Appendix A


	    From A. Jacox et al., Management of Cancer Pain, Clinical

      Practice Guideline no. 9, AHCPR pub. no. 94-0592 (Rockville, Md.:

      U. S. Department of Health and Human Services, Public Health

      Service, Agency for Health Care Policy and Research, March 1994),


       page 186		    WHEN DEATH IS SOUGHT

  A.  Assessment of pain intensity and character

      1 .Onset and temporal paftern-When did your pain start?  How often

	 does it occur?  Has its intensity changed?

      2. Location-Where is your pain? Is there more than one site?

      3. Description-What does your pain feel like?  What words would you

	 use to describe your pain?

      4. Intensity-On a scale of 0 to 1 0, with 0 being no pain and 1 0

	 being the worst pain you can imagine, how much does it hurt right

	 now?  How much does it hurt at its worst?  How much does it hurt

	 at its best?

      5. Aggravating and relieving factors-What makes your pain better?

	 What makes your pain worse?

      6. Previous treatment-What types of treatments have you tried to

	 relieve your pain?  Were they and are they effective?

      7. Effect-How does the pain affect physical and social function?

  B. Psychosocial assessment

     Psychosocial assessment should include the following:

      1 .Effect and understanding of the cancer diagnosis and cancer

	 treatment on the patient and the caregiver.

      2. The meaning of the pain to the patient and the family.

      3. Significant past instances of pain and their effect on the patient.

      4. The patient's typical coping responses to stress or pain.

      5. The patient's knowledge of, curiosity about, preferences for, and

	 expectations about pain management methods.

      6. The patient's concerns about using controlled substances such as

	 opioids, anxiolytics, or stimulants.

      7. The economic effect of the pain and its treatment.

      8. Changes in mood that have occurred as a result of the pain

	 (e.g., depression, anxiety).

  C.  Physical and neurologic examination

      1.  Examine site of pain and evaluate common referral patterns.

      2.  Perform pertinent neurologic evaluation.

	 *  Head and neck pain-cranial nerve and fundoscopic evaluation.

	 *  Back and neck pain-motor and sensory function in limbs; rectal

	    -and urinary sphincter function.

  D. Diagnostic evaluation

      1 .Evaluate recurrence or progression of disease or tissue injury

	 related to cancer treatment.

	 *  Tumor markers and other blood tests.

	 *  Radiologic studies.

	 *  Neurophysiologic (e.g., electromyography) testing.

      2. Perform appropriate radiologic studies and correlate normal and

	 abnormal findings with physical and neurologic examination.

      3. Recognize limitations of diagnostic studies.

	 *   Bone scan-false negatives in myeloma, lymphoma,

	     previous radiotherapy sites.

	 *   CT scan-good definition of bone and soft tissue but

	     difficult to image entire spine.

	 *   MRI scan-bone definition not as good as CT, better images of spine

	     and brain.

      page 187			   Appendix B


	     This form was developed by the Pain Research Group, Department

       of Neurology, University of Wisconsin-Madison, and is used with

       permission.  It appears in A. Jacox et al., Management of Cancer

       Pain, Clinical Practice Guideline no. 9, AHCPR pub. no. 94-0592

       (Rockville, Md.:  U. S. Department of Health and Human Services,

       Public Health Service, Agency for Health Care Policy and Research,

       March 1994), 228-29.

       page 188			   When Death Is Sought

		       Brief Pain Inventory (Short Form)

	Brief Pain Inventory (Short Form)

  Study ID#_________________________________	 Hospital# ______________

			       Do not write above this line

  Date: __/__/__


  Name: ______________________________________________________________________

			Last		    First	       Middle Initial

      1)  Throughout our lives, most of us have had pain from time to time

      (such as minor headaches, sprains, and toothaches).  Have you had

      pain other than these everyday kinds of pain today?   1. Yes 2. No

      2) On the diagram, shade in the areas where you feel pain.

	     [The graphic diagram contained in the orignial printed ]

	     [version of this report cannot be displayed in the text]

	     [format used for this electronic version.		    ]

      3) Please rate your pain by circling the one number that best

      describes your pain at its worst in the past 24 hours.

       0    1	2     3	    4	   5	 6     7    8	  9    10

       No						 Pain  as  bad  as

       pain						 you can imagine

      4) Please rate your pain by circling the one number that best

      describes your pain at its least in the past 24 hours.

       0    1	2     3	    4	   5	 6     7    8	  9    10

       No						 Pain  as  bad  as

       pain						 you can imagine

      5) Please rate your pain by circling the one number that best

      describes your pain on the average.

      0	   1   2     3	   4	  5	6     7	   8	 9    10

      No						Pain  as  bad  as

      pain						you can imagine

			   Appendices			       page 189

      6) Please rate your pain by circling the one number that tells how

      much pain you have right now.

