advanced disease or in generally poor condition are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. In this review, the indications for surgery are examined, the use of nasogastric tube and percutaneous gastrostomy evaluated, and the pharmacologic approach described.