Terminal illness

The Opiates. The International Narcotics Control Board—Vienna, tracks the tick production of narcotic dmgs and annually estimates world requkements for the United Nations. Thek most recent pubHcation (100) points out that more than 95% of the opium for Hcit medical and scientific purposes is produced by India and, in a declining trend, only about 600 t was utilized in 1988. This trend appears to be due to the fact that the United States, the largest user of opium for alkaloid extraction, reduced the amount of opium being imported from about 440 t in 1986 to 249 t in 1987 and 224 t in 1988. The United States used about 48 t of morphine (2, R = H) in 1988, most (about 90%) being converted to codeine (2, R = CH3) and the remainder being used for oral adrninistration to the terminally ill (about 2 t) and for conversion to other materials of minor commercial import which, while clearly alkaloid-derived, are not naturally occurring. 

When a patient does not have a painful terminal illness, drug dependence must be avoided. Signs of drug dependence include occurrence of withdrawal symptoms (acute abstinence syndrome) when tiie narcotic is discontinued, requests for tiie narcotic at frequent intervals around tiie clock, personality changes if the narcotic is not given immediately, and constant complaints of pain and failure of tiie narcotic to relieve pain. Although these behaviors can have other causes, the nurse should consider drug dependence and discuss the problem with tiie primary health care provider. Specific symptoms of tiie abstinence syndrome are listed in Display 19-3. 

Opioid dependence rarely results ftom the prescribing of opioids temporarily for treatment of acute pain or pain of terminal illness. Even use in chronic... 

This protection-freedom dynamic is even more intensive when it comes to drugs that are being tested for use in pahents with terminal illnesses that have no other viable treatment options. In these situations, the FDA receives tremendous pressure to approve these drugs rapidly. The rationale is that the most serious risk of death from an experimental drug is no risk at all compared with the certainty of death in patients with a lethal disease. 

Sourirajan took a few milliliters of desalinized water (collected over a period of a few days in the 15.5 cm cell), to the home of Professor Yuster, by then terminally ill. Nevertheless he excitedly got out of bed and predicted (correctly) that if it could be done with a few milliliters it could be done with a million gallons. (This anecdote was told to me by someone who was present, a relative of Shuster s). 

Interestingly, the debate went beyond the regulated parties. Economists and libertarians commenced a campaign to let the marketplace determine which drugs were effective. Advocates of laetrile (a purported cancer cure), fought in court for an exception to the effectiveness requirements for drugs intended for persons with terminal illnesses that could not be treated by any approved or recognised methods. 

During chronic therapy, especially for noncancer-related pain (or pain associated with other terminal illnesses), the continued need for the use of opioid analgesics should be reassessed as appropriate. 

Should there be any suspicion of development of dependence, the drug should be discontinued slowly and with adequate support for the patient. Dependence, however, is an adverse reaction which has been reported for a wide range of drugs, controlled and non-controlled. In some situations, treatment needs to be continued despite the manifestation of side-effects, even dependence. For example, in cancer patients suffering from severe pain in terminal illness, opioid medication should be continued whether or not dependence is developing. The concept of risk-benefit balance must always be used in any clinical setting. The suspicion of dependence should be reported at least to the national authorities. 

The opium alkaloid morphine is representative for this group of opiates and also for other opioid analgesics. Morphine is a full agonist for both the jx and the k receptors. It is used to relieve severe acute pain, or chronic pain in terminally ill patients. Its oral bioavailability varies from 15% to 35% and its... 

Jennings AL, Davies AN, Higgins JPT, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev 2001. 

The nature of the drug and the intended patient population are important in determining whether an effect should be called adverse. For example, toxicity in a drug intended for patients with terminal illnesses or short life-expectancy might be viewed as acceptable in risk-benefit considerations, whereas the same effect in a drug intended for lifetime administration in a more benign condition could well be considered unacceptable. 

Galloway, K.S., and Vaster, M. (2000) Pain and symptom control In terminally ill children. Pediatr Clin North Am 47 711-746. 

Often, toxic organic states that may be complicated by psychotic symptoms develop in terminally ill patients. Acute confusion has been reported in up to 85% of terminal cancer patients, with restlessness and agitation occurring in up to 42%. Unfortunately, the cause of delirium is determined in only 21% of these patients ( 373, 374). Common sources can include the following ... 

Silverman HD, Croker NA. Pain management in terminally ill patients how the primary care physician can help. Postgrad Med 1988 83 181-188. 

Martin E. Confusion in the terminally ill recognition and management. Am J Hospice Paiiiat Care 1990 7(3) 20-24. 

Danthron (1,8 dihydroxyanthraquinone) derivatives occur in senna, cascara, rhubarb. They are highly effective, and the main side effect is excessive laxative effect and abdominal pain. Danthron reparations shouid oniy be used in older patients and the terminally ill because of the risk of lepatotoxicity. 

Some states have recognized the underutilization of pain medications in the treatment of pain associated with chronic and terminal conditions. California, for example, has enacted an "intractable pain treatment" act that reduces the difficulty of renewing prescriptions for opioids. Under the provisions of this act, upon receipt of a copy of the order from the prescriber, eg, by fax, a pharmacist may write a prescription for a Schedule II substance for a patient under hospice care or living in a skilled nursing facility or in cases in which the patient is expected to live less than 6 months, provided that the prescriber countersigns the order (by fax) the word "exemption" with regulatory code number is written on a typical prescription, thus providing easier access for the terminally ill. 

Analgesic efficacy and clinical use Diamorphine is a strong opioid analgesic used for the treatment of severe pain, especially in terminally ill cancer patients (Sawynok, 1986). In addition it can be used for the treatment of cough associated with terminal lung cancer. 

Side-effects Diamorphine has in principle the same side-effect profile as morphine. High doses as used by addicts may cause fatal pulmonary edema (Darke and Zadol, 1996). Because of its high abuse potential therapeutic administration is prohibited in many countries including Germany and the USA, in other countries like the UK it is used for severe pain mostly among terminally ill patients. 

A form of care which attempts to provide at least superficial or temporary relief of pain and suffering such as that which is provided for cancer and/or terminally-ill patients. 

In dealing therapeutically with a topic of such finality and depth as death, it is difficult to follow the usual format of a scientific presentation. Of necessity one must treat the material from a more holistic and philosophic standpoint. The investigations in this report were designed to make the last months of patients with a terminal illness more meaningful and less distressful. 

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