Download assessment of pain at the end of life

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Management of Pain at
End of Life
Dr. Karimpour
Definition
 The World Health Organization (WHO) defines
palliative care a n “an approach that improves the
quality of life of patients and their families facing the
problem.
 whereas palliative medicine refers to the medical
subspecialty focused on providing symptom relief and
decision – making support for patients with serious
illnesses.
History of Palliative Medicne
 The word palliative comes from the latin
word to clothe and refers to the “covering
up” of symptoms such as pain.
 modern palliative medicine grew out of the
hospice movement that was started by
Dr.Cicely Saunders in 1960
Why is palliative care medicine
needed?
 Patients with serious illnesses have a significant
symptom burden, most often involving pain, dyspnea,
anxiety, and depression, and their family members
report similar concerns.
 Although the quality of pain control during a life-
limiting illness is often a major concern of patients and
their families, several surveys have found that they are
often dissatisfied with the quality of pain control.
INPATIENT PALLIATIVE CARE TEAMS
 In patient palliative care teams reduce hospital costs.
 A retrospective study of six hospitals with well established
palliative care teams showed a decrease of 1700 () per
admission for patients discharged alive and 5000() for
patients who died.
 Palliative care teams become involved with a reduced
length of stay in the intensive care unit(ICU) and fewer
deaths in the ICU. Inpatient palliative care teams increase
patient quality of life and patient and caregiver satisfaction.
Palliative care team
 Teams are interdisciplinary and Include a
nurse, physician, social worker, and chaplain
as well as other professionals, depending on
the need.
CANCER
 Cancer pain syndromes can be grouped in a variety of
categories: acute versus chronic, somatic versus
neuropathic, and disease versus treatment related11 Acute
pain is generally due to invasive procedures, such as
diagnostic or surgical interventions, and is not unlike the
experience of patients with nonmalignant disease.
 Examples of treatmentrelated acute pain unique to
individuals with cancer are noted in Table 70-1. Chronic
pain syndromes often include involvement of bone, soft
tissue, the viscera, and the nervous system. Bone
metastases are common sources of pain, particularly in
patients with breast, lung, or prostate cancers
CANCER
 Lymphedema, occurring in approximately 20% of women
who undergo axillary node dissection, is an example of soft
tissue pain associated with significant physical and
psychological morbidity.12 Visceral pain may arise from
involvement of tumor within the liver, intestine, kidney,
peritoneum, bladder, or other organs.
 Neuropathic pains can evolve from numerous causes, may
be difficult for patients to describe, and are often complex
to treat (see Table 70-2).13–15 Finally, many people with
cancer experience syndromes unrelated to the cancer or its
treatment, such as osteoarthritis.
CANCER
 Examples of treatmentrelated acute pain unique to individuals with
cancer are noted in Table 70-1. Chronic pain syndromes often include
involvement of bone, soft tissue, the viscera, and the nervous system.
Bone metastases are common sources of pain, particularly in patients
with breast, lung, or prostate cancers.
 Lymphedema, occurring in approximately 20% of women who
undergo axillary node dissection, is an example of soft tissue pain
associated with significant physical and psychological morbidity.12
Visceral pain may arise from involvement of tumor within the liver,
intestine, kidney, peritoneum, bladder, or other organs. Neuropathic
pains can evolve from numerous causes, may be difficult for patients to
describe, and are often complex to treat (see Table 70-2).13–15 Finally,
many people with cancer experience syndromes unrelated to the cancer
or its treatment, such as osteoarthritis.
ASSESSMENT OF PAIN AT THE END OF
LIFE
 The assessment techniques described in other chapters
should be applied to patients with cancer or other
lifethreatening illnesses. Intensity, location (or often,
multiple locations), quality, temporal nature of the pain,
and factors that alter the pain are critical to ascertain.
