Brandy

(Vitamise all together, strain, sprinkle with nutmeg.)

one one cup to taste (1-3 drops) 1 teaspoon (optional)

High-energy cordial

1 tablespoon 1 teaspoon 1 cup crushed

(Blend cordial and Glucodin till smooth, stir in water.)

High-energy juice

1 cup

1 dessertspoon

(Blend Glucodin with a little juice till smooth. Stir in remaining juice.) The AIDS patient

The same principles of management apply to the person suffering from the many manifestations of terminal AIDS. Many of these patients wish to die at home and there are excellent caring support groups to help. It is important to become acquainted with the service network. Because of opportunistic infections there are many challenges facing the palliative care of such patients and some management guidelines are included in Chapter 24 .

The stages of the grieving process as described by Kubler-Ross may be experienced by both the patient and family, albeit not exactly according to the five stages. The grieving process following the death of a loved one can vary enormously but many people are devastated. The principles of care and counselling include: 1

• Be available and be patient.

• Allow them to talk while you listen.

• Reassure them that their feelings are normal.

• Accept any show of anger passively.

• Avoid inappropriate reassurance.

• Encourage as much companionship as possible, if desired. (See guidelines for crisis counselling given in Chapter 5 .)

Good communication is essential between the doctor and patient in order to inform, explain, encourage and show empathy. However, it can be very difficult, especially with the cancer patient. Good communication is dependent on honesty and integrity in the relationship. Telling the truth can be painful and requires sensitivity, but it builds trust that enables optimal sharing of other difficult concerns and decisions such as abandoning curative treatment, explaining the dying process and perhaps addressing thoughts on euthanasia.

Improved communication will lead not only to better 'spiritual' care but also to better symptom control. 1 Give patients every opportunity to talk about their illness and future expectations, and be available and patient in offering help and support.

Spirituality is an important issue for all people, especially when faced with inevitable death. Many people are innately spiritual or religious and those with deep faith and a belief in 'paradise' appear to cope better with the dying process. Others begin to reflect seriously about spirituality and search for a meaning for life in

Dying and grieving

Communicating with the dying patient

Spiritual issues this situation; carers, including the attending doctor, should be sensitive to their needs and turmoil and reach out a helping hand, which may simply involve contacting a minister of religion. Spiritual care builds on patients' existing resources to enable them to rise above the physical, emotional and social effects of their terminal illness. 1

The question of euthanasia

It should be a rare experience to be confronted with a request for the use of euthanasia, 3 especially as the media clichés of 'extreme suffering' and 'agonising death' are rarely encountered in the context of attentive whole-person continuing care. The non-use of life support systems, the use of 'round the clock' morphine, cessation of cytotoxic drugs, the use of ancillary drugs such as antidepressants and antiemetics, various nerve blocks and loving attention almost always help the patient cope without undue pain and suffering.

Practice tips

• Consider prescribing antidepressants routinely for patients in pain.

• Remember the 'sit down rule' whereby the home visit is treated as a social visit—sitting down with the patient and family, having a 'cuppa' and sharing medical and social talk. 3

• Early referral of terminal patients with difficult-to-control problems, especially pain, to a hospice or multidisciplinary team can enhance the quality of care. However the patient's family doctor must still be the focus of the team.

References

1. Fairbank E, Banks T. Palliative care: The nitty gritty handbook. Melbourne: RACGP Services Division, 1993, 1-18.

2. McGuckin R, Currow D, Redelman P. Palliative care: Your role. Medical Observer, 27 November 1992, 41-42.

3. Carson NE, Miller C. Care of the terminally ill. Melbourne: Monash University Department of Community Medicine Handbook, 1993, 107-115.

4. K;auubler-Ross E. On death and dying. London: Tavistock, 1970.

5. Moulds RFW et al. Analgesic guidelines. Melbourne: Victorian Medical Postgraduate Foundation, 1992-93, 39-48.

6. Buchanan J et al. Management of pain in cancer. Melbourne: Sigma Clinical Review, 1991; 18:8-10.

7. Burke AL. Palliative care: An update on 'terminal restlessness'. Med J Aust, 1997; 166:39-42.

8. Twycross R. Introducing palliative care. Oxford: Radcliffe Medical Press, 1996, 147.

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