The Common Sense Guide to Improving Palliative Care > Assuring Comfort > 5.1 Chapter Overview

This extract from the online edition of The Common Sense Guide to Improving Palliative Care is used with permission.

Assuring Comfort: Chapter Overview

In This Chapter:

• Identifying burdensome symptoms
• Understanding elements of good symptom management
• Using clinical practice guidelines and other resources
• Using quality improvement to ensure patient comfort

For patients, the experience of illness is often the long story of symptoms and associated suffering and fear. For clinicians, symptoms present diagnostic clues and therapeutic challenges. Controlling symptoms often defines good medical care, particularly for advanced and incurable illnesses, when the patient's priorities focus on comfort and quality of life. Although pain may be the most prominent symptom associated with advanced disease and the end of life, many other symptoms contribute to patient suffering, including dyspnea, fatigue, delirium, depression, anorexia, cachexia, hypoxia, nausea and vomiting, and constipation.

Good practice for symptom management is logical (even when our real-world approach is not).

• Know which symptoms are present by asking the patient (or family, if the patient cannot communicate).
• Ask whether anything has helped in the past. Find out what the symptom means to the patient (e.g., is dyspnea terrifying or just exhausting? Is depression blocking the patient's ability to spend time with family?) Consider any alternative approaches that the patient has found worthwhile—for example, acupuncture or massage therapy—as they may be worth trying again.
• Look for the cause (or, at least, the likely cause) of the symptom.
• Know what works to relieve and prevent this symptom in similar cases, and work with patients and caregivers to make a plan.
• Try out the plan. If it works, great. If not, promptly try something else.
• Be sure to follow up since patients and families often think that they must live with even more severe symptoms.

Keep in mind the following key points for symptom management for end-of-life patients.

• Trust the patient's report of his or her experience. When patients cannot speak, you will have to decide which evidence to trust; just remember that the more common error is to underrecognize and undertreat symptoms.
• Consider all available treatments and their merits in the context of the patient's values, culture, goals, and fears.
• When illness is advanced, and death is near, the exact causes of any given symptom often become irrelevant, but the symptom still must be relieved.
• Anxiety, fatigue, and emotional and psychological stress worsen the experience of the symptoms (and vice versa).
• The psychological component of every symptom presents an opportunity to heal the psyche while relieving the symptoms.