      0	   1   2     3	   4	  5	6     7	   8	 9    10

      No						Pain  as  bad  as

      pain						you can imagine

      7) What treatments or medications are you receiving for your pain?

      8) In the past 24 hours, how much relief have pain treatments or

      medications provided?  Please circle the one percentage that most

      shows how much relief you have received.

       0%   10%	  20%  30%  40%	  50%	60%   70%  80%  90%  100%

       No						     Complete

       relief						     relief

      9) Circle the one number that describes how, during the past 24

      hours, pain has interfered with your:

       A.    General	activity

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       B.  Mood

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       C.  Walking ability

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       D. Normal work (includes both work outside the home and housework)

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       E. Relations with other people

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       F.   Sleep

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

       G.  Enjoyment   of   life

       0    1	2     3	    4	   5	 6     7    8	  9    10

       Does not					       Completely

       interfere				       interferes

      Source:  Pain Research Group, Department of Neurology, University of

      Wisconsin-Madison.  Used with permission.  May be duplicated and

      used in clinical practice.

      Page 190 intentionally left blank

      Page 191			   Appendix C

			 American Pain Society Quality

		       Assurance Standards for Relief of

			   Acute Pain and Cancer Pain

	    These standards were developed by the Committee on Quality

      Assurance Standards, American Pain Society (Mitchell B. Max, chair).

      They appear in Proceedings of the VI World Congress on Pain, ed.  M.

      R. Bond, J. E. Charlton, and C. J. Woolf (New York:  Elsevier

      Science Publishers, 1991), 185-89.

      Pages 192 - 196 Pages in unreadable format

     Page 197			   Appendix D

			    Detection and Diagnosis

				 of Depression

	    From Depression Guideline Panel, Depression in Primary Care:

      Detection, Diagnosis, and Treatment, Quick Reference Guide for

      Clinicians, no. 5, AHCPR pub. no. 93-0552 (Rockville, Md.:  U. S.

      Department of Health and Human Services, Public Health Service,

      Agency for Health Care Policy and Research, April 1993), 2-9.

      Further information, including guidelines for treating major

      depression, may be found in this publication and in the Depression

      Guideline Panel's Depression in Primary Care, Clinical Practice

      Guideline, no. 5, vols. 1 and 2, AHCPR pub. nos. 93-0550 and 93-0551

      (Rockville, Md.:  U. S. Department of Health and Human Services,

      Public Health Service, Agency for Health Care Policy and Research,

  page 198		     WHEN DEATH IS SOUGHT

      The following step-wise process can assist primary care

      practitioners in detecting, diagnosing, and treating major


      1 . Maintain a high

	  index of suspicion and

	  evaluate risk factors.

      Surveys consistently show that 6 to 8 percent of all outpatients in

      primary care settings have major depressive disorder; women are at

      particular risk for depression.  Although sadness is frequently a

      presenting sign of depression, not all patients complain of sadness,

      and many sad patients do not have major depression.  Comnion

      complaints of patients in primary care settings with major

      depressive disorder include:

      * Pain-including headaches, abdominal pain, and other body aches.

      * Low energy-excessive tiredness, lack of energy or a reduced

      capacity for pleasure enjoyment.

      * A mood of apathy, irritability, or even anxiety rather than, or in

      addition to, any overt sadness may be present.

      * Sexual complaints--problems with sexual functioning or desire.

      The clinician should he doubly alert to the likelihood of depression

      in individuals under age 40.

      Additional clinical clues that raise the likelihood of a major

      depressive disorder include:

      * Prior episodes of depression.

      * A family history of major depressive or bipolar disorder.

      * A personal or family history of suicide attempt(s).

      * Concurrent general medical Appendices 199 illnesses.

      * Concurrent substance abuse.

      * Symptoms of fatigue, malaise, irritability, or sadness.

      * Recent stressful life events and lack of social supports.  (Stress

      should not be used to "explain away" depression; stress may

      precipitate a depression in some cases.)

      2. Detect depressive

	 symptoms with a or

	 clinical interview.

      Major depressive disorder is a syndrome consisting of a

      constellation of signs and symptoms that are not normal reactions to

      life's stress.  A sad or depressed mood is only one of the several

      possible signs and symptoms of major depressive disorder.  The

      clinician may find it useful to provide the patient with a written

      list of depressive symptoms (pages 3 and 4) and ask the patient to

      indicate any symptoms experienced.  This patient self- report can

      increase the likelihood of detecting major depression.

				   Appendices		       page 199


       Diagnostic criteria for

       major depressive disorder.

      For major depressive disorder, at least five of the following

      symptoms are present during the same time period, and at least the

      one of the first two symptoms must be present.  In addition,

      symptoms must be present most of the day, nearly daily, for at least

      2 weeks.

