1. PAIN

2.  New concept  Generally agreed upon that it exists  Definition variable

4.  You are born alone and you die alone the rest doesn’t matter.  Steve Jobs

5.  Mahar 1955 began to develop the concept of pain as being both somatic and physical.  This became more expansive to differentiate between acute and chronic  Acute serves as physiologic warning  Chronic pain is “associated with endless meaningless suffering”  Mahar Lancet 268 (1955)

7.  Mental distress may be the most intractable pain of all.  C. Saunders “Treatment of Intractable Pain in terminal cancer”

8.  Spiritual Pain  Bitter anger at the unfairness of what is happening and above all a desolate feeling of meaninglessness.

9.  Suffering is experienced by persons not merely bodies.  NEJM 306 (1982) The nature of suffering and the goals of medicine.

11.  Meaning is essential for life and people are looking for or creating meaning, as meaninglessness is impossible to endure.

13.  Distinction between fear, for something and diffuse unfocused anxiety (dread)  Focused on death anxiety and the dread for annihilation.

15.  Concept of man’s freedom  Man is doomed to freedom, meaning that man must always chose and choices creating anxiety

17.  Freedom which means that man must always choose ( unethical choices)  The question of meaning and meaninglessness  Existential isolation  Death

19.  Current definitions are as varied as the disciplines and biases of those defining the concept of existential pain  Journal of pain and symptom management, Strang and Strang, illustrated this concept

20.  Stressed guilt issues as well as various religious questions

21. Stressed existential pain as related to annihilation and impending separation

22.  Emphasized living is painful

23.  Patient dignity inventory (PDI) Chochinov et al  Patient reports on the factor of their existential distress such as,  Not feeling worth while  Not being able to carry out important roles  Life no longer has meaning  Feeling a burden

24.  Primary goal to improve quality of life  Development of sensitivity and trust relations and awareness of the patient’s existential concerns  Spiritual/religious counseling

25.  Meaning-centered therapy  Cognitive behavioral interventions  Psychoeducational counseling  Hypnotically facilitated therapy

26.  Life tape project  Family counseling  Corticosteroid treatment

27.  Rousseau notes that existential suffering can be as refractory and agonizing as physical symptoms  1) Patients must have a terminal illness  2) A DNR order must be in place  3) All palliative treatments must be exhausted  4) A psychological assessment must be completed  5) An assessment of spiritual issues should be completed

28.  Is it palliative or is it physician assisted suicide?  Removal of life sustaining measures after PS initiated  Slippery Slope: Palliative sedation as an alternative versus an encouraged option

29.  Jack Kevorkian  William Osler “Given the uselessness of men above 60 years of age and incalculable benefits might arise from such a scheme” Statement made in relation to Trollope’s The Fixed Period.  Derek Humphry, Founder of the Hemlock Society

30.  2002 National Health Survey: 40% of patients affirmed use of CAM Therapy  Most common spiritual and religious: 22%  Music and Pet Therapy: 16% and 14%  Followed by other varieties of intervention

31.  Used in multiple medical conditions for pain  Hospital beneficial effects; sedation/euphoria, appetite stimulation

33.  Major Criteria  A. Depressed mood  B. Loss of interest in pleasurable activity Other criteria must have at least 4 of these in addition to one of the major criteria

34.  A. Weight change  B. Sleep disturbance  C. Psychomotor agitation or retardation  D. Fatigue  E. Guilt, worthlessness  F. Diminished ability to think or concentrate  G. Recurrent thoughts of death (suicide)

35.  Excessive worry or anxiety more days than not over a 6 month period.  Difficult to control worry’  At least 3 of the following 6 symptoms  A. Restlessness  B. Fatigue  C. Decreased concentration  D. irritability  E. muscle tension  F. Sleep Distubance

36.  If we have time