ventions and care targeting the spiritual, existential, psychiatric, and psychosocial distress they precipitate.

Negotiating management of physical symptoms at the end of life is often complex: the first issue is dealing with the meaning of the transition from curative to palliative care. This requires sensitive communication by the physician with opportunity for participation of supportive disciplines that can more fully address the concerns of patients and families.

In addition, medical management for the dying patient is complicated by the interaction of the symptoms of disease and the fact that treatments may produce relief or introduce new problems; for example, analgesics cause troubling constipation. Patient education is an essential component of care to ensure a collaborative approach to symptom management. Clinical practice guidelines usually consider a single symptom in isolation; thus, a guideline addressing a single symptom may apply less well because it fails to take into account many coexisting symptoms. Care of the dying requires creative problem solving, as well as the development of clinical guidelines to address this level of complexity. Palliative treatment should be just as aggressively approached as curative treatment. Many patients’ greatest fear is of abandonment, of hearing the echoing words of a physician telling them that there is nothing more that can be done. In fact, treatment of the dying patient continues to the moment of death and beyond, by interventions to assist family members with their grief.

One imperative is improved doctor-patient-family communication about symptoms and more collaborative efforts at symptom management. Uncertainty about the cause of symptoms or what they may signify, fear of future symptoms and worry that symptom control will be inadequate contribute substantially to patients’ and families’ distress. Many fear unbearable and poorly treated pain and respiratory distress in the final days and hours. Clinicians could be helpful by describing the dying process to patients and families in terms of reassurances about comfort and relief of symptoms. Loved ones usually view Cheyne-Stokes respirations as indicators of substantial discomfort and pain or fear that a gurgling sound indicates the patient is drowning, despite the fact that most patients are no longer conscious in this final stage of dying. Adequate preparation of patient and family about the dying process and anticipated symptoms is essential and must begin with showing a willingness to discuss these matters and address fears and concerns. Treatment of distress caused by fear of potentially uncontrolled physical symptoms will significantly improve quality of life. The public issue that has arisen regarding requests for physician-assisted suicide is prompted considerably by the widespread fear of overwhelming pain and its inadequate control in the care of dying patients (Chochinov and Breitbart, 2000; Sachs et al., 1995).

In addition, psychological, social, and existential or spiritual distress



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