the care of the dying: pain management

The care of the dying:

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A Good Death is the

culmination of A Good

Life

WHO’ s definition of palliative care

“An approach that improves the quality of life

of patients and their families facing the

problems associated with life-threatening

illness, through the prevention and relief of

suffering by means of early identification and

impeccable assessment and treatment of

pain and other problems, physical,

psychosocial, and spiritual”

Pain and other symptoms

management

a common goal of

palliative care

Palliative care

The PEACE ToolO assessment 1)pain and other symptoms2)emotive burden3)shared, informed decision making4)care planning and communication5)domestic and economic needs of

patients and care-givers6)spirituality

Assessment

1. Physical symptoms2. Emotive (and cognitive) symptoms3. Autonomy related issues4. Communication, and Completion of

life affairs related issues5. Economic burden and other

practical issues6. Transcendent and spiritual issues

Physical symptoms

PAIN RULESOPainOAnorexia and other appetite or oral intake related issuesOIncontinence and other genitourinary symptomsONausea and other gastrointestinal symptoms (constipation, vomiting, diarrhea)

O Respiratory symptoms (dyspnea, cough)

O Ulcerations and other skin complaintsO Level of functioning O Energy and other related issues such

as fatigue or astheniaO Sedation, sleep and other side effects

of treatment (including opioids and chemotherapy)

Diagnosing dying

O Signs

1. The patient becomes bed-bound

2. The patient is semi-comatosed

3. The patient is only able to take sips of fluid

4. The patient is no longer able to take oral

drugs

“ Multi-professional team agree ”

Symptoms at the end of life

O Breathlessness

O Cough/noisy respirations

O Terminal restlessness

O Myoclonic jerking

Goals of care for patients in the dying phase

O Comfort measures1. Current medication assessed and non-

essentials discontinued2. As required subcutaneous medication

written up as per protocol (pain, agitation, respiratory tract secretions, nausea and vomiting)

3. Discontinue inappropriate interventions (blood test, antibiotics, intravenous fluid/medications)

O Psychological/insight4.Ability to communicate5.Insight into condition assessedO Religious/spiritual support6.Religious/spiritual needs assessed

with patient/family

O Communication with family/other7.Identify how family/other are to be

informed of patient’ s impending death

8.Family/other given relevant hospital information

O Communication with primary healthcare team

9.General practitioner is aware of patient’ s condition

O Summary10.Plan of care explained and

discussed with patient/family11.Family/other express understanding

of plan care

The overriding goal of palliative care is to reduce suffering and maintain an acceptable quality of life

throughout the course of a progressive illness, including

the periods of advanced illness and active dying

Most common symptoms

O Pain

O Nausea and vomiting

O Agitation

O Respiratory tract secretions

Drugs administration

O Analgesic: morphine, oxycodone,

hydromorphone

O Antiemetic: metoclopramide,

dimenhydrinate, haloperidol

O Sedative: midazolam, haloperidol

O Antimuscarinic: glycopyrronium

O Many patients and families suffer from

untreated pain at the end of life

O Failure to treat pain effectively can result

from

1. a lack of clinician training in palliative care

2. the fear of violating ethical, moral, and legal

tenets in the administration of pain

medication to the dying patient

PREVALENCE OF PAIN

O at least one-fifth of the million

patients who die in hospitals each

year experienced pain

O 50 percent had daily pain

O 85 percent had moderate or worse

pain

Pain

O common feature at the end of life

O 93 percent of patients dying from HIV/AIDS

had pain at the end of life

O 75 percent of patients with heart failure had

pain during the last six months of life

O 70 percent of patients with advanced cancer

had moderate to severe chronic pain

O 40 percent of cancer pain had undertreatment

the escalation of pain that is

uncontrolled at the end of

life as a "medical emergency"

Total PainO Suffering pain of clear physical originO More severe pain or exacerbation of

pain that relate to Psychological pain Social pain Spiritual painO Pain “ all over ” and “ unable to

localize ”

Incident Pain

O Subtype of episodic pain

O Transient

O Typical occur on movement

O Rapid onset

O Severe intensity

O Administration of a “ rescue dose ” (fast

action and short duration)

Neuropathic PainO Adjuvant analgesia (malignancy

association) Anticonvulsants Tricyclic antidepressants Benzodiazepine NMDA antagonists steroidO Opioid (partially effective)

Bone Pain

O Opioids

O NSAIDs (rectal, parenteral)

O Dexamethasone

Other symptoms management

O Breathlessness1.Opioids: diamorphone, morphine2.Benzodiazepines: lorazepam,

midazolam3.Oxygen therapyO Cough/noisy respirations1.Appropriate position2.Anticholinergics: hyoscine

hydrobromide, glycopyrronium

O Terminal restlessness1.Exclude: urinary retention,

discontinue steroid2.Benzodiazepines: midazolam,

haloperidolO Myoclonus jerking1.Due to rapid escalation of opioid dose2.Benzodiazepine: midazolam

Summary

O Pain and symptom control together

with the wider consideration of the

patient and family

O The treatment of pain at the end of

life is the right of the patient and a

moral duty, as well as legal obligation,

of the clinician caring for the suffering