      * Depressed mood most of the day, nearly every day.

      * Markedly diminished interest or pleasure in almost all activities

      most of the day, nearly every day (as indicated either by subjective

      account or observation by others of apathy most of the time).

      * Significant weight loss/gain.

      * Insomnia/hypersoinnia.

      * Psychomotor agitation/retardation.

      * Fatigue (loss of energy).

      * Feelings of worthlessness (guilt).

      * Impaired concentration (indecisiveness).

      * Recurrent thoughts of death or


      All depressed patients should be assessed for the risk of suicide by

      direct questioning about suicidal thinking, impulses, and personal

      history of suicide attempts.  Patients arc reassured by questions

      about suicidal thoughts and by education that suicidal thinking is a

      common symptom of the depression itself and not a sign that the

      patient is "crazy."

      Table 1 lists the risk factors associated with completed suicide.

      If suicide is a distinct risk (specific plans or significant risk

      factors exist), consult a mental health specialist immediately.  The

      patient may need specialized care or hospitalization.

	  Table 1. Suicide risk factors


       .    Psychosocial and clinical	 .

       .	   Hopelessness		 .

       .	   Caucasian race	 .

       .	   Male gender		 .

       .	   Advanced age		 .

       .	   Living alone		 .

       .   History			 .

       .       Prior suicide attempts	 .

       .       Family history of suicide .

       .	 attempts		 .

       .       Family history of	 .

       .      substance abuse		 .

       .   Diagnostic			 .

       .       General medical illnesses .

       .       Psychosis		 .

       .       Substance abuse		 .


      Bipolar illness.  A small percentage of patients with major

      depressive disorder have bipolar illness.  These patients experience

      mood cycles with discrete episodes of depression and mania.  In

      between episodes, they may feel perfectly normal.

  page 200		       WHEN DEATH IS SOUGHT

      Diagnostic criteria for mania.  For mania, at least four of the

      following symptoms, including the first one listed, must be present

      for a period of at least 1 week.

      * A distinct period of abnormally and persistently elevated,

      expansive, or irritable mood.

      * Less need for sleep.

      * Talkative or feeling pressure to keep talking.

      * Distractibility.

      * Flight of ideas.

      * Increase in goal-directed activity (either socially, at work or

      school, or sexually) or psycomotor agitation.

      * Inflated self-esteem or grandiosity.

      * Excessive involvement in pleasurable activities which have a high

      potential for painful consequences (buying sprees, sexual

      indiscretions, or foolish business investiments). low interest

      3. Diagnose the mood disorder

	 using clinical

	 history and interview.

      Many patients are aware of only some symptoms and may minimize their

      disability.  Interviewing someone who knows the individual well (a

      spouse, close friend, or relative) can be extremely valuable in

      obtaining an accurate picture of the patients, symptoms, degree of

      disability, and course of illness.


    | Figure 1.Differential diagnosis of primary mood disorders|


  ..............      ............			       .............

  . Sad mood   . Yes  .5 out of 9.  Yes	  .............	  No   .Major	   .

  .   or       . ---> . symptoms .  --->  .Prior manic.	  ---> .depressive .

  .low interest.      .  now?	 .	  .episode?   .\  Y    . disorder  .

  ..............      ............	  ............. \ E    .............

			No |				 \S

			   v				   \


		      . 5 out of 9 .   Yes   .............  Yes  ..........

		      . symptoms in.   --->  .Prior manic.  ---> .Bipolar .

		      . the past?  .	     . episode	 .	 .disorder.

		      . ___________.	     ............. \ N	 ..........

			 No |				    \O

			    v				     \

		       ..............	     ...........      \ ...............

		       .  More than .	Yes  .Dysthymic.	.   Major     .

		       .  2 years of.	---> .disorder .	. depressive  .

		       .  persistent. \	     ...........	. disorder in .

		       .  symptoms? .  \  N			.  partial    .

		       ..............	\ O			. remission   .

					 \			...............


					 .Depression not   .

					 .  otherwise	   .

					 .  specified	   .

					 .(recurrent brief,.

					 .  minor, mixed   .

					 .   anxiety/	   .

					 .  depression)	   .


				  Appendicies	   page 201

      Practitioners should always ask about prior manic episodes, since

      bipolar disorder, if present, requires a different treatment

      approach, Figure I shows the diagnostic decisions needed to arrive

      at a diagnosis of a primary mood disorder.

      4. Evaluate patients

	 with a complete

	 medical history and physical


      The patient's initial complaints should be evaluated

      thoroughly with a medical review of systems and a physical

      examination.  If no cause or associated factors can be found for the

      initial presenting medical complaint, diagnose the Appendices 201

      patient for primary mood syndrome.

