Thursday, November 27, 2008

Palliating terminal cancer - a reality check

With the ongoing discussions on euthanasia, a number of doctors/agencies have made use of the opportunity to advertise their services. There was a letter in the Straits Times Forum yesterday, which I won't reproduce because it was just blatant advertising. Today's ST carried short report about the Palliative Care Clinic in the Tan Tock Seng Hospital which is worth looking at because it is admirable for a hospital that has to look after its financial bottom line, to set aside resources to manage what is very likely be a loss making service.

Palliation of the terminal cancer patient is not an easy task. It is certainly a complex one. It does not include just treating the cancer pain, but also includes managing the patient's social, emotional , psychological and spiritual needs. You can generally tell the inexperienced doctors from the caring ones by the way they 'chiong' (local slang refering to mindless charging, some what like a bull in a china shop) around the place and waxing eloquently about the use of new expensive, fancy painkillers, and how great the care giver is in being able to provide all this.

Truth of the matter is, the science of managing pain hasn't really moved too far from the use of either anaesthetics or analgesics. The former knocks off all sensation (not really desirable) and the latter tries to selectively reduce the pain without greatly affect consciousness. Neither are fully effective. A majority of patients though can be effectively managed because the pain is not so severe. However, cancer pain can be so wide spread, so severe and intractable that the only way to manage the pain is to increasingly anaesthetize the patient. Narcotic painkillers remain the main mode of managing this severe intractable pain. The downside is with the increasing dose of narcotics, the patient will gradually drift into a deepening coma, and increasing risk of just stopping his urge to breathe. Doctors don't like to discuss this, nor will they readily admit it, but here is where the thin red line between palliation and euthanasia blurs into a broad murky band.

One of the important features of effective palliative care is honesty and true concern. The terminal cancer patient is not a moron, and is trying his or her best to deal with an essentially hopeless situation. Giving false hope or blindfolding the patient is not the solution. The patient knows when he/she is being lied to. Pain in this kind of situation takes on a totally different perspective for the patient. Unlike the usual pain we suffer, for which we know will be self limiting and can only see recovery going forward, terminal cancer pain is intractable and will only get worse. Its presence is a constant reminder to the patient that he is dying. He sees no light at the end of the tunnel, and he knows that it can only get worse. Much worse. He is plagued with fear and uncertainty because he cannot foresee how bad and terrible it will become, and how long it will drag out for.

Therein lies the critical need for a good, sincere friend and caregiver. Often what the patient needs most is to be assured there is someone who will walk with him or her through the final steps. That the best is being done. He doesn't need to lied too that the pain will magically disappear with fancy expensive drugs.

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