Page 178 Guide to Pain Management in Low-Resource Settings

166 Th omas Jehser

is often quite astonishing how they help the patient and pain, as well as some dyspnea at rest. Shortly afterwards,
their relatives face the illness with more understanding a scleral icterus begins, and Mr. K. shows periods of dis-
and to deal better with feelings of helplessness, which orientation and depression. His family takes him again
again might help to direct the path of disease to a cer- to the Atbara district hospital for examination. It turns
tain extent. out there that he has developed a serious bone marrow
According to the WHO, “Palliative care is an insuffi ciency so that no further chemotherapy can be giv-
approach that improves the quality of life of patients en. He is now sent home to talk with his family doctor
and their families facing the problems associated with about further action that might be taken.
life-threatening illness, through the prevention and re-
lief of suff ering by means of early identifi cation and im- What are the consequences of
peccable assessment and treatment of pain and other dyspnea, and how is it treated?
problems, physical, psychosocial and spiritual.” Th e
founder of modern palliative care, Dame Cicely Saun- Dyspnea is defi ned as a subjective experience of breath-
ders (1918–2005), developed her fundamental ideas ing discomfort, consisting of diff erent conditions that
when she was trying to ease and diminish cancer pain all lead to an increased breathing eff ort, either needing
by looking at it from more than a “physical” perspective. more strength or a higher respiratory rate. Th is experi-
So she inaugurated treatment strategies for the psycho- ence is also infl uenced by interactions among physical
logical, social, and spiritual needs of the patients besides and emotional conditions. Dyspnea may be caused by,
taking care of their physical condition, according to the but is not at all identical to, respiratory insuffi ciency.
concept of “total pain.” Palliative care, therefore, eases While dyspnea is a subjective sensation of the patient,
physical suff ering and provides information and under- respiratory insuffi ciency is a “physiological” phenom-
standing within the social context of the patient. In the enon that can be exactly quantifi ed by testing. Th ere are
same way, it delivers consolation and assistance to help multiple causes for respiratory insuffi ciency originating
with anxiety and emotional pain caused by the threat- in the pulmonary, cardiac, vascular, bony, muscular, and
ened loss of one’s relations and life. nervous systems. Th e amount of resulting dyspnea de-
pends heavily on the course of development of respira-
Case report—part four tory insuffi ciency and its profoundness. Th erefore, some
patients may be able to live with a greatly decreased re-
Mr. K. fi nally agrees to have chemotherapy. After fi nding spiratory capacity without feeling any dyspnea at rest,
transportation, he visits the district hospital in Atbara while others with minor respiratory insuffi ciency may
routinely for the treatments and the necessary examina- suff er intense shortness of breath. Feeling dyspnea eas-
tions and feels somehow safe and stabilized, although he ily causes anxiety, and vice versa. Th e diff erentiation of
has to take antibiotics for a short term of pyogenic bron- shortness of breath therefore requires the clinician to
chitis. He meets other patients—many of them much evaluate not only vital capacity and FEV , but also the
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younger than himself—who tell him about side eff ects, general condition of the patient, so as to avoid underes-
which he fi nds to be irrelevant to himself at this point. timation of the problem.
He gets a lot of relief when he fi nds a group supervised by For therapy for dyspnea to be eff ective, knowl-
a health care worker in his home town where they prac- edge of its physiology is helpful. In case of a possible
tice breathing and relaxation techniques. With the help treatment of underlying causes, such as bronchospasm
of his family and friends he also gets advice from a tradi- or anemia, priority is given to this type of therapy. As
tional healer, who recommends an additional composite one symptom of dyspnea deals with some sort of agita-
medication consisting of herbal and mineral substances. tion, sedative treatment allows successful symptom con-
In personal meetings with his spiritual adviser Sheikh trol, which might even help the breathing system to run
Farshi, he learns to talk to his wife and three children more effi ciently.
about the possible consequences of a fatal disease for the Besides sedative drugs such as benzodiazepines,
family and their fi nancial aff airs. morphine is probably the most important remedy avail-
After the next course of chemotherapy, he suff ers able for this important clinical situation. Morphine re-
from vomiting and weakness for the fi rst time following duces the subjective “air hunger” signifi cantly, regardless
such a treatment. Again he feels abdominal and back of the actual physiological need for O and CO transport
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