Transcript Pain control in the care of the dying

The care of the dying:
pain management
นายแพทย์ รัฐพล แสงรุ้ ง
คลินิกระงับปวด ภาควิชาวิสัญญีวิทยา
คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร
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
Physical
Spiritual
Psychological
Social
The PEACE Tool
O assessment
1) pain and other symptoms
2) emotive burden
3) shared, informed decision making
4) care planning and communication
5) domestic and economic needs of patients
and care-givers
6) spirituality
Assessment
1. Physical symptoms
2. Emotive (and cognitive) symptoms
3. Autonomy related issues
4. Communication, and Completion of life
affairs related issues
5. Economic burden and other practical
issues
6. Transcendent and spiritual issues
Physical symptoms
PAIN RULES
O Pain
O Anorexia and other appetite or oral intake
related issues
O Incontinence and other genitourinary
symptoms
O Nausea and other gastrointestinal
symptoms (constipation, vomiting, diarrhea)
O Respiratory symptoms (dyspnea, cough)
O Ulcerations and other skin complaints
O Level of functioning
O Energy and other related issues such as
fatigue or asthenia
O Sedation, sleep and other side effects of
treatment (including opioids and
chemotherapy)
Diagnosing dying
O Signs
1.
The patient becomes bed-bound
2.
The patient is semi-comatosed
3.
The patient is only able to take sips of fluid
4.
The patient is no longer able to take oral drugs
“ Multi-professional team agree ”
Symptoms at the end of life
O Breathlessness
O Cough/noisy respirations
O Terminal restlessness
O Myoclonic jerking
Goals of care for patients in
the dying phase
O Comfort measures
Current medication assessed and nonessentials discontinued
2. As required subcutaneous medication written
up as per protocol (pain, agitation, respiratory
tract secretions, nausea and vomiting)
3. Discontinue inappropriate interventions
(blood test, antibiotics, intravenous
fluid/medications)
1.
O Psychological/insight
4. Ability to communicate
5. Insight into condition assessed
O Religious/spiritual support
6. Religious/spiritual needs assessed with
patient/family
O Communication with family/other
7. Identify how family/other are to be
informed of patient’ s impending death
8. Family/other given relevant hospital
information
O Communication with primary healthcare
team
9. General practitioner is aware of patient’ s
condition
O Summary
10. Plan of care explained and discussed with
patient/family
11. Family/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 symptoms
O Pain
O Nausea and vomiting
O Agitation
O Respiratory tract secretions
Drugs administration
O Analgesic: morphine, oxycodone,
hydromorphone
O Antiemetic: metoclopramide,
dimenhydrinate, haloperidol
O Sedative: midazolam, haloperidol
O Antimuscarinic: glycopyrronium
O Many patients and families suffer from
untreated pain at the end of life
O Failure to treat pain effectively can result from
1.
a lack of clinician training in palliative care
2.
the fear of violating ethical, moral, and legal
tenets in the administration of pain medication
to the dying patient
PREVALENCE OF PAIN
O at least one-fifth of the million patients who
die in hospitals each year experienced pain
O 50 percent had daily pain
O 85 percent had moderate or worse pain
Pain
O common feature at the end of life
O 93 percent of patients dying from HIV/AIDS
had pain at the end of life
O 75 percent of patients with heart failure had pain
during the last six months of life
O 70 percent of patients with advanced cancer had
moderate to severe chronic pain
O 40 percent of cancer pain had undertreatment
the escalation of pain that is
uncontrolled at the end of life as a
"medical emergency"
Total Pain
O Suffering pain of clear physical origin
O More severe pain or exacerbation of pain
that relate to
 Psychological pain
 Social pain
 Spiritual pain
O Pain “ all over ” and “ unable to localize ”
Incident Pain
O Subtype of episodic pain
O Transient
O Typical occur on movement
O Rapid onset
O Severe intensity
O Administration of a “ rescue dose ” (fast action
and short duration)
Neuropathic Pain
O Adjuvant analgesia (malignancy association)
 Anticonvulsants
 Tricyclic antidepressants
 Benzodiazepine
 NMDA antagonists
 steroid
O Opioid (partially effective)
Bone Pain
O Opioids
O NSAIDs (rectal, parenteral)
O Dexamethasone
Other symptoms management
O Breathlessness
1. Opioids: diamorphone, morphine
2. Benzodiazepines: lorazepam, midazolam
3. Oxygen therapy
O Cough/noisy respirations
1. Appropriate position
2. Anticholinergics: hyoscine hydrobromide,
glycopyrronium
O Terminal restlessness
1. Exclude: urinary retention, discontinue
steroid
2. Benzodiazepines: midazolam, haloperidol
O Myoclonus jerking
1. Due to rapid escalation of opioid dose
2. Benzodiazepine: midazolam
Summary
O Pain and symptom control together with the
wider consideration of the patient and family
O 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