CASE DISCUSSION Managing Difficult Pain

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CASE DISCUSSIONManaging Difficult Pain

• Saturday 8 November 2009

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WHAT DO WE MEAN BY DIFFICULT PAIN?

• It is estimated that up to 90 of pain in cancer
  can be controlled with medication
• There is a minority of cases that are more
  challenging take longer to relieve, need more
  medication etc.
• Can we predict which cases are going to be
  difficult to manage?

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WHAT MAKES CANCER PAIN DIFFICULT TO CONTROL?

• The Cancer
• The Context
• The Pain
• The Patient

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CAN WE STAGE CANCER PAIN?

• Revised Edmonton Staging system (rESS)
• Edmonton Classification System for Cancer Pain
  (ECS-CP)
• Mechanism of Pain (Neuropathic) N
• Incident Pain (/-)
  I
• Psychological Distress P
• Addictive Behaviour A
• Level of Cognitive Function C
• Concept similar to TNM classification for cancer

Fainsinger, Nekolaichuk et al. JPSM Mar 2005
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WHAT DOES THIS MEAN?

• Presence of certain factors predicts more time
  needed, more modalities required and higher mean
  morphine equivalent daily dose needed to achieve
  stable pain control
• Allows early recognition and referral to
  specialists

Fainsinger RL, Fairchild A, Nekolaichuk C, Lawlor
P, Lowe S, Hanson J.(2009) Is pain intensity a
predictor of the complexity of cancer pain
management? J Clin Oncol 27585-590 Fainsinger
RL, Nekolaichuk CL.(2008) Cancer pain assessment
Can we predict the need for specialist input?
European J of Cancer , 44(8)1072-1077 Fainsinger
RL, Nekolaichuk CL.(2008) A TNM classification
system for cancer pain The Edmonton
classification system for Cancer pain (ECSCP).
Supportive Care in Cancer, 16(6)547-555
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CASE DISCUSSION
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Mdm CSL 34 year old woman

• Self-discovered a left breast lump, defaulted
  follow-up after the excision biopsy confirmed
  breast cancer
• 1 year later developed left axillary swelling but
  did not seek treatment for another six months
• By now with a large, bleeding, fungating wound
• Left arm swollen, weak and painful, with dilated
  veins over the shoulder and scattered skin nodules

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• Received 4 cycles chemotherapy (AC) but left arm
  continued to swell and new nodules appeared
• Did not want further chemotherapy as worried
  about cost and side effects
• Complained of numbness, tightness, weakness in
  her left arm
• Painful fungating bleeding tumour left upper
  chest wall and axilla

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Initial Assessment

• Distressed, in pain, very irritable
• Cachectic
• Big fungating tumour with slough and slight
  odour. Tumour extended into axilla and the back
• Left arm lymphoedema flaccid and weak
• Mild pedal oedema
• Examination limited as patient was in a rush to
  complete dressing and go home patient had to
  travel from Malaysia to the cancer centre in
  Singapore

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• LEFT ARM SWOLLEN, WEAK AND PAINFUL
• DEEP ACHING
• NUMB, DECREASED SENSATION TO TOUCH
• LIGHT STROKING PRODUCED PINS NEEDLES
• LEFT ARM VERY PAINFUL IF NOT POSITIONED PROPERLY

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• Was prescribed MST 30mg 8 hourly but not taking
  consistently
• Preferred Tramadol 50 prn and/or mist morphine
  10-15mg prn
• Was taking average 200mg Tramadol and 40mg
  Morphine daily
• Was given Amitriptyline 25mg previously but
  stopped after a few doses
• If she was in the right position, pain was
  bearable, but almost any movement was painful
• Came three times weekly for dressings

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IS PAIN THE ONLY PROBLEM?

• WHAT ELSE IS GOING ON?

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GET THE APPROACH RIGHT

• GOOD ASSESSMENT
• FIND OUT ALL THE PROBLEMS
• MAKE DECISIONS AND PLANS
• WHAT ARE OUR GOALS?
• WHAT ARE WE GOING TO DO?
• ALWAYS ASK WHY?
• THEN HOW AND WHAT?

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WHY, HOW AND WHAT?

• WHY is the patient having this symptom?
• HOW is it affecting him and the family?
• WHAT kind of help does he want?
• The symptom is just the beginning, not the end

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NOT ONLYWHAT KIND OF PAIN DOES THIS PERSON HAVE?

