A task for every district hospital

One of the first tasks of medicine is to comfort the dying and relieve their suffering. Much of this is due to terminal cancer, which causes severe pain in about 70% of cases. Every day more than 3.5 million people endure it, and only a fraction of these have their pain alleviated. Even in the developed countries 50[nd]80% of patients are not given satisfactory relief. This needs only simple drugs, which are so often successful that they should be available to everyone. Their use is one of the most important technologies in this book.

In the industrial world, the development of hospices, and their outreach into the community, is helping and respecting the dying, as well as alleviating their pain and their other distressing symptoms. In the developing world, where hospices have yet to be established, district hospitals have to fill this role. Unfortunately, many of them provide no terminal care whatever[md]its provision is one of the indicators of ''good care' (34.6).

Any patient who receives terminal care is, by definition, going to die. It is therefore only too easy to neglect him. Your own attitude to him and that of your staff is critical. He must must feel welcomed by people who are determined to help him. There is always something to be done to make his last days more bearable, even if he is dying. Never send him back home immediately[md]he has come to you for help. A long family discussion may have taken place before he came, and if you send him back from the outpatient department, after much wasted effort and expense, he will feel rejected, and so will his family. Admit him, and actively exclude any differential diagnosis that may be curable. A day or two later, when the diagnosis of terminal cancer is confirmed, you can start talking to his relatives, and almost always to him too.

You will have to decide whether to continue to treat him in hospital, or at home. Make this decision on: (1) The extent of the suffering he will undergo at home from bed sores, from malignant ulcers, and from difficulty with his toilet arrangements, etc. For example, if he needs a catheter which must be changed every two weeks, is there a health unit near him which can do this? (2) His own wishes, and those of his family, after they have had the situation explained to them. (3) The length of time he has to live. (4) The reputation of the hospital. If you admit too many patients just to die, this may have as bad an effect on your reputation, as sending too many of them home. The more ''established' you are, the greater your freedom.

Try to palliate the symptoms of death, when this might help him, and only when it might help him. You can: (1) Always alleviate intolerable pain with drugs. (2) Amputate a very painful limb, bypass his obstructed gut, remove ovaries for carcinoma of the breast, or perhaps excise a fungating cancer. (3) Give him chemotherapy yourself (32.2). (4) Refer him for radiotherapy, chemotherapy, or surgery, after you have weighed up the benefit to be gained against: (a) the suffering they will cause, (b) the cost of treatment, (c) the cost of transport to his family.

Unfortunately, ''altering the symptoms of death' can sometimes make them worse. An intolerable and burdensome indignity in one culture (a colostomy for example), may be quite acceptable in another. So make sure that whatever you do, for cure or palliation, you don't make his symptoms worse, and, particularly, don't prolong his last illness painfully. For example, a gastrostomy (11.8) may keep a patient with carcinoma of the oesophagus alive for months, unable even to swallow his saliva. If you attempt palliation, do so with a Celestin tube, that will at least allow him to swallow (32.24).

Tell him, or his family, about his illness. This should not be difficult, but you will have to know your local culture. Usually, you will have to tell the full story to a responsible relative. In India the patient, if he is male, or a male relative should be told. In Africa it is usually correct to explain the complete position to the family: they will inform him, and he will then talk openly to you. Many less educated patients don't understand what malignancy is.

Contemporary Western culture faces death badly, and commonly withholds the truth from a dying patient. If you tell him nothing, except that he is going to get better, he may eventually lose all faith in you, and (alas) even in his family, who have conspired to deceive him. In contrast, many patients have thanked their doctors for telling them the truth. Unfortunately, some patients (few in the developing world) cannot accept the whole truth immediately. So judge how much he really wants to know. How much of the truth is he really able to ''take' at a time? Whatever you tell him, it must be true. It may not be the whole truth, but it should be the start of the truth because: (1) He is going to get worse anyway, and will eventually know. (2) His relatives will know about the deceit, and when their turn comes to be ill, they will not know whether to trust their doctors. (3) He may have affairs to set in order. (4) You may save him the expense of going from doctor to doctor, vainly seeking a cure. (5) You will relieve his family of the responsibility of knowing what to say to him.

If one of his differential diagnoses is a curable condition, be sure to investigate him sufficiently to exclude it. Unless you do this, you will miss diseases that could have been treated. So don't accept a diagnosis of malignant disease until it is confirmed, preferably by biopsy. Many patients have been palliated for supposedly malignant disease, only to be shown at post mortem to have had some treatable condition. What you think is a hepatoma (32.26), may turn out to be a liver abscess (31.12); a rectal lesion may be an amoeboma (31.10), and not a carcinoma (32.27); ''malignant ascites' may in fact be tuberculous (29.6).

Fig. 33-1 PAIN PERCEPTION. A, shows the factors that influence a terminal cancer patient's total perception of pain. Only one of these is the cancer itself. Try to influence as many of these factors as you can. B, the patient herself. After Twycross and Lack from ''Cancer Pain Relief'. WHO, Geneva.