The Nature of Suffering and the Goals of Palliative Care

“I didn’t know it would be so hard”

Case: Mr. X was a young man dying of metastatic cancer. He had spent much of his adult life in prison. Although Mr. X had many symptoms, he remained alert and engaging until the final week or so of his life. Because he was suffering from severe pain, estrangement from family, and concerns about his spirituality, he frequently mentioned that he “didn’t know dying would be so hard.”

Given the complexity of Mr. X’s case, he was seen daily by a multidisciplinary team of aides, volunteers, nurses, social workers, clergy, and a physician. The team worked in concert to help alleviate his suffering by:

1. Treating his pain and other symptoms. During his stay Mr. X needed escalating doses (e.g. more than 1000 mg IV morphine an hour) of opiates, which also contributed to his sedation, myoclonus (twitching), and nausea. Mr. X was eventually maintained on a combination of medicines that allowed him to enjoy his life and even take up painting as a hobby.
   
   
2. Helping him reengage with his family. Mr. X was estranged from his family. Team members were integral in helping to facilitate open conversation between Mr. X and various family members. As a result, despite being estranged for years, the patient and his family were able to reconcile and he had regular visitors during his stay at Forbes.
   
   
3. Helping him achieve peace. Mr. X had developed a strong faith in prison and spoke openly about his willingness to “go to God.” He felt conflicted about dying, however, because he had a long history of drug/alcohol abuse and had made many poor choices in his life. After many conversations with clergy and other team members, Mr. X was able to forgive those whom had wronged him and to receive forgiveness from those whom he had wronged. He died with no fears.

Discussion: The primary goal of medicine is the relief of suffering. In fact, the word patient comes from the Latin “to suffer.” Suffering, however, can be complex and difficult to alleviate. As demonstrated by Mr. X, suffering can include physical pain but is by no means limited to it; psychological, social, and existential issues are often prominent.

Suffering has been defined as anything that threatens the intactness of the person as a complex physical, social, psychological, and spiritual entity. The intactness of a person is at risk at end-of-life when symptoms (physical), loss of mental faculties/control (psychological), worries about burdening one’s family (social), and concerns about one’s legacy/spirituality (existential) come to the forefront. As a result, excellent care of the suffering person often involves the expertise of individuals—physicians, nurses, clergy, social work, aides, psychologists, etc.—from multiple disciplines. By virtue of their expertise, hospice teams are well equipped to assess and treat suffering in seriously ill patients and their families.