Surgical care of elderly persons focuses many of the difficult legal and ethical dilemmas that have arisen in modern medicine. Such issues arise at both macro and micro levels. This paper explores four micro level areas involving physician-patient interaction. These are: informed consent, dying patients, pain relief treatment and medical research, when the patients involved are elderly persons.

The discussion of informed consent includes consideration of refusal of treatment, scope of information, voluntariness, coercion and competency. In particular, the basic presumptions are articulated and variations in the application of these concepts, when aged persons are involved, and justification of such variations, are considered. Within the topic of dying elderly persons, the “living will” and “durable powers of attorney” are discussed. The obligation to provide pain relief treatment can be particularly important in the context of terminally ill and dying persons and it is suggested that there should be a legal obligation to provide such treatment, including in some circumstances, where the treatment could possibly, or even is likely to, shorten life. Finally, aged persons' participation in medical research and the special problems that can be involved in this are addressed.

In conclusion, it is suggested that the greater visibility and identification of old persons needing surgery than of those needing some other forms of medical care is likely to make this an important arena for setting far-reaching precedents regarding humane approaches to, and human rights in, access to and provision of medical care.

Objective: The aim of this study was to clarify the state of pain management in Japanese patients with advanced cancer who initiated opioid therapy in an outpatient setting.

Methods: Interview surveys using questionnaires were conducted and medical records were reviewed. Pain relief was defined as >33% decrease in worst pain intensity score, and significance of early pain relief was investigated in terms of changing self-efficacy for activities of daily living (ADL). Factors related to early pain relief were also investigated.

Results: The study was conducted between June and December 2003, on 20 patients (13 women, 7 men; mean age, 59 years). Compared to score at initiation of opioid administration (Numerical Rating Scale, 8.3 ± 1.3), pain relief was generally insufficient at 2 weeks (early pain relief ratio was only 42%). Patients with sufficient pain relief at 2 weeks displayed significant improvements in numerous ADL functions and symptom-coping efficacy (p = 0.037), confirming the importance of early pain relief. Early pain relief was associated with high frequency of hospital visits before opioid administration and absence of sudden excavation within the first 2 weeks.

Significance of results: Result of this study indicated insufficient pain relief at an outpatients setting with advanced cancer patients. In the meantime, patients had who their pain decrease after 2 weeks also had improved ADL and self-efficacy at the same time. These findings suggest that to achieve early pain relief in an outpatient setting, clinical staff must assess pain earlier and inform patients of possible breakthrough pain following opioid administration and available treatments for such occurrences.