the care of the dying: pain management

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The care of the dying: pain management. นายแพทย์รัฐพล แสงรุ้ง คลินิกระงับปวด ภาควิชาวิสัญญีวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร. A Good Death is the culmination of A Good Life. WHO’ s definition of palliative care. - PowerPoint PPT Presentation


  • The care of the dying:pain management

  • 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 Toolassessment pain and other symptomsemotive burdenshared, informed decision makingcare planning and communicationdomestic and economic needs of patients and care-giversspirituality

  • AssessmentPhysical symptomsEmotive (and cognitive) symptomsAutonomy related issuesCommunication, and Completion of life affairs related issuesEconomic burden and other practical issuesTranscendent and spiritual issues

  • Physical symptoms PAIN RULESPainAnorexia and other appetite or oral intake related issuesIncontinence and other genitourinary symptomsNausea and other gastrointestinal symptoms (constipation, vomiting, diarrhea)

  • Respiratory symptoms (dyspnea, cough)Ulcerations and other skin complaintsLevel of functioning Energy and other related issues such as fatigue or astheniaSedation, sleep and other side effects of treatment (including opioids and chemotherapy)

  • Diagnosing dyingSignsThe patient becomes bed-boundThe patient is semi-comatosedThe patient is only able to take sips of fluidThe patient is no longer able to take oral drugs Multi-professional team agree

  • Symptoms at the end of lifeBreathlessnessCough/noisy respirationsTerminal restlessnessMyoclonic jerking

  • Goals of care for patients in the dying phaseComfort measuresCurrent medication assessed and non-essentials discontinuedAs required subcutaneous medication written up as per protocol (pain, agitation, respiratory tract secretions, nausea and vomiting)Discontinue inappropriate interventions (blood test, antibiotics, intravenous fluid/medications)

  • Psychological/insightAbility to communicateInsight into condition assessedReligious/spiritual supportReligious/spiritual needs assessed with patient/family

  • Communication with family/otherIdentify how family/other are to be informed of patient s impending deathFamily/other given relevant hospital informationCommunication with primary healthcare teamGeneral practitioner is aware of patient s condition

  • SummaryPlan of care explained and discussed with patient/familyFamily/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 symptomsPainNausea and vomitingAgitationRespiratory tract secretions

  • Drugs administrationAnalgesic: morphine, oxycodone, hydromorphoneAntiemetic: metoclopramide, dimenhydrinate, haloperidolSedative: midazolam, haloperidolAntimuscarinic: glycopyrronium

  • Many patients and families suffer from untreated pain at the end of lifeFailure to treat pain effectively can result from a lack of clinician training in palliative carethe fear of violating ethical, moral, and legal tenets in the administration of pain medication to the dying patient

  • PREVALENCE OF PAIN at least one-fifth of the million patients who die in hospitals each year experienced pain50 percent had daily pain85 percent had moderate or worse pain

  • Paincommon feature at the end of life93 percent of patients dying from HIV/AIDS had pain at the end of life75 percent of patients with heart failure had pain during the last six months of life70 percent of patients with advanced cancer had moderate to severe chronic pain40 percent of cancer pain had undertreatment

  • the escalation of pain that is uncontrolled at the end of life as a "medical emergency"

  • Total PainSuffering pain of clear physical originMore severe pain or exacerbation of pain that relate toPsychological painSocial painSpiritual painPain all over and unable to localize

  • Incident PainSubtype of episodic painTransientTypical occur on movementRapid onsetSevere intensityAdministration of a rescue dose (fast action and short duration)

  • Neuropathic PainAdjuvant analgesia (malignancy association)AnticonvulsantsTricyclic antidepressantsBenzodiazepineNMDA antagonistssteroidOpioid (partially effective)

  • Bone PainOpioidsNSAIDs (rectal, parenteral)Dexamethasone

  • Other symptoms managementBreathlessnessOpioids: diamorphone, morphineBenzodiazepines: lorazepam, midazolamOxygen therapyCough/noisy respirationsAppropriate positionAnticholinergics: hyoscine hydrobromide, glycopyrronium

  • Terminal restlessnessExclude: urinary retention, discontinue steroidBenzodiazepines: midazolam, haloperidolMyoclonus jerkingDue to rapid escalation of opioid doseBenzodiazepine: midazolam

  • SummaryPain and symptom control together with the wider consideration of the patient and familyThe 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


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