• BUT ALSO
• WHAT KIND OF PERSON HAS THIS PAIN?

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Family
Housewife. Divorced and remarried. 11 year old
son living with1st husband. Mother moved in to
help care for her. Described as stubborn and
strong-willed
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WHAT ARE WE DEALING WITH?
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ISSUES

• Challenging pain
• Mixed nociceptive neuropathic pain, with
  incident pain
• Fungating malignant wound
• Financial worries
• Strong beliefs about her illness and treatment,
  including analgesics
• Difficult to travel to seek medical help
• Distressed patient
• Distressed family

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TREATMENT PLAN

• Aim to get the pain under control
• Started Epilim Chrono (sodium valproate) 500mg ON
  for brachial plexopathy use a slow release
  version to reduce tablet burden
• Persuaded patient to persist with regular MST
• She declined referral to Hospice home care
  service
• Planned to review patient when she came for
  radiotherapy (RT)

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PROGRESS

• Initially appeared to respond to RT with decrease
  in pain and swelling, but then got worse again.
• Wasnt taking her analgesics consistently, always
  very irritable
• As a result of not changing position, developed
  pressure sores over the sacrum and left scapula
• Family (Mum and husband) stressed, at a loss
  but unable to do much. Patient still refusing
  hospice home care

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CRISIS

• Two weeks later
• Admitted in a highly agitated state. Crying,
  asking for lethal injection
• Had tried to cut herself with a knife at home
• Distressed with pain from malignant wound and
  large pressure sores
• Said she had nothing left to live for
• Why couldnt the doctors do a simple thing and
  help her die angry and upset

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THIS WOMAN IS SUFFERING

• HOW CAN WE HELP HER?

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THE CONCEPT OF SUFFERING
SOCIAL
PHYSICAL
TOTAL PAIN
SPIRITUAL
PSYCHOLOGICAL
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• Urgent referral to MSW
• Told patient we were not going to help her die
• Negotiated time out i.e. deliberate sedation
  for a few hours (using sc midazolam)
• Meanwhile, analgesia retitrated
• Intensive wound care
• Emotional support for patient and family
• Discussed future care family wanted to continue
  to look after her at home

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• Patient settled down emotionally, no longer
  agitated but instead more withdrawn
• Asked repeatedly to go home
• The next day she suddenly deteriorated
• Was very ill, hypotensive, breathless
• Lower limbs flaccid, had ankle clonus, was in
  urinary retention clinically had developed a
  spinal cord compression and likely pneumonia

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• After discussion with family, decided to manage
  her conservatively
• No further investigations were done
• Started on subcutaneous infusion of morphine
• Her husband stated his preference for her to
  remain in hospital in Singapore for her remaining
  days
• Her family including first husband and son
  came to see her
• Remained drowsy and died 3 days later

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WHAT IS SUFFERING?
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SUFFERING ACCORDING TO DIFFERENT RELIGIONS

• Buddhism dukkha
• Hinduism - karma
• Christianity Book of Job

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SUFFERING

• Suffering is experienced by persons, not merely
  by bodies, and has its source in challenges that
  threaten the intactness of the person as a
  complex social and psychological entity.
• The nature of suffering and the goals of
  medicine. EJ Cassell NEJM March 1982

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SUFFERING

• Viktor Frankl (1905-1997), psychiatrist and
  concentration camp survivor
• Without suffering and death human life cannot be
  complete. Mans Search for Meaning.
• "When we are no longer able to change a
  situation  just think of an incurable disease
  such as inoperable cancer  we are challenged to
  change ourselves."

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WHAT DO YOU UNDERSTAND BY SUFFERING?
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SUFFERING

• Is part of being human
• Can be painful to witness
• Can be frustrating to healthcare workers
• Can we relieve all suffering? Maybe not but
• We must not avoid our patients just because we
  cannot solve all their problems

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SUCCESSFUL MANAGEMENT OF DIFFICULT PAIN

• Needs a multi-disciplinary approach
• Takes into account patients other problems
  physical, psychosocial, spiritual
• Respects the patients own priorities
• Treatment has to work across settings i.e.
  continuity of care is essential
• Distinguishes between what could be done, what
  should be done, and what is good enough