      5. Identity and treat

	 potential known causes

	 (if present) of mood


       Approximately 10-1 5 percent or more of major depressive

      conditions are caused by general medical illnesses or other


     |  Figure 2.Conditions assoicated with mood symptoms  |

     |  or major depressive episodes			   |


      Associated		  Initial

      Condition:		  Treatment


      .............   Yes   .............

      . Substance .   -->   . Substance .  -> |

      . abuse	  .	    . abuse  1  .     |

      .............	    .............     |

	   |				      |

	   v				      |

      .............   Yes  ................   |

      . Concurrent.   -->  .   Change	  .   |

      . medication.	   . medications  . -->

      .............	   ................   |

	   |				      |

	   v				      |

     ..............	 .............	      |	  .............	     ...........

     . General	  . Yes  . General   .	      |	  . Mood      .  Yes . Treat   .

     . medical	  .  --> . medical   . --->   |-->. Disorder  .  --> . Mood.   .

     . disorder	  .	 . disorder 1.	      |	  . Persists? .	     . Disorder.

     ..............	 .............	      |	  ........... .	     ...........

	   |				      |

	   v				      |

      ...............	   ...............    |

      . Causal,	    .  Yes .  Causal,	 .    |

      . nonmood	    .  --> .  nonmood	 .    |

      . psychiatric .	   .  psychiatric. ---|

      . disorder    .	   .  disorder	 .    |

      ...............	   ...............    |

	   |				      |

	   v				      |

      ................	   .................  |

      .		     .	   .		   .  |

      .Grief reaction. Yes..Grief reaction . -|  (1) Depending on the clinical

      .		     .	   .		   .-->

      .		     . --> .		   .  |	  and the patient's history,

      ................	   .................  |	  both the mood disordr and the

	   |				      |	  associated condition may be

	   v				      |	  primary treatment objectives.

      ................			      |

      . Primary mood .  Yes		      |

      .  disorder    .  -->		      |


      page 202		  WHEN DEATH IS SOUGHT

      conditions (see figure 2).  Generally, the principal is to

      treat the associated condition first.  If the depression persists

      after treatni nt of the associated condition, major depressive

      disorder should be diagnosed and treated, Potential associated

      conditions include:

       ** Substance abuse.  Too much alcohol, use of illicit drugs, or

       abuse of prescription medicines can cause or complicate a major

       depressive episode.  In most cases, once the substance has been

       discontinued. the depression lifts (Figure 3).

       ** Concurrent medication.  Depression may be an idiosyncratic side

       effect of many medications.  However, the clinician should be aware

       that this effect is uncommon and usually occurs within days to weeks

       of starting the medication.  Current disorder, and some cases of

       evidence clearly implicates only reserpine, glucocorticoids, and

       anabolic steroids with the de novo development of depression as a

       potential side effect of the drug.  Changing to a different

       medication often relieves the depression (Figure 4).

       ** General medical disorders.  Depression can occur in the presence

       of general medical condition (Figure 4) (most commonly, autoimmune,

       neurologic, metabolic, infectious, oncologic, and endocrine

       disorders, among others).  There are several possibilities in such

       cases:  The general medical disorder and the mood disorder

       biologically causes or triggers a depression; for example,

       hypothyroidism can be accompanied by depressive symptoms.  In this

       case, treat the general medical disorder first.  The general medical

       disorder psychologically results in depression; for example, a

       patient with cancer may become clinically depressed as a reaction to

       the prognosis, pain or incapacity, although most patients with

       cancer do not suffer a major depressive episode.  In this case,

       treat the depression as an independent disorder.  The general

       medical disorder and the mood disorder are not causally related.  In

       this case, treat the depression.

       ** Other causal nonmood 203 psychiatric disorders.  These generally

       include eating disorders, and some cases of panic disorder (Figure

       3).  When generalized anxiety disorder co-exists with major

       depression, treatment should be directed toward the major depression

       first.  If panic disorder is present only during major depressive

       episodes, the major depression is treated first.  If panic disorder

       and major another depression are both present and the panic disorder

       has been present without episodes of major depression in the past,

       the clinician must judge which is the most significant condition

       (e.g., by family history, the level of current disability

				 Appendices	       page 203


      |	  Figure 3. Relationship between major depressive and	   |

      |	  other current psychiatric disorders			   |


	  Patient presents with depreession and another

		  nonmood psychiatric disorder




			     ..................	     ....................

			     .Is the disorder . Yes  .  Treat Substance .

			     .substance abuse . -->  .	   Abuse (4)	.

			     ..................	     ....................

						|			  |

						v  NO			  v

	 .................	     ....................    ....................

	 .  Treat  the	 .   Yes     .  Is the Disorder .    . Is depression	.

