PAIN MANAGEMENT

AS PART OF

“PALLIATIVE

CARE”

P. Chaudakshetrin M.D., FFPMANZCA(Hon.)Pain & Palliative Care, Samitivej Sukhumvit Hospital

Bangkok. THAILAND

How I do it

Staff tearoom

Rest room

Rest room

Conference room

CS 5 CS 7

CS 4

CS 3 CS 6

CS 2

Treatment roomCS 1

Counseling room

Rest room

Rest room

Palliative care

office

Pain clinicoffice

Patient waiting

area

Entrance

Symptom control has to precede

spiritual support. A person can not

think about meaning of his life while

he has pain or keeps being sick.

that improves the quality of life

of patients & their families

facing the problems associated with

life-threatening illness,

through the prevention & relief of suffering

by means of early identification &

impeccable assessment & treatment

of pain & other problems,

physical, psychosocial and spiritual.

World Health Organization 2002

Palliative Care is an approach

CA breast with lymphedema pain, Rt upper extremity

Advanced Rectal cancer s/p palliative colostomy, large pelvic mass involved bony structure, incarcerated peri-anal erosion + multiple lymph node metastasis. fecal incontinence,

• Stocking like dysesthesia, • Diminished pinprick sensation • Slight motor weakness

Palliative Care Principles

Symptom control

Disease

management

Psycho-social

care

• High quality

• Cost effective care

• Person oriented, not disease oriented

• Holistic in approach

• Multidisciplinary team

Approach To Pain Control in Palliative Care

1. Thorough assessment by skilled and knowledgeable clinician

– History– Physical Examination

2. Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions

3. Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care

4. Treatments – pharmacological and non-pharmacological; interventional analgesia (e.g.. Spinal)

5. Ongoing reassessment and review of options, goals, expectations, etc.

Be prepare to breaking bad news !

• Disease Diagnosis

• Prognosis

It’s our responsibilities !

Breaking Bad News:The SPIKES Approach

• Setting up

• Perception

• Invitation

• Knowledge

• Emotions

• Strategy and summary

Baile WF, Buckman R, Lenzi R, et al. Oncologist 2000; 5: 302-11

Symptom Management - General Approach

WHY is the patient having this symptom?

In the light of your assessment,Make a TREATMENT planTry to treat the cause at the same time as treating symptomatically

Liaise with the team, patient & familyExplain, educate and supportDocument discussion/decisions/plans

REVIEW / FOLLOW-UP

Pain Assessment

• Listen carefully: What are the words used?

– May deny pain but will admit to having “discomfort”, “aching” or “soreness”

– Do you hurt anywhere?

– Are you uncomfortable?

– How does it affect you?

• Believe the patient “pain is what the patient says hurts….the best judge of a patient’s pain is the patient” Bonica

• Assess for other symptoms: Portenoy: Study of 243 cancer

patients- Average of 11.5 symptoms

12

PRINCIPLES OF SYMPTOM MANAGEMENT

– When possible, choose a drug treatment that targets the likely underlying cause

– Nausea and vomiting, for example, can be secondary to gastric outlet obstruction, hypercalcemia, increased intracranial pressure, esophagitis, opioid use, or constipation

Try to understand the pathophysiologybehind the symptom

PAIN PROBLEMS HAS TO BE DIAGNOSED AND

DIFFERENTIAL DIAGNOSE

DInflammation from IV site

A Fracture from bone metastasis

B Pressure sore

CConstipation colic

What is the cause of this pain ? • Cancer-related

– Bone

– Nerve compression/infiltration

– Soft tissue infiltration

– Visceral

– Muscle spasm

– Lymphoedema

– Raised intracranial pressure

• Treatment related – surgery: postoperative scars

/adhesions

– Radiotherapy: burns/ fibrosis

– Chemotherapy: neuropathy

• Associated with cancer/ debility– Constipation

– Pressure sores

– Bladder spasms

– Stiff joints

– Post-herpetic neuralgia

• Unrelated to cancer– Arthritis

– Angina

– trauma

Attention to “Total P.A.I.N.”

hysical Distress (physical pain/discomfort)

ffective Distress (anger, anxiety, depression)

nterpersonal Distress (relationships)

ormative Distress (spiritual, existential)

ExaminationIt is in itself a powerful, non-verbal message. “ I am interested in you, and this is how I am going to care for you.” and opportunity for

positive comments

( which need to be true)

Pain management

Challenges in Cancer Pain Management

• Bone Pain

• Neuropathic Pain

• Gastrointestinal pain / obstruction

• Mixed Pain

• Treatment related neuropathy

• / arthropathy

• The Role of tumor factors

• “ extra layer” local / systemic

Progression of cancer pain

• Turning in bed• Limb movement• Coughing• spontaneous

Intermittent pain

Constant pain

Episode of break through pain

Extreme pain associate with normal activities

SPECIAL CONSIDERATIONS IN PALLIATIVE CARE PATEINTS

• These people may:

• Be debilitated and cachexic

• Have other medical problems

• Not be able to tolerate side-effects of drugs

• Be on multiple medications +/- complementary therapies

• Have multiple symptoms

Therapeutic limitations

Lack of clinical characterization of pain syndromes

Unpredictable response to treatment

Limited time to get it right

Several pains in single patients

Average of 6 non-pain symptoms

General frailty / co-morbidities

Drug side effects

Palliative Care

Not Just opiates

Address psychosocial problems

Specific therapiesRadiotherapy, chemotherapy,surgery

Co-analgesicsDrugs, nerve blocks, TENS, relaxation, acupuncture

MorphineFentanyl

MethadoneCodeineTramalAspirin

AcetaminophenNSAIDs

‘Good enough’ Relief

• Re-frame goal

• Primary goal of pain management is helping patients move from being overwhelmed by their pain to establishing mastery over the pain

25

Seizures,

Death

Opioid

tolerance

Mild myoclonus

(eg. with sleeping)

Severe myoclonus

Delirium

Agitation

Misinterpreted

as Pain

Opioids

Increased

Hyperalgesia

Misinterpreted

as Disease-Related Pain

Opioids

Increased

Spectrum of Opioid-Induced Neurotoxicity

The needs of the dying

are different from those

who are expected to recover.

When FANTASY stops, the reality begins…

Changed focus of care helps the person begin some of the tasks of life closure.

“When nothing can be done”

‘Caring is the result of an ongoing creativity process. If creativity is arrested or stopped, caring and hope are not possible. You have to restore creativity in order to restore hope”

Clinically, skilled psychosocial and spiritual care can provide a way

out of pharmacologically “intractable” pain without resort

to sedation.

Causes of terminal restlessness

– Uncontrolled pain and other symptoms

– Drugs

– Metabolic

– Infections

– Constipation

– Cerebral causes

– Postictal

– Anxiety– Withdrawal

Terminal sedation

• Sedation should not be intended as a terminal event

• All other options should have been explored first

• The level of sedation is only that required to relieve distress

• Sedation is achieved with sedatives, not opioid

Effective pain management in terminally ill requires

• Understanding of pain control strategies

• Ongoing assessment

• Diagnosis of pain

• Breakthrough pain relief

• Fine adjustment of medications

• Opioid rotation

• Unresolved psychosocial or spiritual issue can be great impact to pain management

The greatest things in this world

can not be seen or touched. They

must be felt by the heart.”Helen keller.