Page 60 Guide to Pain Management in Low-Resource Settings

48 Lukas Radbruch and Julia Downing

• Uses a team approach to address the needs of pa- is very helpful to identify peers or a support team on
tients and their families, including bereavement which they can fall back if needed, to discuss problems,
counseling if indicated; share responsibility, or get emotional support. Th is sup-
• Will enhance quality of life, and may also posi- port will enable them to continue in their work for the
tively infl uence the course of illness; benefi t of the patients.
• Is applicable early in the course of illness, in con-
junction with other therapies that are intended to
Case report
prolong life, such as chemotherapy, radiation, or
antiretroviral therapy, and includes those investi- Grace is a 43-year-old widow. Her husband died from
gations needed to better understand and manage an “unknown cause” 4 years ago, and she has been
distressing clinical complications. bringing up her two children, who are aged 12 and 14,
on her own since then. One year ago she noticed that
How is palliative care provided? she was getting pain on micturition and that her peri-
ods had become irregular and that she was bleeding
Palliative care can be provided across a range of care mid-cycle. She did not seek medical help initially as
settings and models, including home-based care, facili- she thought that this was just part of getting older, and
ty-based care, inpatient and day care. Care can be pro- culturally it was not appropriate to discuss such prob-
vided in specialist as well as general settings and should, lems with anyone. Six months later, having been to visit
where possible, be integrated into existing health struc- a traditional healer fi rst, and not responding to their
tures. Th e concept of palliative care should be adapted treatment, she eventually visited her local health center
to refl ect local traditions, beliefs, and cultures—all of as the pain was getting very bad; she was experiencing
which vary from community to community and from bleeding and found that she was unable to keep herself
country to country. clean and free from odor. On examination at the lo-
Palliative care is holistic and comprehensive, cal health center she was referred to the district hospi-
and thus ideally it should be delivered by a multidisci- tal, from where she was referred to the national cancer
plinary team of care givers, working closely together center, where she was diagnosed as having a fungating
and defi ning treatment goals and care plans together cervical tumor. Initial diagnosis was of a Stage IV cer-
with the patient and his or her family. In many re- vical carcinoma, which had spread to her lymph nodes,
source-poor countries the multidisciplinary care team her pelvis, and her liver. Treatment with surgery was no
will include community workers and traditional healers longer an option, and chemotherapy was not available,
as well as nurses, doctors, and other health care profes- so fi ve fractions of palliative radiotherapy was given to
sionals. Nurses have a key role in the provision of pal- try and reduce the pain and the bleeding. She had lost
liative care due to their availability within resource-poor weight over the past 6 months and was suff ering from
settings, and they are often the coordinators of the mul- fatigue. While she was an inpatient in the cancer unit
tidisciplinary team. Th e health care professional may be she was seen by the local palliative care team because of
working alone with little support from others, particu- severe pain in the pelvis and lower back. Pain manage-
larly in rural settings. Community health workers and ment included low-fraction radiotherapy and she was
volunteers can provide support to the health workers commenced on 5 mg oral morphine every 4 hours. Th is
and have been trained with good eff ect to support them dose was increased gradually to 35 mg of oral morphine
with basic medical care. In many resource-limited set- every 4 hours with a prescribed rescue dose as required.
tings, community workers and volunteers are indispens- Th is regime was combined with 12.5 mg amitryptiline
able for the provision of palliative care and in particular at night for neuropathic pain, and it resulted in signifi -
with regard to social support for patients. cant pain relief. She was also prescribed an antiemetic
Th ere are however, specifi c situations where for nausea and a laxative to prevent her from becom-
professional support from peers or from a team is re- ing constipated from the morphine, and to soften her
quired. Ethical decision-making in complex situations, stool to reduce discomfort from the fungating wound on
disagreeable patients or families, or family systems with defecation. With the radiotherapy along with a cleans-
complex confl icts may trigger a need for such support. ing regimen as well as use of topical metronidazole, the
For health care professionals working on their own it odor disappeared and she felt more comfortable.