	 . depression(1) .   -->     .	 generalized	.    . still present?	.

	 ............... .	     .	   anxiety?	.    ....................

				     .................. .    |		   | YES

				       No    |		  NO |		   |

					     v		     |		   |

	.....................	     ...................     v		   v

	.     Treat  the    .	     .  Is the disorder.    STOP ...............

	.   eating disorder .  YES   .  an eating      .	 .  Treat the  .

	.   or obsessive-   .  -->   .  disorder or    .	 .  depression .


	.    compulsive	    .	     .  obsessive-     .	 ...............

	.    disorder?	    .	     .  compulsive     .

	................... .	     .  disorder?      .

		 |		     ...................

		 v				 |

					 NO	 v

       ....................	    ....................	.................

       . Is Depression	  .	    . Is the disorder  .  YES	. Decide which  .

       . still present?	  .	    .  panic disorder? .  -->	. is primary(3) .

       .................. .	    ....................	. and treat (2) .

       |	      |			     |			.................

       v  No	      V  YES		     |

     ......	...............		     |

     .STOP.	.  Treat the  .		     |  NO

     ......	. depression  .		     |

		...............		     |


	 ......................		  ...................

	 .  Treat  the	      .	  Yes	  . Is the disorder .

	 .  depression;	      .	  -->	  . a personality   .

	 .  reevaluate for    .		  .   disorder?	    .

	 .  personality	      .		  ...................

	 .  disorder; if still.

	 .  present, treat    .


	(1) When the depression is

	    treated, the anxiety

	    disorder should resolve as


	 (2) Choose medications known

	     to be effective for both the

	     depression and the other

	     psychiatric disorder.

	 (3) Primary is the most severe,

	     the longest standing by

	     history, or the one that runs

	     in the patient's family.

	 (4) In certain cases (based on

	     history), both major

	     depression and substance

	     abuse may require

	     simultaneous treatment.

     page 204		   WHEN DEATH IS SOUGHT


     |  Figure 4.  Relationship between major depressive and |

     |  other current general medical disorders		     |


   ................................	   ..................................

   .   Patient has depression,	  .	   .   Patient has depression,	    .

   .   a concurrent		  .	   .   a concurrent		    .

   .   general medical condition, .	   .   general medical condition,   .

   .   and is on		  .	   .   and is NOT		    .

   .   medication for the latter. .	   .   on medication for the latter..

   ................................	   ..................................




   .  Medication causes the depression? .







		    |					     |

		    |				     NO	     v

	     YES    |			     ................................

	    (Maybe) |			     .	 General medical disorder   .

		    v			     .	 causes the depression?	    .

      ................			    ................................

      .	   Modify    .			    |  |  NO

      .  Medication  .			    |  |	   |  Yes

      .	   Regime    .			    |  |	   | (Maybe)

      ................			    |  |	   v

	    |				    |  |	.................

	    v				    |  |	.    Optimize	.

   ...................			    |  |	.  treatment of .

   . Depression still.	 YES		    |  |	.  the general  .

   .   present?	     .  ---------------------  |	.    medical	.

   ...................			       |	.    disorder	.

	    |				       |	.................

      NO    v				       |	       |

					       |	       v

					       |      ....................

	..........			       |      . Depression still .

	.  STOP  .			       v      .	     present?	 .

	..........				      ....................

				  .......................	   |

				  .			.	   v   No

				  . Treat the depression.	  .......

				  .......................	  . STOP.


      Note:In some clinical situations, treatment of the depression (e.g.,

      if severe, incapacitating, or life-threiitening) cannot be del@iyed

      until treatment for the general medical disorder has been optimized.

			Appendices			      page 205

      that condition first.  (Some medications have proven effective for

      both disorders and, therefore, may be preferred in such situations.)

      If a "personality disorder" is suspected, the major depressive

      disorder is treated first, whenever feasible. grief reaction. it is

      important to differentiate a normal grief reaction from depression.

      A normal grief reaction persists for 2 to 6 months and improves

      steadily without specific treatment.  Most grief reactions do not

      meet criteria for a major depressive episode.  Grief reactions are

      usually seen by patients as normal and appropriate.  While

      unpleasant, they rarely cause significant and prolonged impairment

      in work or other functions.  Some individuals experience symptoms of

      depression along with the grief reaction.  If the major depressive

      episode persists for more than 2 months after the loss, a major

      depressive disorder should be diagnosed and treated.

      6. Reevaluate for

       mood disorders.

      If the depression persists after treatment of the associated

      psychiatric, general medical, or substance abuse disorders,

      the depression should be diagnosed and treated.

      April 1993).

	    References in the Depression Guideline Panel's text are to

      American Psychiatric Association, Diagnostic and Statistical Manual

      of Mental Disorders, 3d rev. ed.  (Washington:  American Psychiatric

      Press, 1987).

