End of Life Care, Pain, and the Problem of Intolerable Suffering
Abstract Pain and intolerable suffering presents unique challenges for health care providers caring for patients at the end of life. Suffering, as defined by Cassell (1999) is a "specific state of distress that occurs when the intactness or integrity of the person is threatened or disrupted." The subjective nature of suffering means that it may be difficult to recognize, assess, and address in clinical practice. Unlike other symptoms of disease that are amenable to objective assessment and standardization of practice, suffering is unique to the individual and the meaning the individual ascribes to these symptoms and to the illness itself. Intolerable suffering is a common eligibility criterion for palliative sedation and euthanasia but presents particular conceptual and practical uncertainties with significant ethical implications for physicians and other health care providers who care for dying patients. In this chapter, I argue that these uncertainties provide an opportunity to enrich the patient physician relationship in addressing pain and suffering and in particular to respond to intolerable suffering in the context of end of life care. I draw from the work of Hans Georg Gadamer (1990, 1996a, 1996b) in philosophical hermeneutics to reframe the problem of suffering and its uncertainties as a quest for a common understanding of the patient's suffering by a fusion of horizons between patient and health care provider. I propose that the therapeutic dialogue, which should include the pursuit of mutual understanding, creates the possibility of alleviating a patient's suffering by restoring a sense of intactness of the self and integrity to the patient, even in the face of death.