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40 Topical Seminar Summary: QUANTITATIVE SENSORY TESTING – DOES IT HELP THE PAIN CLINICIAN?
Oral Presentations / European Journal of Pain 13 (2009) S1–S54
Topical Seminar: Quantitative sensory testing – does it help the pain clinician? 40 Topical Seminar Summary: QUANTITATIVE SENSORY TESTING – DOES IT HELP THE PAIN CLINICIAN? P.T. Hansson *. Karolinska University Hospital, Stockholm, Sweden Quantitative sensory testing (QST) has a reputation as a sophisticated means in assessment of pain conditions. This seminar will highlight the usefulness and pitfalls of QST techniques relevant to the pain clinician. Dr Ellen Jorum, ¨ Norway, will discuss QST measures reflecting small fibre damage, supposedly relevant in neuropathic pain assessment. Thermal non-nociceptive and nociceptive perception thresholds are probed and loss of function as well as allodynia / hyperalgesia may be monitored. A drawback is that QST cannot reveal the underlying mechanisms of neuropathic pain. Dr Roman Rolke, Germany, will report on normative data from an exhaustive QST protocol used by the German Research Network on Neuropathic Pain (DFNS). QST reference data were dependent on age, gender, and body region. In unilateral neuropathic pain conditions sensory abnormalities were not restricted to the painful area, but also present contra-laterally. The latter finding points to systemic peripheral effects of the pain disease and/or centrally altered sensory processing also for contra-lateral stimuli. Dr Oliver Wilder-Smith, The Netherlands, will introduce dynamic QST, a strategy to predict vulnerability to nociceptive inputs and their consequences. Here, pain sensitivity is measured before and after a conditioning stimulus, giving insight into how pain processing alters under nociceptive stimulation. He will claim that such an approach may play an important role in reflecting the progression and outcome of pain conditions and discuss specifically how dynamic QST paradigms can determine the balance between inhibitory and excitatory pain modulating systems and the longterm effects which nociceptive input can have and how they are modulated over time.
Topical Seminar: Pain and euthanasia 41 Topical Seminar Summary: PAIN AND EUTHANASIA M. Zenz1 *, G. Bosshard2 , K. Steinhauser3 , B. Zylicz4 . 1 Germany; 2 Switzerland; 3 United States; 4 United Kingdom For years, research on the reasons of patients asking for assisted suicide has largely been doctor-centred. While we have learnt more and more on how doctors view euthanasia, how and how often they perform it, and how they perceive the patients asking for it and their motives, little is known on these very patients’ view on their own. Only recently, research started focussing on the individuals asking to die themselves, and on their family members. A very recent Swiss study compared patients’ reasons for requesting assisted suicide with the perception of these reasons by the doctors assessing their request. It revealed that patients and doctors largely agreed on the importance of pain and neurological symptoms. By contrast, patients rated subjective issues such as loss of dignity and being able to control the circumstances of death much higher than did their physicians. This shows that a substantial and underestimated part of the motivation of individuals asking for assisted suicide is rather existential than medical in nature. In this light, it might be questioned how far palliative care – and be it the best possible – is able to improve the condition of some of these patients in a way that they will refrain from their wish to die. Even more, given the fact that assisted suicide as a response for these kinds of motives has nothing in common with pain and symptom treatment, the
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question arises whether to frame assisted dying in a strictly medical context, as just another “medical end-of-life decision”, might be a misconception. Six major components of a good death can be identified by both physicians, nurses, patients, and bereaved family members: pain and symptom management, clear decision making, preparation for death, completion, contributing to others and affirmation of the whole person. The six themes presented are processoriented attributes of a good death; each theme includes biomedical, psychological, social, and spiritual components. Physicians’ discussions of a good death were most different from other groups’ descriptions. Physicians gave the most biomedical perspective; patients, families and other health care professionals defined a broad range of attributes integral to quality of dying. Although there is no singular “right” way to die, these themes may be used as a rubric for understanding