The care of the dying: pain management

1. The care of the dying:pain management นายแพทย์รัฐพล แสงรุ้ง คลินิกระงับปวด ภาควิชาวิสัญญีวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร

2. A Good Death is the culmination of A Good Life

3. 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”

4. Pain and other symptoms management a common goal of palliative care

5. Palliative care

6. 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

7. 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

8. 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)

9. 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)

10. 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 ”

11. Symptoms at the end of life • Breathlessness • Cough/noisy respirations • Terminal restlessness • Myoclonic jerking

12. 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)

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

14. 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

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

16. 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

17. Most common symptoms • Pain • Nausea and vomiting • Agitation • Respiratory tract secretions

18. Drugs administration • Analgesic: morphine, oxycodone, hydromorphone • Antiemetic: metoclopramide, dimenhydrinate, haloperidol • Sedative: midazolam, haloperidol • Antimuscarinic: glycopyrronium

19. 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

20. 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

21. 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

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

23. 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 ”

24. 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)

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

26. Bone Pain • Opioids • NSAIDs (rectal, parenteral) • Dexamethasone

27. Other symptoms management • Breathlessness • Opioids: diamorphone, morphine • Benzodiazepines: lorazepam, midazolam • Oxygen therapy • Cough/noisy respirations • Appropriate position • Anticholinergics: hyoscinehydrobromide, glycopyrronium

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

29. 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