Editor—Murray et al include pain relief for dying people among the essential health interventions that should be accessible for all, in developing countries.1 Even developed countries, however, have different pain relief policies.
Figure 1.
In Tlingit culture, Land-Otter-Man rescues the souls of drowning people and turns them into land otters
Credit: MUSEUM OF THE AMERICAN INDIAN/HEYE FOUNDATION/WERNER FORMAN ARCHIVE
In Italy, where medicinal morphine consumption for 2000 ranked among the lowest in Europe,2 a restrictive prescription law was held responsible for the undertreatment of pain. The law was modified but with little effect.3,4
The results of a large survey of neonatal physicians and nurses in seven Western European countries (EURONIC) shed some light on additional factors undermining effective pain control in palliative care.5 When asked about acceptable ways of setting limits to intensive interventions felt to be no longer in the best interest of a baby, most respondents in every country but Italy judged the administration of drugs to control pain to be morally acceptable “even if this might cause respiratory depression and death” (table).
Table 1.
Percentages (95% confidence intervals) of respondents who thought that giving drugs to control pain is acceptable in palliative care “even if this might cause respiratory depression and death”
| Country | Doctors (n=1207) | Nurses (n=3008) |
|---|---|---|
| Italy | 64 (56 to 71) | 49 (40 to 57) |
| Spain | 87 (81 to 91) | 83 (79 to 87) |
| France | 96 (91 to 98) | 89 (86 to 92) |
| Germany | 86 (78 to 91) | 76 (71 to 81) |
| Netherlands | 98 (89 to 100) | 92 (90 to 94) |
| United Kingdom | 93 (89 to 96) | 88 (84 to 92) |
| Sweden | 95 (88 to 98) | 90 (84 to 93) |
In multivariate analysis other factors in addition to country and professional role were significantly associated with a positive view of analgesia for dying babies. These were having between 6 and 10 years of experience in neonatal care, as opposed to being junior or older (odds ratio 1.30, 95% confidence interval 1.00 to 1.70); being a parent (1.40, 1.11 to 1.77); and being routinely involved in research (1.46, 1.02 to 2.08). In contrast, religiousness (defined as considering religion very or fairly important in one's life) decreased the likelihood of viewing this form of analgesia as morally acceptable (0.54, 0.45 to 0.65).
Fear of euthanasia, the health professional's beliefs and prejudices, and lack of knowledge may represent obstacles to effective pain management for dying patients in countries where lack of resources for drugs is not an issue. Together with modification of the law, more education is needed in Italy to overcome the existing prejudices against the use of analgesia in palliative care.
Competing interests: None declared.
References
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