CME : Your SA Journal of CPD - Volume 21, Issue 5, May 2003

There is a psychosocial dimension to the work of all professionals involved in palliative care. Patients with life-threatening illness experience a series of losses as the illness progresses. Patients' symptoms and families' reactions are not unrelated and addressing both aspects is healthier for both. Never underestimate the theurapeutic value of listening empathetically to 'the story'. By shattering even unrealistic hope, we run the risk of stripping the ability of patients and family to cope.

Delirium is common in dying patients. To recognise the problem look for features such as inattention, muddled thinking, altered level of consciousness of recent onset and with a fluctuating course. Although in many cases delirium in dying patients is irreversible, infection, hypercalcaemia, faecal impaction, urinary retention and certain drug interactions may be reversible. If aggressive and violent, use appropriate drugs in effective doses to adequately sedate the patient. Carefully explain the cause of the strange behaviour to the patient's family and help them to understand the poor prognosis and the need for effective sedation.

The natural course of untreated HIV / AIDS is characterised by a progressive deterioration of the underlying immune system, punctuated by consequent opportunistic infections and cancers. ART is the most effective palliation for HIV / AIDS so far. Patient care from the time of diagnosis should be multidisciplinary. Palliative care in AIDS is characterised by a higher proportion of extremely emotive issues surrounding sexuality, reproduction, guilt, loss of vitality, loss of productivity and death. Practical management of AIDS patients entails the formulation of individualised care plans for each patient and their families, drawn up by the multidisciplinary team in conjunction with the patient and family or caregivers. Symptoms in the terminal phase may be due to the HIV itself, treatment of HIV or opportunistic infections, associated debility or concomitant illness. Clinical care involves a detailed assessment to ascertain cause, followed by treatment of reversible causes, drug and non-drug palliation of chronic symptoms, and re-evaluation to assess response. Psychosocial care is facilitated by a family meeting involving relevant family members, with or without the patient, which allows for the transfer of information, education of the family on the patient's condition and for support on a practical and emotional level. Caring for terminally ill patients, especially young patients, can be a physically, psychologically and emotionally exhausting task, with which health care workers need to feel confident and comfortable, as personal fears and anxieties surrounding mortality are often conveyed to the patient. AIDS has provided a challenge to the medical fraternity at large, calling for closer collaboration between curative and palliative care, demanding that curative medicine adopts a higher level of care, and that palliative medicine adopt a reasonable measure of cure.

It is important that doctors base their practice on sound ethical principles of autonomy, beneficence, non-maleficence and justice. Respect for autonomy promotes the development of a trusting relationship between doctor and patient. The practitioner should ensure that the patient and family are informed regarding the treatment, benefit and burden and likely improvement in quality of life, and support the patient's decision. Effective palliative care techniques can relieve distressing symptoms without shortening life.

The confident use of morphine in palliative care requires core knowledge of its pharmacology and a confident understanding of the strategies to increase the dose. Dose by the mouth and by the clock. The hand that writes the script must attend to constipation and have a strategy for nausea control. If pain is not controlled or improved by 2 - 3 dose increases it is probably a partially opioidinsensitive pain. Consider the use of co-analgesics. Good patient preparation and proper opioid use can only remove present prejudice and fear for patients and doctors alike. Parenteral doses of morphine are twice as potent as oral doses.