Pain Module End of Life Pain Assessment and Management
Assessing pain at end of life Perform the routine pain assessment asking the typical questions e.g., location, severity, quality and so forth. Perform physical examination as indicated e.g., observation, palpation, auscultation, percussion. Check lab or radiological studies if available. Consult with family and other members of the health care team. When patients cannot communicate APP: Assume Pain is Present if the same condition, disease or procedure is generally considered painful.
Goals of Pain Management at End of Life Consult the Palliative Care Team if they are not already involved (physician s order required). Control physical and emotional pain and suffering Use multimodal pain management Managing pain takes precedence over vital signs e.g., treat the pain not the vital sign Involve patient and family in establishing pain goals. Ask family or caregivers to help identify signs of pain for nonverbal patients.
Some common barriers to pain management Many mistakenly believe that opioids... Will cause the dying patient to become addicted Fact: Addiction is a disease. You cannot give it to someone. Should be saved for when they are really needed Fact: Not true. Pain should be treated early. Untreated pain is harmful. Have unpleasant or dangerous side effects Fact: Most side-effects can be managed. Injections work better than pills Fact: All routes can be effective if the correct drug and dose are given in the appropriate situations (oral, transmucosal, transdermal, SQ, IV, rectal). Are only for dying people Fact: Morphine is prescribed every day to healthy people after surgery or for those who have severe pain. Fact: Morphine is just one of several types of opioid analgesics used to treat moderate to severe pain or moderate to severe breathlessness.
Myth: A dying patient will die sooner if given morphine. FACT: There are no research studies that show that giving pain medicine hastens death as long as the pain medicine is given in the amount that the individual needs to relieve pain and reduce suffering. It is believed that unrelieved pain may hasten death. The person is dying from his/her disease or condition, not from our attempts to relieve the pain in the process. Dying patients already taking opioids have developed tolerance and may require very large doses of an opioid in order to control pain. Morphine is the drug of choice to ease severe dyspnea and labored breathing. Morphine is just one of several types of opioids that can be prescribed. It is believed that when symptoms at end of life are well-controlled, persons may live longer because they are relaxed and no longer suffering.
Do not automatically assume that signs of discomfort are related to the primary disease or condition Use your detective skills. Does the patient have: A distended bladder? A bladder infection? Worsening arthritis Skin breakdown? A history of cancer with new bone metastasis? An occult fracture? Worsening constipation? Discomfort due to his/her positioning? Discomfort due to environmental conditions e.g., too cold, too warm, noise? Anxiety? Restlessness secondary to meds or something else?
Concepts to think about when treating pain Pain is a complex phenomenon. A variety of factors impact on the perception of pain and the effectiveness of a treatment. Enlist the patient s and family s opinions about treatment options. Correct misconceptions and provide educational materials. Reassess regularly. Call physician immediately if medication and nonpharmacologic interventions not effective. Be creative. Advocate, Communicate, Assess and Reassess!
Toxic Neuro Effect of Opioids: Hyperexcitability Syndrome Syndrome characterized by hyperesthesia, myoclonus, and/or seizures due to an accumulation of opioid metabolites in a patient with organ failure. Suggestions: Reduce the dose of the opioid. A lower dose might be just as effective with less side effects. Change to another opioid. Be careful not to D/C the drug altogether because patient will experience withdrawal if he/she has been on the opioid for a while. Eliminate all unnecessary medications. Hydration may be helpful.
Sedation Sedation is an initial side-effect of opioids and usually lessens with time unless the patient has metabolic or organ failure. Sedation may be desirable. Some options if sedation is directly related to the opioid and not to something else, and the patient wants to be more alert: Lower the opioid dose if this will still control the pain, rotate to a different opioid, and/or try lowering the opioid dose and adding a non-opioid e.g., NSAID. Stimulants may be an option: caffeine nicotine patch methylphenidate (Ritalin ) (5-10 mg po in the morning and at lunch) modafinil (Provigil ) 100-200 mg q am has been reported to alleviate opioid induced sedation although no studies exist.
Pain is whatever the experiencing person says it is, existing whenever he/she says it does (McCaffery, 1968); however, at the end of life, a number of factors e.g., sedation, confusion, organ failure, may prevent patients from reporting pain. In these instances, if the patient has any potential physical reasons for having pain, one should assume pain is present and treat it as thus. (American Pain Society, 2003)