Betty R. Ferrell

Issues of control in patients with cancer pain.

The enhancement of patient control isfrequently cited in nursing literature as an important area of nursing intervention. In this article, the concept of control, from the perspective of the patient with cancer pain, the primary family caregiver, and the home-care nurse, is discussed. Lewis identifiedfive types of control: processual control, contingency control cognitive control, behavioral control, and existential control. Lewiss typology of control was used as an organizing analytical framework, in this study, for interpreting the interview responses of each member of the triad. Similarities and differences in the perspectives of each member are discussed and examples of interventions that may be used to increase control in the management of pain are presented.

Providing opioids at the end of life

Pain management is integral to quality hospice and palliative care. Experts advocate for adequate analgesia to be provided to all patients in pain, including older adults, infants and children, nonverbal patients, nonEnglish-speaking people, and those with active or a history of substance abuse. Providing effective pain management should be a primary objective in every clinical setting—especially those settings that provide care to dying patients. Although there is agreement that the goals of palliative care must focus on the prevention and relief of pain and suffering, clinicians, patients, and families may be reluctant to use opioids to achieve this goal in patients who are dying. 8 This hesitancy may stem from the fear that administering opioids depresses respirations, thereby hastening death. However, there is no convincing scientific evidence that administering opioids, even in very high doses, accelerates death. In fact, numerous clinical studies demonstrate no significant association among opioid use, respiratory depression, and shortened survival. 12, 14-20 Respiratory depression and other changes in breathing are part of the dying process and are more likely to be from disease and multisystem organ failure than from opioids. 21 Despite the lack of evidence that opioids hasten death, some clinicians continue to believe that administering opioids can accelerate the dying process; for this reason, they seek moral justification for providing aggressive pain management. The rule of double effect provides ethical justification for the use of opioids in dying patients even if there is a risk of hastening death. According to the rule of double effect, four conditions must be satisfied to establish a clinician’s act as morally permissible: • The act must be good or morally neutral, regardless of its consequences; relief of pain and suffering by administering opioids is a priority in hospice and palliative care and therefore is a “good act.” • The clinician must intend the good effect (relief of the patient’s pain and suffering); although the bad effect (ie, death) may be foreseen and permitted, it is not the clinician’s intended effect. • The bad effect must not be the means by which the good effect is achieved; in other words, the patient does not need to die in order to be relieved of pain. • The benefits of the good effect must outweigh the burdens of the bad effect; in this case, the benefits of achieving pain relief outweigh the minimal risk of hastening death.