 As with all other pain syndromes, a thorough history is
followed by a comprehensive physical examination, with
particular emphasis on the neurologic evaluation.16
Radiographic, laboratory, and other diagnostic techniques
may be indicated, although in caring for those at the end of
life, treatment decisions may be made empirically to avoid
uncomfortable scans or invasive procedures.
ASSESSMENT OF PAIN AT THE
END OF LIFE
As with all other pain syndromes, a thorough
history is followed by a comprehensive physical
examination, with particular emphasis on the
neurologic evaluation.
Radiographic, laboratory, and other diagnostic
techniques may be indicated, although in caring for
those at the end of life, treatment decisions may be
made empirically to avoid uncomfortable scans or
invasive procedures.
ASSESSMENT OF PAIN AT THE END OF
LIFE
 When patients are unable to verbalize or describe their
pain, clinicians can use the furrowed brow as a proxy
measure of pain.17 If there is no response to adequate
doses of opioids or other analgesics, additional sources
of distress (e.g., distended bladder or fecal impaction)
should be explored.
 While the general assessment of pain is universal,
several additional dimensions are critical at end of life
ASSESSMENT OF PAIN AT THE END
OF LIFE
 . A psychosocial assessment is indicated, directed
towards the meaning of the pain as well as the effect of
pain on the patient and their caregiver. The findings of
this assessment may suggest the need for education, to
mediate fears of addiction, for example.
 The results of this questioning may also prompt
referral to social workers, chaplains, or others who are
trained to address the existential distress or suffering
experienced by the patient or their family.
ASSESSMENT OF PAIN AT THE END OF
LIFE
 Pain does not exist in isolation and symptom clusters are
common, particularly at end of life. Several instruments
have been designed to measure clinically multiple
symptoms, including the Edmonton Symptom Assessment
Scale (ESAS),20,21 the M.D.
 Anderson Symptom Inventory (MDASI),22 the Memorial
Symptom Assessment Scale (MSAS),23 and others. Another
tool, the Distress “Thermometer,” is a vertical visual analog
scale designed to look like a thermometer, with 0 meaning
“no distress” and 10 (at the top of the thermometer)
indicating “extreme distress.” 24 Accompanying the distress
scale is a checklist of various physical, psychological,
practical, family support, and spiritual/religious concerns.
ASSESSMENT OF PAIN AT THE
END OF LIFE
 These are brief, clinically useful tools that quantify the
intensity of a variety of symptoms common at end of
life (see Table 70-4). The specific needs of people
enrolled in hospice are addressed in the Brief Hospice
Inventory (BHI).
 The BHI assesses when managing complex pain
syndromes that occur at the end of life. outcomes of
hospice patients, including physical and psychological
symptoms, patient’s perceptions of hospice care, as
well as ratings of their quality of life.
ASSESSMENT OF PAIN AT THE END
OF LIFE
 Each statement is measured using an 11-point scale.
Benefits of these instruments include the systematic
assessment of pain and other symptoms.
 These data inform the clinician as a treatment plan is
developed, particularly when managing complex pain
syndromes that occur at the end of life.
COMPLEX PAIN SYNDROMES AT END OF
LIFE
 Unfortunately, a small percentage of patients will
experience complex syndromes that do not respond to
traditional approaches, such as bone pain, intractable
neuropathic pain, or malignant bowel obstruction, or
will develop severe opioid-induced toxicity.
MALIGNANT BONE PAIN
 Bone pain is often difficult to treat, in that patients may
obtain good relief of movement-associated pain from
higher-dose opioid therapy, yet will be extremely sedated
when they stop moving or placing pressure on the bone.
 Patients at risk include those with cancers that frequently
metastasize to bone, including breast, lung, prostate, or
multiple myeloma.5 Table 70-5 lists treatment options.
INTRACTABLE NEUROPATHIC PAIN
 Neuropathies can be difficult to treat. Standard therapies
include opioids and adjuvant analgesics, including
corticosteroids (Table 70-5).16,27 Additionally, nerve blocks and
other interventional techniques can be useful. In more refractory
cases intravenvous lidocaine infusions are used to treat
intractable pain.
