Page 68 Guide to Pain Management in Low-Resource Settings

56 Lukas Radbruch and Julia Downing

How do you provide bereavement support? significance may be supported by medical staff who
Bereavement support is an important, yet often forgot- explain that the withholding of anticancer therapies
is linked to the poor nutritional status of the patient.
ten, part of palliative care provision, which should not
end with the death of the patient. Grief and loss are However, it has to be realized that cachectic patients
with cancer or with HIV/AIDS most often do not ben-
expressed in a multiplicity of words and languages by
diff erent peoples. A wealth of diverse ritual serves to efi t from nutrition. In most cases, a catabolic metabo-
lism is the major reason for cachexia, and the provi-
guide people in societies through the grief process, and
it is important for the health professional to be aware sion of additional calories does not change that status.
Patients in the fi nal stage of the disease may even de-
of such rituals. Grief not only aff ects relatives, but also
patients themselves, who may experience anticipatory teriorate with parenteral fl uid substitution, when ede-
ma or respiratory secretions are increased. Th irst and
grief prior to their death as they grieve the various loss-
es that they are experiencing such as the loss of their hunger, on the other hand, are not increased when
fl uids and nutrition are withheld. In many cases, and
future and the loss of seeing their children grow up. Pa-
tients need support to work through some of these is- nearly always in dying patients, nutritional supple-
ments, parenteral nutrition, and fl uid replacement are
sues prior to their death and to plan for the future of
their loved ones, where possible. not indicated and should be withdrawn or withheld. If
necessary, small amounts of fl uid (500–1000 mL) may
Many diff erent factors can aff ect the bereave-
ment process for family members, including their re- be infused with a subcutaneous line.
lationship with the person who died, the way that they
How should we react if patients ask
died, whether they were experiencing symptoms and
for hastened death?
were seen to be suff ering, stigma, a lack of disclosure
Palliative care by defi nition neither hastens nor post-
about their illness, local cultural practices and beliefs,
pones death. Active euthanasia is not a medical treat-
personality traits, other stresses that they may also be
ment and cannot be part of palliative care. However,
experiencing, and bereavement overload if they have
there are a few patients receiving palliative care who ask
lost several friends and relatives in a short space of time.
for assisted suicide or for active euthanasia or for other
Ongoing bereavement support may be provided to rela-
forms of hastened death.
tives, either by the palliative care team or by referral to
In most countries, withholding or withdrawing
local community networks and support systems. It is
life-sustaining treatment is legally and ethically accept-
important that the need for bereavement support be
able, and so treatment reduction may off er an option.
recognized and support provided as appropriate.
In selected cases with intolerable suff ering, palliative
sedation may be indicated. However, for most patients
Ethical decision making
asking for hastened death, a more detailed exploration
Whereas guidelines and recommendations are avail- and more empathic care should be off ered. Often the
able for most areas of symptom control, there are statement “I do not want to live anymore” means “I do
some issues in palliative care that are loaded with ethi- not want to live like this anymore,” and communica-
cal implications. tion about problems or fears may help to alleviate the
wish for hastened death. For most patients it is possible
Are nutrition and fl uid substitution necessary to fi nd a solution that allows them to spend the rest of
if oral intake is not possible? their days with an acceptable quality of life.
Patients and more often other caregivers and health
care professionals insist on enteral or parenteral nutri- References
tion or at least fl uid substitution if patients are no lon-
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