11Pain, Discomfort, and Humanitarian Care

Introduction

The Department of Health, Education and Welfare in collaboration with the White House has identified chronic pain and terminal illness as areas needing increased emphasis and awareness in our country. The Interagency Committee on New Therapies for Pain and Discomfort is serving as the federal focal point for planning activities in research, education and the organization of health care services. In order to document the scientific base for future activities, a "Conference on Pain, Discomfort and Humanitarian Care" was held at the National Institutes of Health on February 15-16, 1979. This conference was organized by the Interagency Committee to review the present status of scientific information and to identify areas which should receive additional attention.

As part of the meeting, a "consensus development" panel on "The Management of Pain and Discomfort in the Terminally Ill" was held on February 16. The consensus development program at NIH brings together biomedical research scientists, practicing physicians, consumers, and others in an effort to reach general agreement on the efficacy and safety of a medical technology.

Topics addressed during the consensus development panel included "The Care of the Aged," "Death and Dying," "The Hospice Approach to Terminal Illness," and "Pain and Well-being: A Challenge for Biomedicine." In the discussion period, the panel agreed on the following statements:

1. Biomedical scientists recognize that compassion plus knowledge and technical skills are required to manage the aged person and the terminally ill patient. The physician with this humanitarian approach will be able to shift his emphasis from keeping the patient alive ("curing") to allowing the patient to die with dignity ("caring").
2. The chronic pain experienced by many persons afflicted with long-term or terminal illnesses is a multidimensional, hierarchical phenomenon that is influenced by somatosensory, affective, cognitive, social and behavioral factors. The treatment of this suffering requires an integrated approach exemplified by the hospice model which addresses the patient's physical, mental, social and spiritual needs.
3. Important principles for the management of terminally ill patients include the following:

   • Chronic pain should be treated with continuous, oral narcotic or other analgesics individually titrated to keep the patient in the therapeutic range.
   • Antinauseants, antibiotics, stool softeners, corticosteroids. and antidepressants should be used as necessary for symptom management. Because many patients are dying at home, a contingency plan should be developed for medical emergencies to prevent inappropriate hospital admissions, which often include excessive diagnostic studies and therapies.
   • The patient and the family should be treated as a unit in order to lessen the loneliness, guilt, anger, and conflict that often accompany death.
4. A number of professionals, in addition to practicing physicians, contribute to the care of the dying patient; nurses, social workers, rehabilitation specialists, nutritionists, pharmacists, spiritual counselors, volunteer aids, health administrators, etc. are important members of this health team.
5. The principles of the care of the aged and terminally ill are compatible with the goals of the existing health care system in the United States. In order to define an effective mechanism for delivering these services, the role of the traditional medical center, of the health care professional, and of society will have to be reassessed in light of the hospice concept.
6. Clinical research is required to define more clearly issues related to the aged and terminally ill. This research should include studies of the following:

   • The epidemiology of aging and death in the United States; the mechanism, measurement, and management of chronic pain in these conditions, the efficacy of bereavement counseling; and the identification of the psychological and social issues related to the aged and the terminally ill.
7. Practicing physicians and nurses need to be educated in chronic pain and cancer pain diagnosis and management. The curricula of medical and nursing schools should include factual material and clinical experience in pain management, the problems of the aged, and care of the dying.

Consensus Development Panel

Diane Fink, M.D., Chairperson

• Division of Cancer Control and Rehabilitation,
• National Cancer Institute

Robert N. Butler, M.D., Director

• National Institute on Aging

Paul F. Engstrom, M.D., rapporteur

• American Oncologic Hospital
• Philadelphia, Pennsylvania

William Fischer, M.D

• Hospice, Inc.
• New Haven, Connecticut

Melvin J. Krant, M.D

• University of Massachusetts Medical Center

Lorenz K.Y. Ng, M.D

• Division of Research
• National Institute on Drug Abuse

Thomas West, M.D

• St. Christopher's Hospice
• London

Conference Sponsors

• National Institute of Mental Health
• Alcohol, Drug Abuse and Mental Health Administration (ADAMHA)
• National Institute on Aging, NIH
• National Cancer Institute, NIH
• National Institute of Neurological and Communicative Disorders and Stroke, NIH
• National Institute of Dental Research, NIH
• National Institute on Drug Abuse, ADAMHA
• Bureau of Drugs, Food and Drug Administration (FDA)
• Office of Medical Applications of Research, NIH
• Fogarty International Center, NIH

This statement was originally published as: Pain, Discomfort, and Humanitarian Care. NIH Consens Statement 1979 Feb 16;2(1):7-8.

For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Pain, Discomfort, and Humanitarian Care. NIH Consens Statement Online 1979 Feb 16 [cited year month day];2(1):7-8.

NIH Consensus Statements are prepared by a nonadvocate, non-Federal panel of experts, based on (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the consensus panel and is not a policy statement of the NIH or the Federal Government.