ABC of palliative care: Non-malignant conditions

doi:10.1136/bmj.316.7127.286

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Tony O'Brien,
John Welsh,
Francis G Dunn

Much medical practice is still concerned with control of symptoms rather than cure, and doctors spend considerable time palliating and modifying symptoms associated with incurable disease.

A strong body of opinion argues that the skills and philosophies of palliative care should be extended to all care settings. This is optimally delivered by those working in their own specialty—such as neurology, cardiology, and respiratory medicine. Training in basic palliative care should form part of the undergraduate and postgraduate curricula for healthcare professionals. The success and relevance of palliative care will be judged not by the number of specialist teams but by the capacity to influence the care offered to all patients irrespective of diagnosis and place of care

The role of specialists in palliative medicine is to offer what has been learnt about palliation of malignant disease to those caring for patients with progressive, incurable, non-malignant conditions and to share and exchange best practice. Many symptoms experienced by cancer and non-cancer patients are similar: cancer patients' symptoms may be more severe, but those of non-cancer patients tend to be more prolonged.

Symptoms common to malignant and non-malignant conditions

Physical

Pain
Breathlessness
Anorexia
Immobility
Constipation

Social

Loss of employment
Role change
Fear for dependants

Psychological

Depression
Fear and anxiety
Uncertainty
Guilt

Existential

Religious
Non-religious
Meaning of life
Why?

The approach to controlling pain in progressive non-malignant conditions can be adopted from the strategy for managing cancer related pain. After an accurate diagnosis of the pain, appropriate treatment can be started: the principles of the World Health Organisation's analgesic ladder (discussed in the first article of this series) apply equally to non-cancer patients. The strength of analgesia chosen depends on the severity of the pain, and the choice of adjuvant analgesic depends on the pathogenesis of the pain.

Doctors may be concerned about giving opioids to patients with chronic non-malignant pain. This is a …