Q. Hello, Dr. C. My name is Mary and I live in Richmond Hill. I am seventy-five years old and have been very upset about the Terri Schiavo case. While the government debates her fate, is she in pain? Do the doctors know if she is in pain? If she becomes dehydrated, won’t she be in terrible pain? It seems to me that it is medically unethical to allow her to be in continuous pain until she dies?

A. Mary, you have raised several important questions that have ramifications at multiple levels. Mary is said to be in a “persistent vegetative state.” If this is the case, she is awake but is unable to respond to her environment. The extent to which she is “aware” of her environment is open to debate between the parties in conflict. The parents say she responds to happy events (visiting family, etc) but her husband states she is not aware of her surroundings (and even if minimally aware, she would not want to live in her current condition.). As to whether she is in continuous pain, there is reasonable evidence that she is not. For patients able to tell us about their pain, we can gauge it as mild, moderate, or severe. We can rate it on a scale with 1-4 representing mild pain, 5-6 corresponding to moderate pain, and 7-10 representing severe pain. This scale helps the physicians communicate with each other regarding patients’ levels of discomfort at various times in order to make changes in medications to control pain. For patients awake but unable to communicate verbally, pain may be gauged by facial grimacing, changes in heart rate, and any abnormal vocalizations. If Terri shows these signs at times, they could be manifestations of anxiety or pain. In either case, the physicians address these regularly by searching for potential causes of pain such as may be caused by pressure sores, muscle spasms or contractures, infections that may occur, for example, in the skin, lungs, bowels, or bladder. While a patient in a coma may not feel pain, the patient in a persistent vegetative state may indeed feel pain. As patients become clinically more ill, the apparent or real pain may become worse. For patients with mild pain, acetaminophen (Tylenol) works well and is the drug of choice in the absence of liver disease. Acetaminophen has a ceiling effect such that if the pain is not improved by taking a total daily amount of 2.5 grams (i.e. five tablets containing 500mg), a stronger analgesic is called for. For moderate pain, tramadol, hydrocodone, or codeine is frequently given. For pain at the level of 7-10 stronger opioids are given and these include morphine, methadone, oxycodone and trandermal fentanyl. Morphine is the most widely used and versatile opioid. It is available by tablet, liquid, long-acting, short-acting formulations, intramuscularly, intravenously, subcutaneously, or per rectum. So even if Terri does not have an intravenous line or a feeding tube, any pain can and will be controlled to the extent it can be defined as being present. At times in patients with neurologic disorders and pain, anticonvulsants and antidepressants are very helpful adjuncts to provide pain relief. As patients become more ill and death may appear near, pain may also rise to a higher level. At this point, physicians are allowed to provide whatever analgesic is necessary to relieve the pain. There may exist the fear that treating the pain may hasten death by suppressing breathing reflexes. That is not a common event and physicians experienced in such circumstances (i.e. hospice care) recognize that it is ethical and humane to provide pain relief even if it risks hastening death. Looking at the related issue of ending life because of pain from a legal point of view, there is almost no justification for the use of analgesics or any other drugs to hasten death because the patient is in pain. Stated another way, the inability to control pain at the end of life is not a valid argument for advocates of physician-assisted suicide or euthanasia. Finally, there is the question of pain in the presence of dehydration. Most experts subscribe to the opinion that dehydration is not a painful circumstance; there is some evidence that this condition may be associated with a reduced level of pain perception. On this point, we are at the limit of our certainty regarding the factors that affect pain at the end of life. From the point of pain management in the case of Terri Schaivo, there is every reason to believe that she can be allowed to die in comfort and dignity whenever the courts and providence allow. I hope this answer provides you with some measure of comfort while answering your specific questions. >