 Using techniques and protocols originating from pain clinics,
intravenous lidocaine 1 to 2 mg/kg is given over 15 to 30 min. If
effective, a continuous infusion of 1 to 2 mg/kg/hr is started. The
analgesic effects can be as prolonged as weeks of relief. Perioral
numbness is an early warning sign of potentialtoxicity. Hepatic
dysfunction and significant cardiac conduction abnormalities are
relative contraindications to the treatment, viewed in balance
with the patient’s goals of care and prognosis.
MALIGNANT INTESTINAL OBSTRUCTION
 Bowel obstruction is common in progressive
gynecologic and colorectal malignancies. The majority
of patients with bowel obstruction will die within 6
months.
 Palliation can include surgery in selected cases, or,
more commonly, intravenous or subcutaneous
octreotide, nasogastric tube suction, and venting
gastrostomy, in addition to analgesics and
antiemetics.30 Table 70-5 lists specific treatment
options.
OPIOID NEUROTOXICITY
 The neuroexcitatory effects of opioids include myoclonus,
hyperalgesia, delirium, and grand mal seizures. These
toxicities have been reported in association with morphine,
hydromorphone, hydrocodone, fentanyl, methadone, and
oxycodone.31,32 The 3-glucuronide metabolites are
implicated as contributing to these neuroexcitatory
effects.33 Both morphine-3-glucuronide (M3G) and
hydromorphone-3-glucuronide (H3G) are believed to
produce myoclonus and seizures.
 Renal failure appears to be a significant, but not absolute,
risk factor, as patients are unable to clear the metabolite.
OPIOID NEUROTOXICITY
Case reports suggest that H3G plasma levels are greatly increased in the presence
of renal failure, with the ratio of H3G to the parent compound four times higher
thanthe ratio seen in patients with normal renal function.35 The treatment of
mild myoclonus generally includes switching to another opioid, lowering the
dose of the opioid, and adding a benzodiazepine.
Clonazepam 0.5 mgorally twice daily with upward titration may be effective. If
the patient is unable to swallow, midazolam or lorazepam may be used.
Hyperalgesia frequently is misdiagnosed and the first response by well-meaning
clinician often is to increase the opioid dose.
OPIOID NEUROTOXICITY
 This generally results in greater pain, with potential
progression to delirium and possibly seizures. When these
more severe neurotoxicities occur, the opioid dose should
be reduced by at least 50%. Some advocate stopping the
opioid altogether, since the half-life of these metabolites is
long and the patient is unlikely to experience the
abstinence syndrome.
 Naloxone appears to be ineffective in reversing this
toxicity. In select cases, spinal delivery of analgesics can be
effective in relieving pain and reducing systemic opioid
exposure. Should seizures occur, first- and secondline
therapies include phenytoin and benzodiazepines, such as
diazepam or lorazepam.
OPIOID NEUROTOXICITY
 In some cases the seizures will progress in frequency and
intensity, advancing to status epilepticus.38 Refractory
status epilepticus treatment may require midazolam,
barbiturates, and propofol.39 l Midazolam is particularly
useful in palliative care due to its rapid onset and short
duration, as well as its ability to be given subcutaneously,
intravenously, orally, buccally, sublingually, or rectally.
 Furthermore, its only known drug incompatibility is with
corticosteroids, particularly betamethasone,
dexamethasone, and methylprednisolone.39 l The
standard dose of phenobarbital in the management of
seizures is 20 mg/kg intravenous infusion, with a
maximum rate of 50 to 100 mg/min.
 The recommended dose of propofol to treat refractory
status epilepticus is 1 to 2 mg/kg via intravenous
injection over 5 min and repeated if necessary.
