Page 376 Guide to Pain Management in Low-Resource Settings

364 Andreas Kopf

an investigation by Tang et al. in 2006, the suicide rate is recognized that the borderline may present some dif-
among chronic pain patients is increased (prevalence fi culties when it comes to deciding whether a sensation
5–14%) in comparison to the general public. Depression is pleasant or unpleasant. It should always be specifi ed
is usually the strongest predictor of desire for death. It whether the sensations are spontaneous or evoked.
is important to distinguish between passive thoughts of
Dyspnea
death or death wishes and active suicidal thoughts that
involve an intent to take one’s life. It is helpful and reliev- Dyspnea is diffi culty in breathing and is often mixed
ing for the patient when concrete questions are asked: up with respiratory depression. While dyspnea causes
For example: “Do you ever think about committing sui- major suff ering by the feeling of suff ocation and may
cide?” “Do you have a plan of how you want to commit be successfully relieved by morphine or other opioids
suicide?” “Are you obsessed by thoughts of suicide?” Very in most cases, respiratory depression is a state of unre-
often, patients have set a time, and so questions regard- sponsiveness of the central breathing regulation, which
ing the point in time are important; the patient may may be caused by opioids. Since breathing depression
agree to a postponement. Furthermore, previous suicide does not cause the patient to suff er (and therefore the
attempts should be noted because they are an increased patient will not complain), personal or electronic moni-
risk factor for a renewed suicidal tendency. toring, especially in the immediate postoperative period
or after opioid applications, is necessary to avoid possi-
Do-not-resuscitate (DNR) orders bly fatal complications.

Instructions written, usually in the patient’s chart, by a
Epidural space
doctor or other health care provider. A rather “impre-
cise” method to indicate that because of an advanced Th e epidural space surrounds the dura mater of the
disease stage the treatment of a patient should be re- spinal cord. It is bounded by the pedicles of the verte-
stricted and especially exclude cardiopulmonary re- bral arches and by the anterior and posterior ligaments
suscitation (CPR) or other related treatments. Usually, connecting the bony vertebral column. Th e epidural
DNR orders are written after a discussion between a space contains nerve roots, fat, and blood vessels and
doctor and the patient and/or family members. Today is routinely used for perioperative analgesia as a single
another concept is slowly replacing DNR called AND analgesia technique or in combination with general an-
(“Allow Natural Death”). In this modern concept, the esthesia. Epidural analgesia is specially popular in the
limitations in therapy are precisely documented after obstetrics department.
discussion between the caregivers, the patient, and the Ethics
family. Orders for AND may include specifi c topics such
A system of moral principles and rules that are used as
as antibiotics, ventilation, intensive care, dialysis, and
standards for professional conduct. Many hospitals and
catecholamines.
other health care facilities have ethics committees that
Durable power of attorney for health care can help doctors, other health care providers, patients,
(DPOAHC) and family members in making diffi cult decisions re-

In some countries a legal document has been intro- garding medical care. Besides helping in diffi cult medi-
duced in the last years to allow communication be- cal situations, ethics conferences may also help bringing
tween the patient and a caregiver in case the patient is together the diff erent disciplines of health care, allowing
unresponsive due to his health situation. Th e document a joint approach for optimal care. Ethics committees are
specifi es one or more individuals (called a health care usually not meant to set ethical standards—something
proxy) the patient wants to make medical decisions if which mostly develops in society and in religious com-
the patient becomes unable to do so. munities—but they help to interpret and transfer soci-
ety’s standards into specifi c standards or fi nd solutions
Dysesthesia
for specifi c therapeutic dilemmas.
An unpleasant abnormal sensation, whether spontane-
ous or evoked. Compare with pain and with paresthe- Fatigue
sia. Special cases of dysesthesia include hyperalgesia and A feeling of becoming tired easily, being unable to com-
allodynia. A dysesthesia should always be unpleasant, plete one’s usual activities, feeling weak, and having dif-
and a paresthesia should not be unpleasant, although it fi culty concentrating. Fatigue should not be confused