திக over, patients remained alert and ambulatory. Many of these patients were subsequently able to go back to their oral medication and be maintained in a pain-free state. This treatment was also highly effective in relieving severe shortness of breath, a frightening symptom for both the patient and family. This treatment is now available for large numbers of patients, both inside and outside of hospitals because we and others found safe and easy to use methods for prolonged venous access and because commercial companies have developed appropriate constant rate infusion pumps. A second major effort of ours concerns relief of patient psychologic distress. We hypothesize that dying does not have to be a negative experience. Many patients find solace in their terminal months and have related to us that this time has been very important and even satisfying. A nurse on our unit therefore devised a research study to investigate the effects of therapeutic use of self. In this study nurses will establish a therapeutic alliance with the patient that will be maintained until death. As part of the therapeutic relationship nurses will use guided imagery, therapeutic touch and relaxation exercises as aids to discover causes of suffering and to externalize these causes. Florence Nightingale once said "What the nurse has to do is put the patient in the best condition for nature to act upon him." That is the goal of this study. If beneficial results are obtained, we envision that paramedical personnel could easily be trained in these techniques. Finally, I would like to consider the question of burnout in terminal care staff. Out of 25 nurses who started work on our cancer ward 10 to 15 years ago, at least 7 still continue to work only with cancer patients. I think that a major reason for these nurses' continued job satisfaction is the hope that is instilled in patients and staff by finding new and better ways to solve old distressing problems. Our research orientation toward improving as much as possible the remaining life of our patient is a continuing stimulus to professional growth and a continuing source of emotional award. In conclusion, there are numerous important unanswered questions about caring for the terminally ill, the answers to which could greatly alleviate suffering and result in improved quality of life. Such questions are best answered by carefully planned and executed research studies performed in a controlled environment. Veterans' Administration hospitals have the personnel and facilities to conduct these studies. I have presented several examples of such research as it is conducted on our unit. I urge your continued support of such programs. Thank you. Mr. PRINCIPI. Thank you, doctor. [The prepared statement of Martin H. Cohen, M.D., chief, oncology section, Veterans' Administration Medical Center, Washington, DC, follows:] PREPARED STATEMENT OF MARTIN H. COHEN, M.D., CHIEF, ONCOLOGY SECTION, VETERANS' Terminal Care: The Veterans Administration's Unique Opportunity to Do it Better The goals of terminal care are to reduce or eliminate human suffering while allowing dying to occur. Suffering always accompanies a terminal illness. It results, according to Eric Cassel, whenever the physical, emotional, social and spiritual being that constitute a person is disrupted. Thus, overwhelming pain causes suffering. Knowing that one will never again be well causes suffering. Disruption of normal body functions causes suffering as does inability to participate in usual everyday activities. Loss of hope is a major cause of suffering. The patient is dying against his will. He will die before those he loves; the awareness of his aloneness and separateness, of his helplessness against the ravages of disease often cause almost unbearable suffering. Society has recognized the needs of the terminally ill. It has developed programs to meet these needs using acute care hospitals, nursing homes, community health agencies and, most recently, hospices. While these programs may, with greater or lesser success, ameliorate patient suffering more basic questions are still unanswered. As far as I am concerned we still don't know the optimal way to control pain, to relieve the myriad of distressful symptoms that terminal patients suffer, to improve a patient's functional status and mobility, to improve the quality of a patient's social interactions, to increase life-satisfaction or to relieve feelings of isolation and helplessness. We do not know the psychological consequences of telling a patient that there is no more treatment available and that from now on we will only provide for his comfort. My impression is that this is often the worst thing that can be done. Further, we do not even know how to prevent "burn-out" in the staff providing care for terminally ill patients nor have we developed ways of dealing with the conflicts that inevitably occur among physicians, nurses and other health care personnel in the management of these patients. I submit that answers to the above questions could greatly improve the format for managing the needs of the terminally ill. I further strongly believe that Veterans Administration Medical Centers are ideal places to conduct this research. First, VA Medical Centers already employ the multidisciplinary personnel required for such an undertaking including physicians, nurses, psychologists, social workers, physical therapists, occupational therapists, speech therapists