Advances in palliative care relevant to the wider delivery of healthcare

Phillip D Good
Med J Aust 2003; 179 (6): S44. || doi: 10.5694/j.1326-5377.2003.tb05579.x
Published online: 15 September 2003


  • The availability of a variety of opioids, together with the discovery of new uses for old drugs (such as ketamine), assists individualised pain management in palliative care.

  • Experience in palliative care provides reassurance that the effective use of opioids and sedatives does not accelerate the approach of death.

  • In taking patient histories, recognising the spiritual component of life experience enlarges the focus of care.

  • Interdisciplinary care brings many different insights to care situations in a prospective and cooperative way.

  • Models of bereavement care established in palliative care units deserve wider implementation in medicine.

  • An “experiential” model of medical student education encourages a focus on the whole experience of patients and their journey with their carers.

Individualised pain relief

The increasing range of opioids available has meant that patients have a better chance of satisfactory pain relief without experiencing side effects such as drowsiness, delirium, nausea or vomiting. Opioid rotation recognises that the individual response to different opioids varies and that a change to an alternative drug may yield a better balance between analgesia and side effects. The reasons why individuals respond differently to opioids are unclear, but proposed mechanisms include differences in opioid receptor profiles, opioid receptor subtype binding, and genetically determined drug metabolism, as well as the mechanism of pain influencing opioid receptor affinity.1,2

Choice of different routes of administration enables the patient to receive the best medication with the least discomfort. The availability of continuous subcutaneous administration and slow-release oral morphine was a big advance, and more recent innovations have included the transdermal or buccal administration of fentanyl and the intranasal administration of sufentanil (particularly useful for incident pain).3 All areas of medicine and pharmacy can benefit from looking outside the traditional approaches to drug administration.

Ketamine is a good example of a drug that has been used in anaesthetic medicine for a long time but has undergone a resurgence in use in palliative care for treating refractory cancer pain. A recent trial has shown its benefit in treating many different types of pain, including somatic (eg, incident pain and mucositis), neuropathic and possibly visceral pain.4 Use over a short term (3–5 days) can have a long-lasting effect on pain control (up to 8 weeks in one instance) and may overcome some practical difficulties of access and cost.

Use of medication at the end of life

Most palliative care physicians are comfortable with the routine giving of opioids (for pain) and sedation (for terminal delirium) as well as the less common administration of sedation for “refractory symptoms”. The most common symptoms that are refractory to standard palliative treatments are delirium, breathlessness and, less often, pain.5 Traditionally, there has been a fear in the medical fraternity that opioids and sedatives hasten a patient’s dying phase. This has meant some patients have been left to die an uncomfortable death. However, recent research suggests that using these medications does not influence length of life and that their use should be encouraged in the terminal phase.5

Medical practitioners should not be afraid to use medications to relieve suffering if they are initiated in response to a specific symptom or sign and are titrated in response to the symptom or sign. This is appropriate annd compassionate treatment for patients at the end of life. Consultation with specialist palliative-care medical or nursing staff may give medical practitioners greater knowledge and confidence, particularly when dealing with unfamiliar doses of medication. However, increasing doses of opioids and sedatives with the aim of deliberately hastening death is not part of palliative care practice.

There is a community perception that morphine treatment is the “last resort”. Experience in palliative care shows this is far from the truth. Patients can function well on opioids for long periods of time.6 This fact needs to be communicated to all areas of medicine to allay the fear that symptom control will compromise length of life — a particularly relevant message for palliative care practitioners as they become more involved in symptom control for non-malignant diseases.


Spirituality is a dynamic, personal and experiential process whose features include a quest for meaning and purpose, transcendence (a sense that there is someone or something greater than ourselves), connectedness (with a transcendent power) and values (eg, love, compassion and justice).7 Spirituality plays an important part in people’s lives, and many patients, especially when very ill, would like to talk to their doctors about some of these issues.8 Exploration of the area of spirituality can be therapeutic in itself, but it does not easily lend itself to the history/examination/therapeutic approach taken in mainstream medicine. This may be one of the reasons why doctors can be uncomfortable entering this area. There are, however, guides available for clinicians to assist in making spiritual assessment part of history-taking (Box).9 Talking to patients about their spirituality can help doctors learn about the most important goals patients have, especially as death approaches.


Palliative care offers a number of unique contributions to the advancement of care at the end of life. Perhaps its most valuable contribution is in providing a model of care that addresses the physical, psychological, spiritual and social needs of all patients. This holistic approach deserves wider implementation in other fields of medicine.

“HOPE” questions for spiritual assessment9

H: Sources of hope, meaning, comfort, strength, peace, love and connection:

  • What are your sources of strength?

  • What sustains you and keeps you going?

O: The role of organised religion:

  • Are you part of a religious or spiritual community?

P: Personal spirituality and practices:

  • Do you have personal spiritual beliefs?

  • What aspects of your spirituality or spiritual practices do you find most helpful?

E: Effects on medical care and end-of-life decisions:

  • How do your beliefs affect the kind of medical care you would like me to provide over the next few days/weeks/months?

  • Would it be helpful for you to speak to a pastoral care worker?

  • Phillip D Good

  • Department of Palliative Care, Newcastle Mater Misericordiae Hospital, Newcastle, NSW.


Competing interests:

None identified.

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  • 10. Kissane DW. Neglect of bereavement care in general hospitals. Med J Aust 2000; 173: 456. <eMJA full text>


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