Page 67 Guide to Pain Management in Low-Resource Settings

Principles of Palliative Care 55

increasing intensity, or with sudden vomiting of clot- Psychosocial and spiritual care
ted blood from gastrointestinal bleeding. With minor
bleeding sometimes blood transfusions may be indicat-
What is the impact of psychosocial issues
ed. For more severe bleeding, benzodiazepines or mor-
on medical care?
phine via subcutaneous bolus administration may be in-
dicated, but often they will not take eff ect fast enough. Psychosocial issues are often neglected by medical staff ,
With massive hemorrhage the patient will quickly be- even though they are paramount for many patients.
come unconscious and die with little distress, and treat- Fears about the progression of the disease, about death
ment should be restricted to comfort measures. Enough and dying, about fi nancial problems, or about stigmati-
towels or similar material should be available to cover zation with diseases such as HIV/AIDS may overwhelm
the blood. patients, alienate them from their family and friends,
and often aggravate the impact of physical symptoms.
What is palliative sedation? For most patients in resource-poor countries the loss of
Rarely, patients with extreme distress from pain, dys- support is an immediate implication of a life-threaten-
pnea, agitation, or other symptoms that are resistant ing disease, often endangering the survival of the patient
to palliative treatment, or do not respond fast enough as well as of the family. Social support that provides the
to adequate interventions, should be off ered palliative means to sustain basic requirements is as mandatory as
sedation. Th is means that benzodiazepines are used the medical treatment of symptoms.
to lower the level of consciousness until distress is re- Most patients with life-threatening disease also
lieved. In some patients deep sedation is required, ren- have spiritual needs, depending on their religious back-
dering the patient unconsciousness. However, for other ground and cultural setting. Spiritual support from
patients mild sedation may be enough, so that patients caregivers as well as from specialized staff , for example
can be roused and can interact with families and staff to religious leaders, may be helpful.
some degree. Intravenous or subcutaneous midazolam
How do you communicate bad news?
is used most often, as it can be titrated to eff ect easily.
It should be realized that palliative sedation is Palliative care staff should have special communication
the last resort if symptomatic treatment fails. Before skills. Health care professionals should be able to col-
the initiation of this treatment, other treatment op- laborate with other staff and volunteers who care for the
tions have to be considered, and the priorities of the patient, and agree on treatment regimens and common
patient should be clarifi ed. Some patients prefer to suf- goals for the patient. Th ey must also be able to commu-
fer from physical symptoms instead of losing cognitive nicate with patients and families on diffi cult topics, for
capacity, and sedation should only be initiated if the example ethical decisions such as treatment withdrawal
patient agrees. Eff ective services will fi nd an indication or withholding of treatment. Specifi c models are avail-
for sedation in only a few selected patients with very able, for example the SPIKES model for breaking bad
severe symptoms. news (Table 3).

Table 3
SPIKES model for breaking bad news
Setting Choose the setting for the talk, talk on same eye level with patient, avoid disturbances and
interruptions, allow for family members to be present.
Perception Check the capacity of the patient, impairment from medication or from disease, or from
interaction with family members, use verbal and nonverbal cues for perception.
Invitation Ask the patient about his level of information, what does he know about his disease and
about the topic of the talk, and ask the patient how much he wants to know.
Knowledge Inform the patient about the bad news, in a structured way with clear terminology, allow
for questions and give as many details as the patient requires.
Empathy Leave time for emotional reactions of the patient, explore emotional reactions and react
empathically.
Summary Provide a concise summary, if possible with some written summary, and off er a follow-up
talk if possible.