Thomas A Cavalieri. Pain management at the end of life. J Am Osteopath Assoc 1999;99(6_suppl):S16–S21. doi: 10.7556/jaoa.1999.99.6.S16.
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Pain at the end of life is often undertreated, yet clearly defined management strategies have demonstrated that pain at the end of life can be prevented. Although many barriers to effective pain management exist, the primary care physician is in a pivotal role to coordinate the management of pain through a multidisciplinary approach. Two types of pain, nociceptive and neuropathic, have been described, and appropriate management requires identifying which type of pain is present. The World Health Organization has proposed the "three-step analgesic ladder" approach to pain
management whereby nonopioid, opioid, and adjuvant analgesics are used based on the type and intensity of pain. Although opioids are the mainstay of severe pain management, misconceptions exist regarding the significance of drug dependence and addiction. Through appropriate knowledge of opioid dosing intervals and titration, healthcare practitioners can effectively manage severe pain at the end of life; pain should not be used to justify the acceptance of physician-assisted suicide or euthanasia. Through the ethical principle of the " double effect," opioids intended to control pain at the end of life can be administered even if such administration hastens the dying process. Physicians can and should enhance the quality of life of their dying patients by enabling them to avoid pain.
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