				   Appendix E

		       Questions to Ask In the Assessment

			   of Depressive Symptoms for

			     Severely Ill Patients

	    This list of questions was formulated by Jimmie C. Holland,

      M.D., who served as a consultant to the Task Force.  The process of

      evaluating clinical depression in cancer patients is discussed in A.

      J. Roth and J. C. Holland,"Treatment of Depression in Cancer

      Patients," Primary Care in Cancer 14 (1994):  24-29.


	   * How well are you coping? Well? Poorly? (Well being)

	   * How are your spirits?  Down?  Blue?  Depressed?Sad?  Do you

	     cry sometimes?  How often?  Only alone?  (Mood)

	   * Are there things you still enjoy doing or have you lost

	     pleasure in the things you used to do?  (Anedonia)

	   * How does the future look to you? Bright? Black?  (Hopelessness)

	   * Do you feel you can change things or are they out of

	     control?  (Helplessness)

	   * Do you worry about being a burden? Feel others might be better

	     off without you?	 (Worthlessness, guilt)

  Physical Symptoms

  (Evaluate in the context of illness-related symptoms.)

	   * Do you have pain which isn't controlled?	 (Pain)

	   * How much time do you spend in bed? Weak? Fatigue easily? Rested

	     by sleep? (Fatigue)

	   * How are you sleeping? Trouble going to sleep?  Awake early?

	     Often?    (Insomnia)

	   * How is your appetite? Food tastes good? Weight loss or

	     gain?     (Appetite)

	   * How is your interest in sex? Extent of sexual activity?

	     Concerned about partner? (Libido)

	   * Do you think or move more slowly? (Psychomotor slowing)

  Suicidal Risk

	    (Open with a statement acknowledging the normality of suicidal

      thoughts for those with the patient's illness; asking about these

      thoughts does not enhance risk.)

	   * Many patients with your illness have passing thoughts about

	     suicide, such as"I might do  something if it gets bad enough."

	     Have you ever had thoughts like that?   (Acknowledge normality)

	   * Do you have thoughts of suicide? How? Plan?   (Level of risk)

	   * Have you ever had a psychiatric disorder,  depression,

	     or made a suicide attempt?	   (Prior history)

	   * Have you had a problem with alcohol or drugs? (Substance abuse)

	   * Have you lost anyone close to you recently? (Bereavement)

				   Appendix F

			    Requests for Euthanasia

			 and Assisted Suicide: Nursing

			     Management Principles

	    From N. Coyle,"The Euthanasia and Physician-Assisted Suicide

      Debate:  Issues for Nursing," Oncology Nursing Forum 19, no. 7

      suppl.  (1992):  45.

	   * Establish a rapport with the patient.

	   * Know the issues for the individual patient.

		      ---Inadequate symptom control

		      ---Depression, hopelessness, spiritual despair

		      ---Being a burden on the family

		      ---Altered quality of life and

			 unacceptable limitations

		      ---Has lived a full life and wants

			 to die while still in control

	   * Address the issues.

	   * Do not act independently; involve colleagues from other


	   * Address suicide vulnerability factors.

	   * Assess family status and adequacy of support resources.

	   * Know the law.

	    Reprinted from the Oncology Nursing Forum with permission from

      the Oncology Nursing Press, Inc.

				   Appendix G

			      Additional Resources

	    Academy of Hospice Physicians

	    500 Dr.  M. L. King Street N., Suite 200

	    St.  Petersburg, FL 33705

	    (813) 823-8899

	    Agency for Health Care Policy

	      and Research (AHCPR)

	    Executive Office Center, Suite 501

	    2101 East Jefferson Street

	    Rockville, MD 20852

	    (800) 358-9295 to order publications

	    Agency of the Department of Health and Human Services that has

      produced separate guides for patients and clinicians on a number of

      topics, including acute pain management, cancer pain management, and

      depression.  These are available free of charge.

	    Acute pain management:  Pain Control After Surgery:  A

      Patient's Guide, Clinical Practice Guideline on Acute Pain

      Management, Quick Reference Guide on Acute Pain Management in

      Adults, and Quick Reference Guide on Acute Pain Management in

      Infants, Children, and Adolescents.

	    Cancer pain management:  Managing Cancer Pain (Patient Guide),

      Clinical Practice Guideline on Management of Cancer Pain, and Quick

      Reference Guide on Management of Cancer Pain:  Adults.

	    Depression:  Depression Is a Treatable Illness:  A Patient's

      Guide, Clinical Practice Guideline on Depression in Primary Care

      (vols. 1 and 2), and Quick Reference Guide on Depression in Primary

      Care:  Detection, Diagnosis, and Treatment.

