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NORTH CAROLINA
End-Of-Life Responsibilities and Palliative Care
Source: North Carolina Medical Board
Adopted: October 21, 1999
Assuring Patients
Death is part of life. When appropriate processes have determined that the use of life-sustaining or invasive interventions will only prolong the dying process, it is incumbent on physicians to accept death "not as a failure, but the natural culmination of our lives."*
It is the position of the North Carolina Medical Board that patients and their families should be assured of competent, comprehensive palliative care at the end of their lives. Physicians should be knowledgeable regarding effective and compassionate pain relief, and patients and their families should be assured such relief will be provided.
Palliative Care
There is no one definition of palliative care, but the Board accepts that found in the Oxford Textbook of Palliative Medicine: "The study and management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life." This is not intended to exclude remissions and requires that the management of patients be comprehensive, embracing the efforts of medical clinicians and of those who provide psychosocial services, spiritual support, and hospice care.
A physician who provides palliative care, encompassing the full range of comfort care, should assess his or her patient’s physical, psychological, and spiritual conditions. Because of the overwhelming concern of patients about pain relief, special attention should be given the effective assessment of pain. It is particularly important that the physician frankly but sensitively discuss with the patient and the family their concerns and choices at the end of life. As part of this discussion, the physician should make clear that, in some cases, there are inherent risks associated with effective pain relief in such situations.
Opioid Use
The Board will assume opioid use in such patients is appropriate if the responsible physician is familiar with and abides by acceptable medical guidelines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. (See the Board’s position statement on the Management of Chronic Non-Malignant Pain for an outline of what the Board expects of physicians in the management of pain.) Because the Board is aware of the inherent risks associated with effective pain relief in such situations, it will not interpret their occurrence as subject to discipline by the Board.
Selected Guides
To assist physicians in meeting these responsibilities, the Board recommends Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996), Cancer Pain Relief and Palliative Care (1990), Cancer Pain Relief and Palliative Care in Children (1999), and Symptom Relief in Terminal Illness (1998), (World Health Organization, Geneva); Management of Cancer Pain (1994), (Agency for Health Care Policy and Research, Rockville, MD); Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th Edition (1999) (American Pain Society, Glenview, IL); Hospice Care: A Physician’s Guide (1998) (Hospice for the Carolinas, Raleigh); and the Oxford Textbook of Palliative Medicine (1993) (Oxford Medical, Oxford).
*Steven A. Schroeder, MD, President, Robert Wood Johnson Foundation.