After years of neglect, care at the end of life is receiving
increasing attention and concern. It is then that the body is
consumed by a progressive and mortal illness, and the person must cope
not only with the bodily symptoms, but also with the existential crisis
of the end of life and approaching death. As the body suffers, the mind
is indeed “commanded … to suffer with the body,” as
Shakespeare so well described. Thus, suffering near the end of life
encompasses both the mind and the body. Providing optimal symptom
relief and alleviation of suffering is the highest priority. However,
evidence suggests that we continue to fall far short of this ideal
(American Society of Clinical Oncology, 1996;
Cassem, 1997; Cassel &
Foley, 1999; Carver & Foley,
2000). Although pain management guidelines have been the most
widely disseminated, we know that many patients continue to suffer not
only from pain, but other troubling physical symptoms in their final
days (American Nursing Association, 1991;
Carr et al., 1994; American
Pain Society, 1995; American Academy of Neurology,
1996; American Board of Internal Medicine,
1996; Ahmedzai, 1998). Despite clear
advances in the identification and treatment of psychiatric disorders, we
continue to underdiagnose and undertreat the debilitating symptoms of
depression, anxiety, and delirium in the final stages of life (Carroll et al., 1993; Hirschfeld et
al., 1997; Holland, 1997, 1998, 1999; Breitbart et al., 2000; Chochinov & Breitbart, 2000). And, beyond these
physical and psychological symptoms, we fall even shorter of our goals
of alleviating the spiritual, psychosocial, and existential suffering
of the dying patient and family (Cherny &
Portenoy, 1994; Cherny et al., 1996;
Fitchett & Handzo, 1998; Karasu, 2000). And this is in spite of the ethical
imperative “to comfort always” (Pellegrino, 2000).