	    Alzheimer's Association

	    919 N. Michigan Avenue, Suite 1000

	    Chicago, IL  60611-1676

	    (800) 272-3900 or (312) 335-8700

	    American Cancer Society

	    1599 Clifton Road, N.E.

	    Atlanta, GA  30329-4251

	    (800) ACS-2345

	    Provides information about cancer, treatment, and services to

      patients and families, as well as health care professionals.

      Together with the National Cancer Institute, publishes Questions and

      Answers About Pain Control:  A Guide for People with Cancer and

      Their Families.

	    American Chronic Pain Association

	    P.O. Box 850

	    Rocklin, CA  95677-0850

	    (916) 632-0922

	    American Pain Society

	    5700 Old Orchard Road, First Floor

	    Skokie, IL  60077-1057

	    (708) 966-5595

	    Publishes Principles of Analgesic Use in the Treatment of

      Acute Pain and Cancer Pain and a membership directory of health care

      professionals and institutions, and conducts educational programs.

	   American Society of Clinical Oncology

	   435 N. Michigan Avenue, Suite 1717

	   Chicago, IL  60611-4067

	   (312) 644-0828

	    Conducts educational programs for physicians.  The

      Society's"Cancer Pain Assessment and Treatment Curriculum

      Guidelines" appear in Journal of Clinical Oncology 10 (1992):


	   American Spinal Injury Association

	   355 E. Superior, Room 1436

	   Chicago, IL  60611

	   (312) 908-6207

	    A source of information for health care professionals.

	    Amyotrophic Lateral Sclerosis (ALS) Association

	    21021 Ventura Boulevard, Suite 321

	    Woodland Hills, CA  91364-2206

	    (800) 782-4747 or (818) 340-7500

	    Provides education, information, and referral services to

      assist ALS patients and their families, and information for health

      care professionals.  Publications include Managing ALS guides for

      patients and family members.

	    Arthritis Foundation

	    1314 Spring Street, NW

	    Atlanta, GA  30309

	    (404) 872-7100

	    Cancer Care

	    1180 Avenue of the Americas, Second Floor

	    New York, NY  10036

	    (212) 221-3300

	    Provides support services, counseling, and information for

	    cancer patients and families.

	    Centers for Disease Control (CDC),

		National AIDS Hotline

	    (800) 342-2437; Spanish

	    (800) 344-7432;

	    TDD (800) 243-7889

	    A source of information about HIV/AIDS and support services.

	    Commission on Accreditation of

	       Rehabilitation Facilities

	    101 N. Wilmot Road, Suite 500

	    Tucson, AZ  85711

	    (602) 748-1212 (voice or TDD)

	    Provides lists of accredited facilities and programs.

	    Gay Men's Health Crisis

	    129 West 20th Street

	    New York, NY 10011-0022

	    (212) 807-6655

	    Provides support services and legal advice for people with


	    International Association for the Study of Pain (IASP)

	    909 NE 43rd Street, Suite 306

	    Seattle, WA  98105

	    (206) 547-6409

	    Publishes Core Curriculum for Professional Education in Pain.

	    International Hospice Institute

	    1275 K Street, NW, 10th Fl.

	    Washington, D. C. 20005

	    (202) 842-1600

	    Mayday Fund

	    30 Rockefeller Plaza, 55th Floor

	    New York, NY  10112

	    (212) 649-5800

	    A private foundation that provides grants and executes

      programs to reduce the human problems associated with pain and its


	    Memorial Sloan-Kettering Cancer Center

	    1275 York Avenue

	    New York, NY  10021

	    (212) 639-2000Pain Hotline (212) 639-7918

	    Hospital and research institution that is a WHO Collaborating

      Center for Cancer Pain Research and Education.  Operates Network

      project that trains educators and clinicicans nationwide in

      palliative care.

	    Muscular Dystrophy Association

	    New York Metropolitan Chapter:

	    10 E. 40th Street, Suite 4105

	    New York, NY  10016

	    (212) 679-6215

	    National Office:

	    3300 E. Sunrise Drive

	    Tucson, AZ  85718

	    (602) 529-2000

	    National Cancer Institute,

	     Cancer Information Service

	     Office of Cancer Communications,

	    Building 31, Room 10A24

	    Bethesda, MD  20892

	    (800) 4CANCER

	    Provides information for patients and families, are

      professionals, and the public about pain control and other topics

      related to cancer.

	    National Chronic Pain Outreach Association

	    7979 Old Georgetown Road, Suite 100

	    Bethesda, MD  20814-2429

	    (301) 652-4948; fax (301) 907-0745

	    Offers information and pamphlets for patients, information

      about chronic pain support groups, and referrals to pain management

      specialists and clinics.

