Masterpieces of literature can bring us deeply into our experiences as patients and physicians, revealing otherwise obscure or hidden truths. Leo Tolstoy's The Death of Ivan Ilyich is such a work of art. This article presents an approach to teaching this novella in a seminar format.

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Dear Editor:Treatment of pain at the end of life is a priority for hospice patients. Ketorolac is indicated for short-term treatment of moderate to severe pain in patients requiring opiate-level analgesia. 1 Recommendations are to limit use to five days of therapy by either oral or parenteral routes. The risks include bleeding in patients on NSAIDs and renal failure. 2,3 In our 10-year community hospice experience, continuous subcutaneous infusion of ketorolac has improved analgesia with minimal harm for durations exceeding five days.We reviewed all hospice patients over a period of 10 years who received subcutaneous ketorolac for more than five days. Patients over 18 years of age and not receiving other forms of ketorolac were included. Exclusion criteria included patients who died before infusion, had subcutaneous infusion for less than five days, or received ketorolac via methods other than subcutaneous delivery.The 88 eligible patients had a mean age of 65 years (range 27-92); 57% (n = 50) were female. Seventy-five patients had a diagnosis of malignancy and 13 had a noncancer terminal diagnosis. Five patients (5.7%) received ketorolac subcutaneous infusion in the general inpatient hospice unit only. Thirty-seven patients (42%) were in home hospice only. Forty-six (52%) were treated in both the general inpatient hospice unit and home hospice.The average inpatient days on ketorolac was 3.81 (range 0-21), and average home days on ketorolac was 19.59 (range 0-238). The average length of infusion for all patients on ketorolac was 23.49 days (range 6-238). Subcutaneous sites were located most commonly on the arm, abdomen, and thigh. Site complications were rare. Seventy-one patients (81%) remained on the ketorolac until death. Eighty-six patients were prescribed concurrent opiate therapy. Four patients concurrently received NSAID medications other than ketorolac, including ibuprofen, and another four patients received concurrent steroid therapy. One patient was prescribed a lidocaine patch concurrently.Serious adverse events included nausea/vomiting (n = 12) and gastrointestinal bleeding (n = 2). Hematuria was the only renal event (n = 3). Other adverse events were edema (n = 8), hallucinations (n = 1), back hemorrhage (n = 1), apnea (n = 1), and epistaxis (n = 1). Seventeen patients (19%) discontinued ketorolac subcutaneous infusion, only five due to complications.In the 67 patients where pain scores were recorded, 38 (57%) had a positive response of at least two points over five days. There was a significant reduction of average pain scores from day 1 to day 5 ( p < 0.001), with an average day 1 score of 5.03, day 3 score of 3.31, and day 5 score of 2.89.Use of long-term ketorolac subcutaneous infusion provided good pain relief and was well tolerated in hospice patients nearing death. Ketorolac offered greater ease of administration than other analgesics and was continued until the time of death in most patients. Many patients initiated the infusion safely in the home hospice setting. The retrospective uncontroll...

Case 1We cared for a 68-year-old man who had a lymphoma with oesophageal involvement and a tracheo-oesophageal fistula which was stented, providing partial relief. He was receiving over 2,000 calories (2,000 cc) per day full feeding via a PEG (gastrostomy) tube. When he came to us he complained of diarrhoea, nausea and vomiting, abdominal pain, dyspnoea and cough. He was miserable. He and his family were looking to us to make him more comfortable.We were convinced that most of his symptoms were due to excess food and water. The challenge proved to be convincing the patient and family of this. It is very common in this situation for several of the doctors (in their white coats) to have said something to the effect of: "If you ever stop the PEG tube -this food and water -he will die." So the negotiation point in this case was "He can have all he wants, we'll put a syringe next to his bedside, and you can shoot it in." Thereafter he took 300-400 cc/day and all of his symptoms resolved in less than 24 h. He had simply been getting too much food and water.His needs, his true needs, had not been recognised. He had just been plugged in to an equation. Nobody had asked him if he was full or not. They just started dumping it in. He had gotten plugged into the equations of so much height and weight and age and everything else and the answer that came up was 2,200 calories, so if we can get it through that PEG tube then we are going to get it through. Basic human needsWhat are our basic human needs? This type of clinical situation should cause us to reflect on basic human needs such as food and water; being kept clean, warm and dry;Abstract We are all persons in need. The question we face as healthcare workers is: Do we recognize this need in the persons we care for … and then, do we provide that need? This paper uses case examples of our failure to recognize basic human needs in the provision of nutrition and hydration at the end of life -in these instances far too much food and water was given. Sources of basic human needs are reviewed and a model is presented to aid clinicians in better matching patients needs to their current clinical reality.

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