END-OF-LIFE TREATMENT OPTIONS

    Physicians who encounter patients in need of end-of-life care should focus on two principles: (1) constantly redefine the goals of treatment . . . move away from curative care and toward palliative care; and (2) ask for help . . . call on additional resources to meet the patients multiple physical, emotional, psychological and spiritual needs.

PAIN MANAGEMENT

    In this era of modern pharmacology, adequate, even complete control of pain is almost always possible, particularly when needed for only a limited time in the dying patient. So why don’t we provide it? A number of factors commonly play a role in inadequate pain control, originating from both patients and physicians. Patients are often reluctant to report pain for fear of distracting physicians from treating and “curing” their disease. They are reluctant to deviate from being a “good, brave” patient or to become “addicted” to or tolerant of medications. Physicians and other health care providers may have little training and knowledge of pain assessment and management techniques or of palliative care. They are often afraid of scrutiny for use of any, much less adequate narcotics and avoid early initiation of palliative care because they feel this is perceived as “giving up” on the patient. Health care workers may confuse appropriate pain relief through terminal sedation with inappropriate and illegal euthanasia.

    But what about pain management, in general, as a core aspect of palliative and general patient care?  The following key concepts in pain management should be applied:(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)

1)     Be the physician you would want to have if you were in pain.

2)     Assess the pain carefully and reassess regularly.

a)     Characterize the pain meticulously, including interference with sleep and daily activities.

b)     Begin treating the pain while you perform the initial assessment. Don't wait until you complete your evaluation.

c)      Diagnose the type of pain: specific pains respond to specific treatments.

d)     Measure pain and make the scales visible in the patient’s chart (e.g., as the 5th vital sign).

e)     Nurses are the health professionals that spend the most time with patients. Their assessment of pain should always be taken into consideration before making any changes in therapy.

f)       Reassess the pain intensity frequently in order to guide dosage adjustments in much the same way a blood glucose level guides the adjustment of insulin therapy.

3)     Pain is a subjective phenomenon; believe the patient.

a)     Pain is whatever the experiencing person says it is, existing whenever he/she says it does (McCaffery).

b)     Vital signs and behavioral cues are not reliable indicators of pain severity.

c)      Minority patients, women and the elderly are particularly susceptible to under-treatment of pain.

d)     Treat the worry as well as the discomfort. Elicit the meaning of pain.

e)     Help the patient establish realistic goals for pain control (e.g., should the patient expect to be able to return to work, play golf, ambulate on his own, etc).

f)       Placebos should never be used in pain management.

4)     Use the World Health Organization 3-Step Analgesic Ladder for Pain:

a)     Step 1 (mild pain) Prescribe acetaminophen +/- adjuvants.

b)     Step 2 (moderate pain) Add weaker opioids +/- adjuvants +/- non-opioids.

c)      Step 3 (severe pain) Use stronger opioids +/- adjuvants +/- non-opioids.

5)     Prescribe an adequate opioid dose at correct intervals with a breakthrough or rescue dose:

a)     There is no ceiling effect for opioids: individualize the treatment.

b)     Escalate dosage at least 50% when pain is not under control.

c)      Write intervals as "around the clock” (ATC) that the patient may refuse instead of "as needed (PRN)".  Prescribing PRN dosage will not provide adequate, continuous pain control.

d)     Provide rescue doses every 1–2 hours (generally 15–20% of total daily opioid dosage).

e)     Increase the basal dosage periodically (every 24–72 hours depending if it is short or long acting, oral, transdermal or parenteral). Factor in the rescue dosage required during that period.

6)     Consider the benefit from adding an adjuvant medication early on during treatment.

a)     Prescribe gabapentin (Neurontin) or a tricyclic antidepressant (desipramine or nortryptiline) +/- an opioid for neurophatic pain.

b)     Bone pain may respond to NSAIDs and glucocorticosteroids.

c)      Pain associated with swelling (e.g., intracraneal edema, swollen liver) may respond to glucocorticosteroids.

d)     Psychostimulants (e.g., Ritalin) may enhance pain relief, reduce drowsiness, and improve mood and energy.

7)     Utilize equianalgesic tables every time you rotate opiods or change the administration routes.

a)     Become familiar with a few common drugs (e.g., morphine, hydromorphone, oxycodone, fentanyl, methadone) their onset, duration of action, presentation, and their oral/parenteral conversions.

b)     Find out the opioids and adjuvant analgesics available in the hospital and local pharmacies.

8)     Favor oral preparations.

a)     The simplest dosage schedule and least invasive pain management modalities should be used first.

9)     Prevent, recognize, and treat side effects of analgesics:

a)     "The hand that prescribes the opioid must also prescribe the laxative." Patients never develop tolerance to opioid induced constipation.

b)     Beware of nausea and sedation induced by opiods (particularly opioid-naive patients). They are more prevalent at the beginning of treatment or when the dose is increased. Treat them aggressively and explain to the patient that tolerance to these side effects will eventually develop.

c)      Use naloxone ONLY if life threatening opiod induced respiratory depression is present in a non-terminally ill patient. If naloxone is indicated, it should be diluted before administration (e.g., 1 ml of naloxone in 10 ml of normal saline).

10) Address common misunderstandings about tolerance and addiction with opioids:

a)     Increased dosage requirements more often reflect increased pain rather than tolerance.

b)     Physical dependence is a normal physiological response to the administration of various medications including opioids. Opioids should be tapered slowly once they are no longer needed if the patient has been taking them frequently for more than a week.

c)      Many patients believe that opioids are dangerous drugs, are addictive, can shorten life, & are used as a last resort.

11) When the pain is not responding, perform a full reassessment of the patient:

a)     Evaluate the role of psychosocial factors, including compliance factors.

b)     Changes in pain patterns or the development of new pain should trigger a new diagnostic evaluation & modification of the treatment plan.

c)      Seek help.

^[1] American Pain Society, Principles of Analgesic Use in the Treatment of Acute Cancer Pain, 5th edition; 2005.

^[2] American Academy of Hospice and Palliative Medicine. UNIPAC Three: Assessment and Treatment of Pain in the Terminally Ill. Second Edition; 2003.

^[3] American Academy of Hospice and Palliative Medicine. UNIPAC Four: Management of Selected Non-pain Symptoms in the Terminally Ill. Second Edition; 2003.

^[4] Ballantyne J. The Massachusetts General Hospital Handbook of Pain Management. Second edition; 2002.

^[5] Fowler B, Lynch M, Abrahm J. Pain Management Tables and Guidelines. Dana Farber Cancer Institute/Brigham & Women's Hospital; 2002.

^[7] Ogle K, Lovell K, Zaluski H. Opioid Management of Pain. Online Module; 2000.

^[8] Snyder L, Quill T. Physician's Guide to End of Life Care. ACP-ASIM End-of-Life Consensus Panel; 2001.

^[9] Abraham JL. A Physicians Guide to Pain and Symptom Management in Cancer Patients. The Johns Hopkins University Press; 2005.

^[10] Clinical Practice Guideline Number 9. Management of Cancer Pain. U.S. Department of Health and Human Services; 1994.

^[11] EPEC Trainer's Guide. Module 4: Pain Management; 1999.

^[12] Warfield CA, Fausett HJ. Manual of Pain Management. Second Edition; 2002.

^[13] Hunt J. Bedside Pain Manager. Conversions and Information for Pain and Symptom Control; 2002.

^[14] Weissman D. EPERC Educational Materials Fast Facts Series Pain Management Sections; 2003.

^[15] WHO Cancer Pain Publication. Alternatives to the Oral Delivery of Opioids; 2003.

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