Chapter 5 Review and Report
Cat Calhoun
WS0313 Biomedical Treatment of Disease 1
AOMA Graduate School of Integrative Medicine
Spring 2011
Out of Class Assignment
Dr. MANDYAM
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Out of Class Assignment – Chapter 5 CMDT
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The topic of this chapter is care of the client at the end of life. Practitioners must have the ability to
recognize when life is indeed ending and when it is no longer medically possible to sustain a client’s
life. The end may be either immanent or in coming weeks or months. The ability to determine this
requires the clinical prognosis skills to help patients identify the end period of their lives. The shift in
focus upon this determination is not on curing a disease, but on providing relief of symptoms and
improving the quality of the client’s remaining life. This chapter also addresses communication with
clients regarding their care and helping them make decisions at the end of life regarding DNR orders and
medication choices to manage symptoms and emotional status. This can also include helping family and
friends with post-death decisions such as organ donation, autopsy, and dealing with grief.
One the determination if impending death has been reached a western medical practitioner has a number
of medications to manage pain, dyspnea, nausea and vomiting, constipation, and psycho-emotional
issues such as delirium and agitation. The opioid class of drugs, while used cautiously in non-end of life
situations due to addiction potential, can give great relief to clients experiencing great pain due to
various illnesses at the end of life. Clients may develop a tolerance to a single opioid; equianalgesic
dosing can assist in better pain management without building drug tolerance. Acetaminophen and
NSAIDS can offer anti-inflammatory benefits to manage pain from inflammation and can also manage
fevers through their anti-pyretic effects. Care must be taken however as these can cause liver damage
and complications when used in cases of congestive heart failure. Opioids, tricyclic antidepressants,
gabapentin, lidocaine patches and tramadol are useful for neuropathic pain. Clients who have paint that
cannot be controlled without undesirable side effects can be given medication “cocktails” in lower doses
to defeat these side effects. In addition to medication therapy, end-of-life clients may benefit from
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physical therapy, chiropractic manipulations, acupuncture, biofeedback, and qigong among other nonpharmacological interventions. These may also help with stress and depression which can result from
chronic pain and end of life.
Difficulty breathing can cause a sense panic and extreme discomfort for clients at any time, but certainly
near the end of life. Immediate release morphine (IV drip, oral, inhaled, etc.) can relieve dyspnea as can
supplementing oxygen and benzodiazepines in cases where dyspnea is associated not with a physiologic
problem but with anxiety. Nausea and vomiting, common and sometimes associated with other drug
therapies, can be managed with a variety of medications depending on the cause of the problem.
Laxatives and prokinetic agents can help relieve nausea and vomiting associated with constipation and
other gastric obstructions. If associated with increased intracranial pressure, corticosteroids can be used.
If associated with the inner ear anticholinergics and antihistamines may provide relief. Benzodiazepines
provide relief for chemotherapy types of nausea and vomiting. Constipation can be managed with stool
softeners and bowel stimulants. This is particularly important with the administration of opioids.
Delirium and restlessness can be treated with neuroleptics, benzodiazepines or sedation agents.
The points to be addressed in palliative care are identifying and giving a prognosis, communication with
and care for the patient, assisting clients with decisions about when to terminate curative efforts and
focus on palliative care, how to deal with pain and suffering on both a pharmacological and nonpharmacological level, dealing with grief and spiritual care of the client and the family. The task of
caring for one’s self as a practitioner is also an important issue. Though clinical skill and technique is
important, when a client is nearing the end of life, communication becomes an extremely important skill
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as well. A practitioner must understand suffering and the client’s fears about death and the process of
dying. Clinicians can communicate that while a cure is not likely or possible the client can focus on
what is indeed possible: relief of pain, reconciliation with family and loved ones, finding meaning and
spiritual transformation in the death process. A physician or any practitioner can also offer a dying
patient the gift that they will not abandon the client and will care for them through the end. This is
compassion and communication and is as important as any drug regimen. If this attitude is shared
throughout the healthcare team caring for this client everyone benefits – the client, the practitioners, the
family and loved ones.
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