what participants tend to value at the end of life. Biomedical care is critical but only a point of departure toward total end-of-life care. For patients and families, psychosocial and spiritual issues are on equal footing with physiological concerns. However, there is no one definition of a good death. Efforts to evaluate and improve patients’ and families’ experiences at the end of life must account for the diverse perceptions of quality. Improving care of the dying has become a priority. Integral to the success of each of this effort is a clear understanding what patients, families and health care providers view as important at the end of life. Pain specialists have a key role in qualified and sensible care for dying patients. But effective care of pain problems alone is not a solution for existential problems. Total care – palliative care is the central answer to existential suffering at end of life. “Palliative care aims to prevent or reduce suffering and hopelessness at the end of life. Respect for autonomy is an important goal of palliative care, which seeks to strengthen and restore autonomy and not to destroy it. Access to high-quality palliative care must be promoted through national and international policies . . . ” Reference(s) Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physicianassisted suicide in Oregon – the first year’s experience. NEJM, 1999;18:577–83. Fischer S, Huber CA, Furter M, Imhof L, Mahrer Imhof R, Schwarzenegger C, Ziegler SJ, Bosshard G. Reasons why people in Switzerland seek assisted suicide: The view of patients and physicians. Swiss Med Wkly (in press). Materstvedt LJ, Clark D, Ellershaw J, Førde R, Boeck Gravgaard A-M, Muller¨ Busch H Ch, Porta i Sales J, Rapin C-H. Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force, Palliative Medicine 2003;17:97/101. Saunders C, Baines M. Living with Dying: The Management of Terminal Disease. Oxford University Press, 1989. Steinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA. Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med. 2002 Dec;5(6):829–41 Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA: Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284: 2476–2482. Steinhauser KE, Clipp EC, Bosworth HB, et al: Measuring quality of life at the end of life: Validating the QUAL-E. Palliat Supp Care 2004;2:3–14. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-de Wolf JE, Janssen AG, Pasman HR, Rietjens JA, Prins CJ, Deerenberg IM, Gevers JK, van der Maas PJ, van der Wal G. End-oflife practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007, 356:1957–1965. Van der Maas PJ, van der Wal G, Haverkate I, de Graaff CLM, Kester JGC, Onwuteaka-Philipsen BD. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands 1990–1995. NEJM 1996;335:1699–1705.
Topical Seminar: Quantitative sensory testing – does it help the pain clinician? 40 Topical Seminar Summary: QUANTITATIVE SENSORY TESTING – DOES IT HELP THE PAIN CLINICIAN? P.T. Hansson *. Karolinska University Hospital, Stockholm, Sweden Quantitative sensory testing (QST) has a reputation as a sophisticated means in assessment of pain conditions. This seminar will highlight the usefulness and pitfalls of QST techniques relevant to the pain clinician. Dr Ellen Jorum, ¨ Norway, will discuss QST measures reflecting small fibre damage, supposedly relevant in neuropathic pain assessment. Thermal non-nociceptive and nociceptive perception thresholds are probed and loss of function as well as allodynia / hyperalgesia may be monitored. A drawback is that QST cannot reveal the underlying mechanisms of neuropathic pain. Dr Roman Rolke, Germany, will report on normative data from an exhaustive QST protocol used by the German Research Network on Neuropathic Pain (DFNS). QST reference data were dependent on age, gender, and body region. In unilateral neuropathic pain conditions sensory abnormalities were not restricted to the painful area, but also present contra-laterally. The latter finding points to systemic peripheral effects of the pain disease and/or centrally altered sensory processing also for contra-lateral stimuli. Dr Oliver Wilder-Smith, The Netherlands, will introduce dynamic QST, a strategy to predict vulnerability to nociceptive inputs and their consequences. Here, pain sensitivity is measured before and after a conditioning stimulus, giving insight into how pain processing alters under nociceptive stimulation. He will claim that such an approach may play an important role in reflecting the progression and outcome of pain conditions and discuss specifically how dynamic QST paradigms can determine the balance between inhibitory and excitatory pain modulating systems and the longterm effects which nociceptive input can have and how they are modulated over time.
