Greek Orthodox.

There are approximately 300 million members of the Greek Orthodox Church worldwide. It is the second-largest Christian church. Followers of this religion believe in eternal life. Thus, the church strongly emphasizes a positive outcome in death- "the deceased is alive with God." God is believed to be the healer of our souls and bodies, which is facilitated through prayer and participation in the life of the Church. Traditional medical interventions are generally accepted. Artificial life support is justifiable only when it offers a hope for meaningful recovery. Just as death should not be hastened, the natural dying process should not be prolonged. Timely advance care planning and early treatment goals discussions to help understand how the patient would define quality of life is paramount to setting limitations on what could be considered as nonbeneficial care. The medical team should not assume that all patients of the Greek Orthodox faith will feel the same around end-of-life beliefs and practices. This chapter aims to identify common themes and the historical contextual framework that may influence the way in which medical decision making is made by those who specifically subscribe to the Greek Orthodox faith.

A Unique Case Report on Methadone Used for Treatment of Opioid-induced Hyperalgesia in a Cancer Patient at the End of Life.

Opioids are the cornerstone of palliative pain management. Opioids work on the mu-opioid receptor as an agonist for the treatment of pain. Repeated exposure to opioids over time can lead to undesired desensitization of the antinociceptive receptor while sensitizing the N-methyl-D-aspartate (NMDA) pathway, causing a paradoxical effect where the treatment of pain creates more sensitivity to certain stimuli. This phenomenon is known as opioid-induced hyperalgesia (OIH). Methadone, a synthetic opioid, may be more effective for pain and offers advantages over other opioids in specific clinical situations due to its partial antagonistic effect on the NMDA pathway. We describe a unique case where as needed (prn) and continuous intravenous (IV) methadone was effective in relieving OIH caused by high doses of IV Dilaudid for intractable cancer pain at the end of life. Given its unique pharmacokinetics, effective pain control, and the prevention of suffering from OIH, methadone should be considered earlier on in palliative pain management, especially in those patients predicted to require high levels of opioid dosing.