 A maintenance intravenous infusion of 2 to 10
mg/kg/hr is then started, using the lowest dose
needed to suppress seizure activity.
OTHER SYMPTOMS COMMON AT END OF
LIFE
 Dyspnea, anxiety, depression, and other symptoms are
common in the face of advanced illness. Palliation of
these symptoms, which are frequently linked with
pain, can result in improved pain control and
enhanced quality of life.
DYSPNEA
 Dyspnea, or air hunger, can occur as a result of a
variety of illnesses, including cancer, congestive heart
failure, or pulmonary diseases. Opioids are the first
drug of choice, often in small doses that do not cause
sedation.
 Shortacting anxiolytics are indicated in the face of
severe anxiety. Simple measures such as bedside fans
can provide additional comfort.
ANXIETY
Anxiety is highly correlated with unrelieved pain.41 Additionally,
many medications commonly used in palliative care, such as
corticosteroids, neuroleptics (including metoclopramide),
bronchodilators, antihistamines, digitalis, and occasionally
benzodiazepines (which can cause a paradoxical reaction in elderly
patients), can result inmotor restlessness and agitation. Abrupt
withdrawal from alcohol, opioids, benzodiazepines, and nicotine
also produce agitation.
Hypoxia, pulmonary embolus, sepsis, hypoglycemia, thyroid
abnormalities, and heart failure are associated with anxiety, as are
certain tumors, including pheochromocytomas, and some
pancreatic cancers. Primaryor metastatic lung cancers and chronic
cardiopulmonary conditions can lead to dyspnea, which can also
produce anxiety.
ANXIETY
 Pharmacologic treatment of anxiety usually consists of
benzodiazepines, particularly lorazepam as it has a short
duration of action and produces fewer adverse effects. A typical
initial dosage is 0.5 to 2 mg orally 3 or 4 times daily. Lorazepam
can be placed sublingually, which is useful when patients have
difficulty swallowing, or given parenterally as a bolus or infusion.
 Haloperidol is frequently used for short-term management of
severe anxiety and as an antipsychotic, with initial dosage
starting at 0.5 to 1 mg orally twice daily.41 Frank discussion of
patients’ fears in a supportive environment, along with the use of
relaxation strategies, such as audiotapes, breathing exercises,
and guided imagery, may alleviate anxiety.
DEPRESSION
 Depression is often poorly recognized in people at end of
life.43 Diagnosis may be difficult in advanced disease, as
the usual physical symptoms of depression (fatigue,
anorexia, and sleep disturbance) can result from the
disease itself or its treatment.
 Psychological symptoms suggestive of depression in the
patient with life-threatening illness include loss of
selfworth, unremitting sadness and hopelessness, and
suicidal ideation. There is evidence that a simple screening
question “Are you depressed?” or “Are you sad?” is the most
valid measure of a patient’s depression.44 Supportive
psychotherapy may be of benefit, although limited life span
may be a barrier.
DEPRESSION
 Antidepressant medications, such as serotoninspecific
reuptake inhibitors (SSRIs), such as citalopram, fluoxetine,
paroxetine, and sertraline, are usually well tolerated.
However, the 2 to 4 weeks required for the drug to take
effect is often too long for patients with advanced disease
and a very short life span.
 Newer, “atypical antidepressants” (bupropion, mirtazepine,
and venlafaxine) have a relatively rapid onset of action and
few reported side effects. However, for patients with a very
limited life span, stimulants such as methylphenidate and
pemoline provide rapid relief, usually within hours to days.
CONCLUSION
Pain, dyspnea, anxiety, and depression are serious symptoms
experienced by people with life-threatening illnesses. All
health-care professionals are responsible for care of the
dying, and, therefore, must be aware of the most common
syndromes occurring in this population, able to conduct
specific assessment techniques, and knowledgeable about the
therapies used to treat these symptoms.
Resources, such as palliative care services and hospices, can
assist physicians as they provide care to these patients and
their families.
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