Topical Seminar: Pain and euthanasia 41 Topical Seminar Summary: PAIN AND EUTHANASIA M. Zenz1 *, G. Bosshard2 , K. Steinhauser3 , B. Zylicz4 . 1 Germany; 2 Switzerland; 3 United States; 4 United Kingdom For years, research on the reasons of patients asking for assisted suicide has largely been doctor-centred. While we have learnt more and more on how doctors view euthanasia, how and how often they perform it, and how they perceive the patients asking for it and their motives, little is known on these very patients’ view on their own. Only recently, research started focussing on the individuals asking to die themselves, and on their family members. A very recent Swiss study compared patients’ reasons for requesting assisted suicide with the perception of these reasons by the doctors assessing their request. It revealed that patients and doctors largely agreed on the importance of pain and neurological symptoms. By contrast, patients rated subjective issues such as loss of dignity and being able to control the circumstances of death much higher than did their physicians. This shows that a substantial and underestimated part of the motivation of individuals asking for assisted suicide is rather existential than medical in nature. In this light, it might be questioned how far palliative care – and be it the best possible – is able to improve the condition of some of these patients in a way that they will refrain from their wish to die. Even more, given the fact that assisted suicide as a response for these kinds of motives has nothing in common with pain and symptom treatment, the
S19
question arises whether to frame assisted dying in a strictly medical context, as just another “medical end-of-life decision”, might be a misconception. Six major components of a good death can be identified by both physicians, nurses, patients, and bereaved family members: pain and symptom management, clear decision making, preparation for death, completion, contributing to others and affirmation of the whole person. The six themes presented are processoriented attributes of a good death; each theme includes biomedical, psychological, social, and spiritual components. Physicians’ discussions of a good death were most different from other groups’ descriptions. Physicians gave the most biomedical perspective; patients, families and other health care professionals defined a broad range of attributes integral to quality of dying. Although there is no singular “right” way to die, these themes may be used as a rubric for understanding what participants tend to value at the end of life. Biomedical care is critical but only a point of departure toward total end-of-life care. For patients and families, psychosocial and spiritual issues are on equal footing with physiological concerns. However, there is no one definition of a good death. Efforts to evaluate and improve patients’ and families’ experiences at the end of life must account for the diverse perceptions of quality. Improving care of the dying has become a priority. Integral to the success of each of this effort is a clear understanding what patients, families and health care providers view as important at the end of life. Pain specialists have a key role in qualified and sensible care for dying patients. But effective care of pain problems alone is not a solution for existential problems. Total care – palliative care is the central answer to existential suffering at end of life. “Palliative care aims to prevent or reduce suffering and hopelessness at the end of life. Respect for autonomy is an important goal of palliative care, which seeks to strengthen and restore autonomy and not to destroy it. Access to high-quality palliative care must be promoted through national and international policies . . . ” Reference(s) Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physicianassisted suicide in Oregon – the first year’s experience. NEJM, 1999;18:577–83. Fischer S, Huber CA, Furter M, Imhof L, Mahrer Imhof R, Schwarzenegger C, Ziegler SJ, Bosshard G. Reasons why people in Switzerland seek assisted suicide: The view of patients and physicians. Swiss Med Wkly (in press). Materstvedt LJ, Clark D, Ellershaw J, Førde R, Boeck Gravgaard A-M, Muller¨ Busch H Ch, Porta i Sales J, Rapin C-H. Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force, Palliative Medicine 2003;17:97/101. Saunders C, Baines M. Living with Dying: The Management of Terminal Disease. Oxford University Press, 1989. Steinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA. Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med. 2002 Dec;5(6):829–41 Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA: Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284: 2476–2482. Steinhauser KE, Clipp EC, Bosworth HB, et al: Measuring quality of life at the end of life: Validating the QUAL-E. Palliat Supp Care 2004;2:3–14. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-de Wolf JE, Janssen AG, Pasman HR, Rietjens JA, Prins CJ, Deerenberg IM, Gevers JK, van der Maas PJ, van der Wal G. End-oflife practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007, 356:1957–1965. Van der Maas PJ, van der Wal G, Haverkate I, de Graaff CLM, Kester JGC, Onwuteaka-Philipsen BD. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands 1990–1995. NEJM 1996;335:1699–1705.