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5. The crisis of under-treated pain.

Although most people would prefer to die peacefully at home, in fact about 80% of us die in institutions, and half of those die in pain that could be greatly relieved or eliminated completely. This under-treatment of pain is a national health care crisis. As happened with awareness of the need for advance decisions about life-sustaining treatment, there is a growing awareness of the need for palliative care. This movement has much to overcome:

It has been not only possible but usual for a physician to complete his/her entire medical education, in excellent institutions, without having a single course in managing pain, in some cases, without hearing a single lecture on pain management. Fortunately, caring doctors and teachers are becoming aware of the need to focus on palliative care in those cases where cure is not possible. The percentage of medical schools with vigorous programs in this area is still small, but progress is being made. The UAB Center for Palliative Care has an excellent program, and similar programs are being initiated around the state, but there are still too few.

Public policy contributes to the problem. We have a system that will pay vast sums for dramatic treatment that has little or no chance of success, but that does not reimburse physicians for time spent counseling patients and families or devising creative ways to treat pain.

Consumers play a part, too. We have many unrealistic ideas about pain relief. Some are concerned about addiction, although in fact dying or chronically ill patients who are given adequate comfort care often use less pain medicine than prescribed, perhaps because they know that when they need relief it will be there. Families sometimes fear that if a suffering loved one receives pain relief he will “stop fighting”. Severe, constant pain, however, is so exhausting that relieving it can release energy that can be spent on getting well, if that is possible. These are just two of the myths that have prevented some patients and their families from demanding palliative care.

The cure for untreated pain is better medical and public education, so that consumers and professionals will join together to change policies that defeat rather than encourage compassionate care.

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