	    National Coalition for Cancer Survivorship

	    1010 Wayne Avenue, 5th Floor

	    Silver Spring, MD  20910-9796

	    (301) 650-8868

	    Publications include Teamwork:  The Cancer Patient's Guide to

      Talking with Your Doctor, and Charting the Journey:  An Almanac of

      Practical Resources for Cancer Survivors.

	    National Headache Foundation

	    5252 North Western Avenue

	    Chicago, IL  60625

	    (800) 843-2256 or (312) 878-7715

	    National Hospice Association

	    1901 N. Moore Street, Suite 901

	    Arlington, VA  22209

	    (800) 658-8898

	    Offers information and referral services.

	    National Multiple Sclerosis Society

	    733 Third Avenue

	    New York, NY  10017

	    (800) LEARNMS

	    National Spinal Cord Injury Association

	    600 W. Cummings Park, Suite 2000

	    Woburn, MA  01801

	    (617) 935-2722

	    National Spinal Cord Injury Hotline

	    (800) 526-3456

	    Offers information about spinal cord injury and living with

      spinal cord injury, as well as referral services and access to

      support groups.

	    Oncology Nursing Society

	    501 Holiday Drive

	    Pittsburgh, PA  15220

	    (412) 921-7373

	    Publications include Cancer Related Resources in the U. S. and

      ONS Position Paper on Cancer Pain.

	    Rehabilitation Nursing Foundation,

	     Association of Rehabilitation Nurses

	    5700 Old Orchard Road, First Floor

	    Skokie, IL  60077-1057

	    (708) 966-3433

	    Publishes The Specialty Practice of Rehabilitation Nursing:  A

      Core Curriculum.

	    United Cerebral Palsy Foundation Association

	    1522 K Street, NW, Suite 1112

	    Washington, DC 20005

	    (800) 872-5827

	    Offers a referral service and information about interventions,

      patient and family support, assisted technology, and employment.

	    Washington State Medical Association

	    2033 Sixth Avenue, #1100

	    Seattle, WA  98121

	    (206) 441-9762

	    Publishes Pain Management and Care of the Terminal Patient, a

      handbook for health care professionals.

	    Wisconsin Cancer Pain Initiative

	    3675 Medical Science Center

	    University of Wisconsin Medical School

	    1300 University Avenue

	    Madison, WI  53706

	    (608) 262-0978

	    Pamphlets for patients include Cancer Pain Can Be Relieved,

      Children's Cancer Pain Can Be Relieved, and Jeff Asks About Cancer

      Pain (for adolescents).  Also publishes a Handbook of Cancer Pain

      Management for health care professionals.

	    World Health Organization

	    WHO Publications Center USA

	    49 Sheridan Avenue

	    Albany, NY  12210

	    (518) 436-9686

      Publishes Cancer Pain Relief (1986) and Cancer Pain Relief and

      Palliative Care (1990).

  Other Publications

	    Bonica, John J., ed., The Management of Pain, 2d ed.

      (Philadelphia:  Lea and Febiger, 1990).  A comprehensive two-volume

      work for health care professionals.

	    Cowles, Jane, Pain Relief:  How to Say No to Acute, Chronic,

      and Cancer Pain (New York:  MasterMedia, 1993).  A comprehensive and

      accessible guide for patients; includes extensive lists of


	    Dittmar, Sharon S., Rehabilitation Nursing:  Process and

      Application (St.  Louis:  C. V. Mosby, 1989).  Includes as an

      appendix a list of"Organizations for the Disabled."

	    Doyle, Derek, Geoffrey W. C. Hanks, and Neil MacDonald, eds.,

      Oxford Textbook of Palliative Medicine (New York:  Oxford University

      Press, 1993).

	    Holland, Jimmie C. and Julia H. Rowland, eds., Handbook of

      Psychooncology (New York:  Oxford University Press, 1989).

	      Other Reports by the Task Force

      *  When Others Must Choose: Deciding for Patients

	 Without Capacity, May 1992 (288 pp.)

      *  Surrogate Parenting: Analysis and Recommendations

	 for Public Policy, May 1988 (,143 pp.)

      *  Transplantation in New York State: The Procurement

	 and Distribution of organs and Tissues,

	 January 1988 (164 pp.)

      *  Fetal Extrauterine Survivability, January 1988 (13 pp.)

      *  Life-Sustaining Treatment: Making Decisions and

	 Appointing a Health Care Agent, July 1987 (180 pp.)

      *  The Determination of Death, July 1986 (48 pp.)

      *  Do Not Resuscitate, Orders, April 1986 (113 pp.)

      *  The Required Request Law, March 1986 (16 pp.)

      copies of Task Force reports can be obtained by writing or


			Health Research Inc.

		     Health Education Services

			   P.O. Box 7126

			  Albany, NY 1224

			   (518) 439-7286