Editor's Message  |   June 2007
Pearls for End-of-Life Care
Author Notes
  • Dr Nichols, chair of the AOA Council on Palliative Care Issues (formerly the End-of-Life Care Committee), an AOA trustee, and a member of the JAOA Editorial Advisory Board, is dean of Midwestern University's Chicago College of Osteopathic Medicine in Downers Grove, Ill. 
Article Information
Pain Management/Palliative Care / Palliative Care
Editor's Message   |   June 2007
Pearls for End-of-Life Care
The Journal of the American Osteopathic Association, June 2007, Vol. 107, ES1-ES2. doi:
The Journal of the American Osteopathic Association, June 2007, Vol. 107, ES1-ES2. doi:
Pain management and end-of-life care—I would submit that these two terms call out the best that osteopathic medicine has to offer. Our profession was begun to address the treatment of patients to provide them “rest from pain” in new and innovative ways. Further, there is probably no occasion when all the aspects of osteopathic medicine come into play more than when osteopathic physicians provide care at the end of life. In this, the first of a refreshed series of four supplements on pain management, we focus on the context of the elderly and end-of-life care. 
The five articles in this issue are packed with pearls. Two are more global, and the others focus on more specific aspects of our topic. The first article, by Jimmie P. Leleszi, DO, and Jeanne G. Lewandowski, MD, provides excellent insight into what “pain” is. The totality of the pain experience includes physical noxious stimuli, emotional discomfort, interpersonal conflict, and nonacceptance of one's own dying. Further, the authors thoroughly outline the physiology of pain in the context of the whole person. In summary, the “gold standard” of the assessment of pain in pain management is that pain is whatever the patient says it is. 
In his article titled “Managing Pain in Older Adults,” Thomas A. Cavalieri, DO, points out that physicians are hampered by a lack of training, inappropriate pain assessment methods, and reluctance to use opioids. He beautifully details the proper approaches to pain from pharmacologic and nonpharmacologic points of view. His article culminates in the 10 principles for effective pain management that every physician should have well in mind. 
Bringing methadone hydrochloride, an old medication, back to the forefront for consideration in pain management is the focus of the article by John F. Manfredonia, DO. He aptly points out that while we physicians must nurture the physical and psychological well-being of our patients, we must also be the stewards of society's financial resources. For such reasons, use of methadone is having a resurgence in the management of pain and is particularly well suited for use in the elderly. Current updated cautions about proper dosing management are included. 
Tracy L. Marx, DO, writes from a perspective of a physician partnering with hospice in a nursing home. She also references one of the few studies that have identified predictors of short-term mortality in nursing home residents. It is crucial that all physicians understand these points. She gives excellent insight into the issues in hospice, making the important point that different disease states have different patterns of dying. 
A totally new article by Nicholas G. Parise, DO, provides superb guidance on proper patient education and effective use of opiates at the end of life. He dispels many common myths that prevail regarding this topic. 
Finally, this supplement provides two excellent American Osteopathic Association (AOA) communications reprints. Both were drafted by the Council on Palliative Care Issues, formerly called the End-of-Life Care Committee. The first is a reprint of the policy statement on end-of-life care,1 which was adopted by the AOA in 2005. The second is an excellent paper stating the position of the AOA against the use of placebos in pain management in end-of-life care,2 deeming such use as unacceptable, unjustified, and unethical. In July 2004, the AOA House of Delegates approved this policy statement. 
One of the most delightful additions to this refreshed series is the set of case presentations. I doubt that you can maintain a dry eye when you read about Scotty, Fred and Audrey, and others. Once again we are reminded that the strength of the osteopathic medical profession is the emphasis on our patients as people. We hope you will find this supplement useful as you provide “rest from pain” for your patients at end of life. 
 Dr Nichols has no conflicts of interest.
 “For all the happiness mankind can gain Is not in pleasure, but in rest from pain.”
 John Dryden (1631–1700) English poet, dramatist, and critic from The Indian Emperor
End-of-Life Care Committee. American Osteopathic Assoiation's Policy statement on end-of-life care, J Am Osteopath Assoc. 2005;105(suppl 5): S32-S34.
Nichols KJ, Galluzzi KE, Bates B, Husted BA, Leleszi JP, Simon K, et al for the American Osteopathic Association End-of-Life Care Committee. AOA's position against use of placebos for pain management in end-of-life care. J Am Osteopath Assoc. 2005;105(suppl 1):S2-S3.