The care of the dying: pain management

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The care of the dyingpain management

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• A Good Death is the culmination of A Good Life

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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

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• Pain and other symptoms management

a common goal of palliative care
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Palliative care
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The PEACE Tool

• assessment
• pain and other symptoms
• emotive burden
• shared, informed decision making
• care planning and communication
• domestic and economic needs of patients and
  care-givers
• spirituality

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Assessment

• Physical symptoms
• Emotive (and cognitive) symptoms
• Autonomy related issues
• Communication, and Completion of life affairs
  related issues
• Economic burden and other practical issues
• Transcendent and spiritual issues

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Physical symptoms

• PAIN RULES
• Pain
• Anorexia and other appetite or oral intake
  related issues
• Incontinence and other genitourinary symptoms
• Nausea and other gastrointestinal symptoms
  (constipation, vomiting, diarrhea)

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

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Diagnosing dying

• Signs
• The patient becomes bed-bound
• The patient is semi-comatosed
• The patient is only able to take sips of fluid
• The patient is no longer able to take oral drugs
• Multi-professional team agree

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Symptoms at the end of life

• Breathlessness
• Cough/noisy respirations
• Terminal restlessness
• Myoclonic jerking

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Goals of care for patients in the dying phase

• Comfort measures
• Current medication assessed and non-essentials
  discontinued
• As 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)

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• Psychological/insight
• Ability to communicate
• Insight into condition assessed
• Religious/spiritual support
• Religious/spiritual needs assessed with
  patient/family

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• Communication with family/other
• Identify how family/other are to be informed of
  patient s impending death
• Family/other given relevant hospital information
• Communication with primary healthcare team
• General practitioner is aware of patient s
  condition

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• Summary
• Plan of care explained and discussed with
  patient/family
• Family/other express understanding of plan care

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• 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

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Most common symptoms

• Pain
• Nausea and vomiting
• Agitation
• Respiratory tract secretions

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Drugs administration

• Analgesic morphine, oxycodone, hydromorphone
• Antiemetic metoclopramide, dimenhydrinate,
  haloperidol
• Sedative midazolam, haloperidol
• Antimuscarinic glycopyrronium

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

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PREVALENCE OF PAIN

• at least one-fifth of the million patients who
  die in hospitals each year experienced pain
• 50 percent had daily pain
• 85 percent had moderate or worse pain

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Pain

• common feature at the end of life
• 93 percent of patients dying from HIV/AIDS
• had pain at the end of life
• 75 percent of patients with heart failure had
  pain during the last six months of life
• 70 percent of patients with advanced cancer had
  moderate to severe chronic pain
• 40 percent of cancer pain had undertreatment

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

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Total Pain

• Suffering pain of clear physical origin
• More severe pain or exacerbation of pain that
  relate to
• Psychological pain
• Social pain
• Spiritual pain
• Pain all over and unable to localize

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Incident Pain

• Subtype of episodic pain
• Transient
• Typical occur on movement
• Rapid onset
• Severe intensity
• Administration of a rescue dose (fast action
  and short duration)

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Neuropathic Pain

• Adjuvant analgesia (malignancy association)
• Anticonvulsants
• Tricyclic antidepressants
• Benzodiazepine
• NMDA antagonists
• steroid
• Opioid (partially effective)

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Bone Pain

• Opioids
• NSAIDs (rectal, parenteral)
• Dexamethasone

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Other symptoms management

• Breathlessness
• Opioids diamorphone, morphine
• Benzodiazepines lorazepam, midazolam
• Oxygen therapy
• Cough/noisy respirations
• Appropriate position
• Anticholinergics hyoscine hydrobromide,
  glycopyrronium

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• Terminal restlessness
• Exclude urinary retention, discontinue steroid
• Benzodiazepines midazolam, haloperidol
• Myoclonus jerking
• Due to rapid escalation of opioid dose
• Benzodiazepine midazolam

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Summary

• Pain and symptom control together with the wider
  consideration of the patient and family
• 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