In-patient and out-patient palliative medicine - a challenge for the anaesthesiologist

Traditional approaches to the treatment of the incurable and terminally ill are often felt by patients and their families to be inadequate, since the distressing physical symptoms and psychological concomitants of the disease are not given sufficient consideration. New strategies for providing therapy and care have resulted from the international hospice movement and have been included in medical training programmes, collectively referred to as palliative medicine. In the past few years, palliative care services have increasingly been established in Germany. These are mainly in-patient facilities, such as palliative-care wards or hospices. Beside other medical fields, anaesthesiology departments are often involved. A major advance was made in May 2003, when the Federal General Assembly of German Physicians passed a resolution to include palliative medicine in the postgraduate medical training regulations. In addition to giving greater recognition to this medical specialisation, that crucial step will bring about an improvement in the qualification of the physicians working in this field and better provision of palliative care. This review primarily addresses the alleviation of pain and other physical symptoms as well as the psychosocial needs of the individual. After diagnosis of the disease and assessment of pain, treatment commences with the selection of appropriate analgesics and an effective mode of application. Following dosage titration until the effective dosage is reached, long-term therapy is initiated with slow-release analgesics and supplemented with co-analgesics, particularly in the case of neuropathic pain, as well as with adjuvant drugs to diminish the side effects of analgesics. The significance of constipation and its associated complications is often underestimated in patients with advanced malignant disease. Effective prophylaxis and therapy based on the elimination of the cause of the problem can improve alimentation and intestinal transit and prevent the development of a paralytic ileus. New findings concerning the role of neurotransmitters in triggering nausea and vomiting have resulted in the development of purposeful approaches to treatment. Dyspnoea therapy places high demands on the medical team as nursing and physiotherapy must effectively supplement the limited possibilities offered by medical treatment alone.