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1 Focus on Cancer

2 Springer London Berlin Heidelberg New York Barcelona Budapest Hong Kong Milan Paris Santa Clara Singapore Tokyo

3 Robert Dunlop Cancer: Palliative Care, Springer

4 Robert Dunlop St Christopher's Hospice Lawrie Park Road Sydenham London SE26 6DZ, UK British Library Cataloguing in Publication Data Dunlop, Robert Cancer : palliative care. - (Focus on cancer) I.Cancer - Palliative treatment I.Title 616.9'94'06 Library of Congress Cataloging-in-Publication Data Dunlop, Robert, Cancer : palliative care 1 Robert Dunlop. p. ern. - - (Focus on cancer) Includes bibliographical references and index. ISBN-13: e-isbn-13: DOl: / Cancer - -Palliative treatment 1. Title. II. Series. [DNLM: 1. Neoplasrns- -therapy. 2. Palliative Care- -methods. 3. Pain, intractable- -therapy. QZ 266 D922c 1998] RC271.P33D '406- -dc21 DNLMlDLC for Library of Congress CIP Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms shonld be sent to the publishers. Springer-Verlag London Limited 1998 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regnlations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by Richard Powell Editorial and Production Services, Basingstoke, Hants RG22 4TX 28/ Printed on acid-free paper

5 Contents Foreword... vii Preface... ix 1. EVOLUTION OF PALLIATIVE CARE MANAGEMENT OF PAIN MANAGEMENT OF RESPIRATORY SYSTEMS GASTROINTESTINAL SYMPTOMS IN ONCOLOGy MANAGEMENT OF OTHER SYMPTOMS PSYCHO-SOCIAL CARE SPIRITUAL CARE AND SUFFERING TEAMWORK AND PALLIATIVE CARE... III 9. DELIVERING PALLIATIVE CARE IN DIFFERENT SETTINGS EVALUATION OF PALLIATIVE-CARE SERVICES ETHICAL ISSUES AND PALLIATIVE CARE Conclusion References Index v

6 Foreword Hospice and palliative care are now recognised internationally, but far too many patients still fail to receive its benefits. Much of the groundwork has been researched, developed and demonstrated, but all countries need access to the publications which will spread the knowledge. Every patient needs appropriate and individualised treatment throughout the course of illness. Not all can be cured and all will eventually die. How that happens is not only important for their dignity as individuals but also as members of a family network. A life ended with much unfinished business or uncontrolled suffering has not been met with due respect and does not leave good memories. To accept that life is ending can give value, freedom and hope. Openness and the respectful sharing of bad news can lead to creativity and the healing of relationships. Those of us who have travelled alongside many people at the end of their lifes' journeys have seen not merely endurance and courage, but much growth through loss. All this calls for great competence in the analysis and relief of the various forms of suffering that make up the Total Pain of a terminal illness. Much evidence-based therapy is available and is presented in this compassionate, practical and challenging book. 'Efficiency is very comforting', said one family member. It is indeed comforting, both to the patient, family members and to the staff team caring for them. The past decades have seen much learning of psychological, social and spiritual, as well as physical, needs. This book, the fruit of years of experience, brings understanding and help to all those who set out to give the best, most appropriate and personal care to those facing the end of life. There is medical challenge, reward and personal hope in the possibilities of the human being whose final needs and potential demand our attention. Dame Cicely Saunders, OM, DBE, FRCP Chairman, St. Christopher'S Hospice, London vii

7 Preface Despite major advances in diagnosis and treatment, cancer remains a leading cause of death. Traditionally, people were told 'nothing more can be done' when anti-cancer treatments were exhausted or not possible. This left patients and families feeling abandoned, facing the worst part of the illness alone. Palliative care offers hope and support to patients with advanced, incurable cancer, and to their families. It has become a recognised specialty with a rapidly expanding knowledge base that has spread worldwide. This book provides an introduction to palliative care as part of the Springer Focus on Cancer series. It offers a broad overview of the specialty, complementing the other books in the series on anti-cancer treatments and on psychological support for cancer patients. It has been written for health professionals from all disciplines, particularly doctors and nurses who work with cancer patients but have little or no experience of palliative care. The opening chapter presents an overview of palliative care and its development. Throughout history, the care of the dying has been neglected. A review of the reasons for this emphasises the important issues for the future, such as the desire of patients for cure and the difficulties that health professionals have with death and dying. The principles of palliative care are outlined, including patient and family care, multi-disciplinary teamwork and bereavement support. The next chapters describe how to control the myriad of symptoms of cancer including pain, nausea, vomiting and breathlessness. Useful therapies are highlighted, as well as the potential psychological attributions which affect patients and families just as much as the physical symptoms. This leads into the chapter on psycho-social care and suffering. A chapter is devoted to the practicalities of team working which is so essential to dealing with the needs of cancer patients and families. Some readers will be interested in a career in palliative care. There is a chapter which describes the variety of settings in which this specialty is now practised. There is also a chapter on evaluating palliative care services, including a more detailed review of quality-of-life issues, audit and the evidence for effectiveness of various services. Finally, several ethical issues are discussed, including end-of-life treatment decisions and ix

8 x Preface euthanasia. Throughout the book, cultural diversity is addressed, as well as the potentially difficult overlap between anti-cancer treatments and palliative care. Acknowledgement We gratefully acknowledge the contributions of Dr Nigel Sykes, FRCGP and Dr Mary Baines, FRCP who are the authors of Chapter 4 (Gastrointestinal Symptoms in Oncology). London, September 1997 Robert Dunlop