Palliative surgery in the do-not-resuscitate patient: ethics and practical suggestions for management.

Palliative care in the United States has made tremendous strides in the last decade. One of the most perplexing issues arises when a palliative care patient presents to the operating room with an already existing do-not-resuscitate (DNR) order. This article describes the most common conflicting issues that may arise and provides guidance to surgeons, anesthesiologists, patients, and their primary physicians to reach satisfactory resolution and optimal care. Anesthesia departments should appoint a liaison to surgical and perioperative nursing departments to provide education and create an atmosphere conducive to discussions with palliative care patients about goals of care, including DNR status.

Living in the electronic age: musings on nearly two decades in Cyberspace.

My journey through Cyberspace began about 20 years ago with an introduction to e-mail. A few years later, I had the good fortune of working with artificial intelligence engineers who were developing information retrieval techniques and expert systems. By serendipity this led to an early introduction to the World Wide Web (www) and the use of Web browsers as tools for gathering information, long before the Internet became commercialized. Internet content and form are now so omnipresent that they have affected our language in both amusing and utilitarian ways. We are entering an era where social networking, from personal to professional lives, is potentially a vibrant new direction for the Internet. Future articles for this feature will explore how to maximize the utility of the Internet.

Pain management in palliative care oncology patients.

Palliative care is an interdisciplinary approach to relieving aversive symptoms in people with life-threatening illnesses; it aims to improve the lives of patients and their loved ones, the "patient-family unit." Palliative care should occur in parallel with all other medical interventions. Indeed, good symptom management is important in helping patients cope with the unpleasantness associated with potentially curative or life-prolonging interventions; it is absolutely essential near the end of life. Unrelieved pain is the symptom that people fear the most. In most cases, adequate pain relief can be achieved with systemic medications alone. When systemic medications fail, due to inadequate analgesia or burdensome side effects, invasive techniques may complement, or replace, systemic therapy. Using a case-based format, we illustrate some complex issues that clinicians face and offer strategies to improve the lives of oncology patients with pain.

Ethical considerations at the end of life in the intensive care unit.

Intensive care units (ICUs) confront the healthcare system with end-of-life situations and ethical dilemmas surrounding death. It is necessary for all providers who treat dying patients to have a working knowledge of the philosophical principles that are fundamental to biomedical ethics. Those principles, however, are insufficient for compassionate care. To function well in the intensive care unit, one also must appreciate the behaviors that surround mortality. Human conduct is not predicated solely on rules; complex, unpredictable interactions are the norm. Palliative care, moving forward as a discipline, will become the perfect complement to intensive medical care, rather than being seen as an embodiment of its failures. We need to be as aggressive about respecting patient dignity as we are about using the technology that is central to health care. This article will outline end-of-life ethical principles, explore the sociology that influences human interactions in intensive care units, and show how palliative care should guide behaviors to improve how we deal with death.

The American Medical Association "Pain Management: the Online Series".

There is a growing number of Internet based programs on pain management. Many of them offer continuing medical education credits (CMEs). "Pain Management: The Online Series" from the American Medical Association (AMA) is a recent addition. Its content is robust but the self-assessments tests needed to obtain CME are weak.

A prototypical gateway to the World Wide Web: Making sense of pain relief.

The World Wide Web site entitled Making Sense of Pain Relief is described. This site, intended for consumers, was created by the American Chronic Pain Association, American Pain Foundation and National Pain Foundation. Other websites directly linked to this site are listed.

World Wide Web resources for cancer support groups.

World Wide Web (internet) resources that pertain to cancer support groups, especially pain and symptom control, are listed and reviewed. How to start using these services; services for patients, families, and friends; disease-specific websites; and other types of electronic information repositories are discussed.

The International Association for Hospice and Palliative Care Website.

The Website of the International Association for Hospice and Palliative Care is reviewed. The Association newsletter, resources, links, access to the IAHPC Manual of Palliative Care 2nd Edition, frequently asked questions, and other useful information are provided on this site.

The web site of the center to advance palliative care.

The web site of the Center to Advance Palliative Care is reviewed. This is an excellent resource containing resources that address financial tutorials and customizable Excel worksheets, development and marketing tools, particularly the decision checklists, satisfaction tools, the information on tracking and reporting outcomes, bereavement tools and a press kit.

An annotated guide to pain and palliative care on the World Wide Web.

Two dozen leading sites on the World Wide Web that pertain to pain management and palliative care are listed and described. Strengths and limitations are discussed.