What Is End Of Life Pain Management?
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Given that patients who are at the end of life frequently present with complex problems in addition to their symptoms of pain, it is likely that end of life pain is best managed within the context of a comprehensive palliative care approach. Indeed, a large portion of individuals report that they would prefer to die at home; however, a very small portion (i.e., around about 25%) actually end up doing so. Previous studies have estimated that about half of all individuals are expected to die in a hospital setting, while 25% will see the end of their life in a nursing home or other facility providing long-term care.
Perhaps the most critical aspect of end of life pain management is assessment and ongoing monitoring of symptoms. In most cases, specially trained physicians and nurses conduct the initial assessment, as well as regularly monitor the patient’s symptoms throughout. Other health care professionals who are typically available on a comprehensive palliative care team include clinical pharmacists, rehabilitation specialists, social workers, psychologists, and even spiritual counselors. These individuals provide key assistance in optimizing the patient’s quality of life, repairing strained relationships, finalizing unfinished business, helping the patient remain comfortable, and reaching a place of acceptance and peace as the patient approaches death.
Types Of End Of Life Pain ManagementThorough assessment of the patient’s symptoms of pain and discomfort is essential to providing effective and comprehensive treatment. The examining physician or nurse practitioner will want to know the location, duration, severity, and onset of symptoms. Further, they will gather information regarding characteristics of the pain, what factors make the pain better (i.e., alleviate), what factors make the pain worse, and any additional associated symptoms.
One challenge to providing effective pain management at the end of life is the factor of cognitive decline. In an effort to buffer the negative impact that cognitive decline has on the individual’s ability to provide a reliable self-report of their symptoms of pain, three behavioral pain tools were developed, including:
- Critical Care Pain Observation Tool (CPOT)
- Pain Assessment in Advanced Dementia (PAINAID)
- Behavioral Pain Scale (BPS)
The most commonly used treatment for managing end of life pain is pharmacotherapy. According to guidelines established by the World Health Organization, the first line treatment in managing the pain associated with cancer is non-steroidal anti-inflammatory drugs (NSAIDs). This type of intervention can be particularly challenging given that end of life patients have several unique challenges, including difficulty taking oral medication and sensitivity to side effects.
Several adjuvant analgesics are available and indicated for a number of pain conditions. In advanced diseases in particular, adjuvant analgesics may provide relief for neuropathic pain, pain associated with a bowel obstruction, and pain associated with a bony metastases. However, similar to NSAIDs, many of the most commonly used adjuvant medications (e.g., anticonvulsants or antidepressants) are unavailable as an intravenous preparation, therefore are not commonly utilized to manage end of life pain.
The principal class of analgesics used to manage pain at the end of life are opioids. These medications are preferred for use at the end of life due to their potency and the availability of multiple delivery routes. Moreover, these medications have both mild sedative and anxiolytic properties, which can help patients feel more comfortable.
The most commonly used opioids for end of life pain include:
In some instances of refractory pain at the end of life, a more interventional approach may be warranted. Neural blocks, using either phenol, glycerol, or alcohol, can be employed to effectively impede the function of the neural tissue within a particular area. Finally, a very small portion of patients suffering from advanced disease with more than just physical pain may require palliative sedation. This includes those patients whose pain was unable to be controlled by any means previously attempted. Given the significant degree of controversy over palliative sedation, not every institution offers this form of end of life intervention.
Conditions Related To End Of Life Pain ManagementIn most cases of end of life pain, the patient’s symptoms arise as the result of an underlying pathology. The most commonly reported medical conditions associated with significant pain at the end of life include:
- Cancer: Pain associated with cancer is believed to be the most common cause of end of life pain among adults. Surveys have indicated that between 50% and 90% of patients who are in the advanced stages of cancer report significant degrees of pain.
- Degenerative diseases: Tissue damage in most instances of degenerative diseases leads to pain that likely worsens over time.
- Late HIV disease: The condition of AIDS itself, as well as its treatment, is associated with significant symptoms of pain. In fact, nearly half of all patients receiving treatment for AIDS report significant degrees of pain.
- Neurological diseases: Many neurological diseases, including Parkinson’s disease, multiple sclerosis, cerebral vascular disease, or spinal cord injury can be associated with high degrees of pain at the end of life.
- Other processes that occur at the end of life are also known to contribute to the patient’s experience of pain. These factors include the breakdown of skin tissue, functional decline, weight loss, and contractures.
ConclusionSignificant pain at the end of life is quite common and treating these symptoms of pain and discomfort is the priority of both the patient and their family. End of life pain is most effectively managed within a comprehensive palliative care team. This is due to the fact that patients at the end of their life often present with a number of complex problems. Comprehensive palliative care teams are staffed with a variety of specialists who are available to provide the patient with the most comprehensive care possible. Opioid medications are among the most commonly used treatment for managing pain at the end of life. Palliative sedation is reserved only as a last case scenario.
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