and dietitians. Second, VA outpatient services have expanded in recent years and hospital based home care is also available. Third, there are large numbers of patients in the VA system who require terminal care. Fourth, because personnel, patients, and facilities are already available, research in this important area could probably be done more cheaply in the VA than anywhere else. An operational research program would require that personnel from each of the above disciplines meet to identify specific patient needs as they relate to their specialty. Research protocols could then be developed to determine which methods are most efficacious and cost effective in meeting these needs. I firmly believe that research protocols constitute the best available treatment for the condition under study. Research protocols are the end result of considerable thought as to 1) what is the most appropriate and important question that can be asked to improve a given condition and 2) what methods can be used to best answer this question. Research studies are emotionally rewarding to both staff and patients because beneficial results are often clearly demonstrated. A strongly positive patient-staff interaction results which motivates both groups to maintain hope and continue seeking even further improvements. I would like to illustrate these points by describing some of the studies being conducted at the Washington, D.C. VA Medical Center that relate to the care of the terminally ill cancer patient. The most important problem that these patients face is pain control. We theorized that pain control could be best achieved by continuously infusing morphine so as to maintain a constant drug level in the blood stream. We tried this in patients who had persistent pain despite large doses of potent narcotics taken by mouth and found that we could achieve complete pain relief by our method. Moreover, patients remained alert and ambulatory throughout their days or weeks of treatment. Many of these patients could then go back to their oral medication and be maintained in a pain-free 'state. This treatment was also found to be highly effective in relieving severe shortness of breath, a frightening symptom for both the patient and for any family member watching the patient struggle to breathe. I consider these results to be a significant advance. To make such treatment available for large numbers of patients, both within and outside of hospitals, requires that a safe method of prolonged venous access be found and that small, portable, lightweight constant rate infusion pumps be developed. We and others have demonstrated the safety and efficacy of catheters inserted in large central veins. Patients and families can easily be taught to manage these catheters at home. Concurrently, several companies have developed appropriate pumps. Thus a successful treatment for a highly distressing symptom is now ready for widespread use. A second major effort of ours concerns relief of patient psychologic distress. We hypothesize that dying does not have to be a negative experience. Many patients find solace in their terminal months and have related to us that this time has been very important and even satisfying. A nurse on our unit therefore devised a research study to investigate the effects of "Therapeutic Use of Self". In this study nurses will establish a therapeutic alliance with the patient that will be maintained until death. As part of the therapeutic relationship nurses will use guided imagery, therapeutic touch and relaxation exercises as aids to discover causes of suffering and to externalize these causes. Florence Nightengale once said "What the nurse has to do is put the patient in the best condition for Nature to act upon him." That is the goal of this study. Study results will be evaluated by objective parameters. If beneficial results are obtained we envision that it would be relatively easy to train paramedical personnel in the techniques to be used. Finally I would like to consider the question of "burn-out" in staff who constantly deal with terminally ill patients. Out of 25 nurses who started work on our cancer unit 10-15 years ago at least 7 still continue to work only with cancer patients. Why have some nurses not burned out? I think that a major reason for continued job satisfaction is the hope that is instilled in patients and staff by finding new and better ways to solve old distressing problems. Our staff never feels that a dying terminal patient should be shunted to a back room and be given minimal support. Our research orientation toward improving, as much as possible, the remaining life of our patient is a continuing stimulus to professional growth and a continuing source of satisfaction. Patients on our ward are never considered incurable. We can always do something better for them. In conclusion, there are numerous important unanswered questions about caring for the terminally ill, the answers to which could greatly alleviate suffering and result in improved quality of life. Such questions are best answered by carefully planned and executed research studies performed in a controlled environment. Veterans Administration hospitals have the personnel and facilities to conduct these studies and they see a patient population that would receive maximum benefit from the results. I have presented several examples of such research as it is conducted on our unit. I urge continued support for such programs. |