Fibromyalgia is an illness seen mostly in women and characterized by widespread body pain with abnormality located in the nervous system. A diagnosis of fibromyalgia should be considered when a patient presents with widespread body pain lasting for longer than 3 months, with associated tenderness to palpation of soft tissues, as well as the possible presence of symptoms of sleep disturbance, fatigue, cognitive symptoms, and mood changes. Nervous system, genetic, and psychological mechanisms likely all play a part in the final expression of fibromyalgia, with evidence showing abnormalities at multiple levels. Ideal management includes both non-pharmacological and pharmacological treatments in a multimodal approach incorporating a strong patient-centered internal locus of control. Non-pharmacological treatments with emphasis on a regular exercise program, stress management, and coping skills should be an integral part of any treatment strategy for fibromyalgia. The traditional pharmacological treatment paradigm begins with simple analgesics and tricyclic antidepressant medications (TCAs).

The expert management of pharmacological and non-pharmacological treatments is essential to the concept of proportionality. When physicians use appropriate analgesics and write orders to titrate medication based on evidence of pain and suffering, such as groaning, agitation, verbal complaints, diaphoresis, hypertension, or unexplained tachycardia, they demonstrate that the intention of the act is geared toward alleviating pain. Until relatively recently, dying patients were routinely under-treated for pain because physicians feared that the treatment would hasten death. This chapter explains the case study of a 58-year-old woman with widely metastatic breast cancer. In the context of caring for a terminally ill patient, the double effect (DE) allows for good pain management. DE asks physicians to carefully examine their motives and assumes that one's private moral intentions are morally relevant. The principle of double effect permits aggressive treatment of pain when death may be an unintended effect of that treatment.

Sleep patterns of nursing home residents are extremely fragmented. This is manifested not only as disrupted night-time sleep, but also by frequent daytime sleeping. Poor sleep represents more than a mild annoyance for nursing home residents. Nursing home residents often suffer from multiple medical and psychiatric co-morbidities and are often in poor physical health. Circadian rhythm changes contribute to sleep problems in nursing home residents. Real change will require administrators and other staff to recognize that sleep is important and encouraging better sleep would benefit both residents and staff over the long term. Sleep disturbance is associated with negative outcomes among nursing home residents. While data to support the use of pharmacotherapy for sleep in the nursing home are limited, there is some suggestion that disturbed sleep improves with non-pharmacological treatments; however, these treatments have not been adapted for implementation into routine care.