Transcript pain management in the terminally ill

The Consortium for Advancements in Health & Human Services, Inc.
Educational Program Development Team: BC Farnham, MSW, MBA;
Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS;
Jenny Gilley Carpenter, LPN.; Karina Lemos, RN.; Elizabeth R. Pugh,
LBSW.
This program is made possible through a collaborative community-education partnership between The Consortium for
Advancements in Health & Human Services, Inc. and the presenting agency. The primary goal of this effort is to increase
public awareness and access to hospice care, through the provision of community-based education. Contact Hours are
awarded to professionals who complete this program by The Consortium for Advancements in Health & Human Services,
Inc.
© 2011 The Consortium for Advancements in Health & Human Services, Inc.
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This education program for healthcare professionals was developed by The Consortium for Advancements in
Health and Human Services, Inc. (CAHHS) and is facilitated by the presenting agency via a community education
partnership agreement. CAHHS is a private corporation and is solely responsible for the development,
implementation and evaluation of its educational programs. There is no fee associated with receiving contact
hours for participating in this program titled, Improving Quality of Life Through Effective Pain and Symptom
Management. However, participants wishing to receive contact hours must offer a signature on the sign-in
sheet, attend the entire program and complete a program evaluation form.
The Consortium for Advancements in Health and Human Services, Inc. is an approved provider of continuing
nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses
Credentialing Center's Commission on Accreditation.
The Consortium for Advancements in Health & Human Services, Inc., is approved as a provider of continuing
education in Social Work by the Alabama Board of Social Work Examiners, #0356, Expiration Date: 10/31/2014.
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In most states, boards providing oversight for nursing and social work recognize contact hours awarded by
organizations who are approved by another state's board as a provider of continuing education. If you have
questions about acceptance of contact hours awarded by our organization, please contact your specific state
board to determine its requirements. Provider status will be listed on your certificate.
CAHHS does not offer free replacement certificates to participants. In the event that CAHHS elects to provide a
replacement certificate, there will be a $20.00 administrative fee charged to the individual who requests it.
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The attendee will be able to:
◦ Assess patient pain and differentiate between types
of pain.
◦ Identify appropriate medications for treatment of
pain.
◦ Utilize equianalgesic table for titration of opioids.
“Pain is a more terrible lord of mankind than
even death itself.”
- Albert Schweitzer
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Pain is “whatever the experiencing
person says it is, existing whenever
s/he says it does”.
(McCaffery, 1968)
PAIN DEFINED
Unpleasant Somato-Psychic Experience
No Fun
It originates in
the body
(most of the
time)
It affects the mind
It is what the patient says
it is
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Problems related to
◦ Healthcare professionals
◦ Patients
◦ The health care system
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Behavioral signs of pain is more reliable
than self-report.
Pain teaches a person to be more tolerant
of pain.
Non-cancer pain is not as severe as cancer
pain.
Use of opioids for pain causes addiction.
Infants have decreased pain sensation.
Tolerance
 Physical Dependence
 Addiction
 Pseudo-addiction
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 Patients
in pain do not get
addicted
 May
develop tolerance
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Professional, Patient and Family Team
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Assess pain and associated symptoms
regularly and systematically.
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Asking patient to identify most troublesome
symptom.
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Believe patient and family reports of pain and
what relieves the pain.
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Choose pain-control appropriate for the
patient, family and setting.
Deliver interventions in a timely, logical,
coordinated fashion.
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Empower patients and families.
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Develop effective plan of care
PAIN CYCLE
Pain
Decreased Tolerance
of Pain
Anxiety
Sleeplessness
Increased Anxiety
Feelings of
Hopelessness
Decreased Appetite
Decreased Mobility
Hopelessness
Decreased Psychological
Functioning
Despair
Loneliness
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JCAHO: Right to appropriate assessment and
management of pain.
Self-report of pain is the single most reliable
indicator of pain.
Use pain scales appropriate to patient
population.
Chronic pain patient maybe more sensitive to
pain
Unrelieved pain has adverse physical and
psychological consequences
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ACUTE PAIN – “complex, unpleasant
experience with emotional and cognitive,
as well as sensory, features that occur in
response to tissue trauma.”
Elevated pulse, blood pressure and
respirations, diaphoresis, dilated pupils,
moaning, crying, rubbing
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CHRONIC PAIN –a persistent pain that
“disrupts sleep and normal living, ceases to
serve a protective function, and instead
degrades health and functional capability.”
After more than 4 months, adaptive
mechanisms, no measurable indications of
pain
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Somatic –
◦ Pain in the muscles, bones, ligaments or joints
◦ Described as aching, gnawing, constant and
localized
◦ Examples: Bone metastasis, surgical pain
◦ Responds to opioids, but may require adjuvant
medications such as anti-inflammatories or
muscle relaxers
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Visceral –
◦ Pain in smooth muscles and organs
◦ Caused by infiltration, compression,
distention, or the stretching of tissue
◦ Described as aching, constant, not localized,
may radiate to other areas
◦ Examples: Pancreatic cancer, liver metastasis
◦ Responds to opioids, but may require
corticosteroid or anti-spasmodic adjuvant
therapy.
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Neuropathic –
◦ Painful nervous system discharges
◦ Caused by inflammation, damage or pressure
around a nerve
◦ Described as burning, aching, shooting, shocklike
◦ Examples: Peripheral neuropathy, spinal cord
compression
◦ Responds poorly to opioids alone, but opioids
may be used with an anti-depressant, anticonvulsant, anti-arrhythmic or other adjuvant
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Site – Where is your pain?
Character – What does it feel like?
Onset – When did it start?
Duration – How long does it last?
Frequency – How often does it occur
Intensity –
◦ What is the worst your pain gets?
◦ What is the rate of your pain one hour after
taking your pain medication?
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Exacerbation – What makes the pain
worse?
Associated symptoms – Does your pain
cause you to have nausea, fatigue,
dyspnea or weakness?
Alleviation – What helps relieve your pain?
Effect on quality of life – Does your pain
cause you to have anxiety, fear,
depression or spiritual stress?
What does the pain keep you from doing?
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Non verbal cues
Examine sites of pain
Palpation
Auscultation, percussion
Neuro exam
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Changes in pain
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Assess pain relief
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Make pain visible
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Children and elderly
Cognitively impaired
Patients who deny pain
Non English speaking
Different cultures
History of substance abuse
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Communication improves pain
management
Describe intensity, limitations, and
response to treatments
STEP 3, severe pain
STEP 2, moderate pain
STEP 1, mild pain
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
+ Nonopioid analgesics
Acet or ASA +
Codeine
Hydrocodone
Oxycodone
Dihydracodeine
Tramadol (not available with ASA or Acet)
+ Adjuvants
Aspirin (ASA)
Acetaminophen (Acet)
Nonsteroidal anti-inflammatory drugs (NSAIDS)
+ Adjuvants
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Acetaminophen (Tylenol)
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Toxicity
Maximum 4,000mg qd short term
Maximum 3,200mg qd long term
Maximum 2,400mg qd in elderly or debilitated
Mild pain, poor anti-inflammatory capacity
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Extra Strength Tylenol
Darvocet N 100
Vicodin ES
Lortab 2.5, 5, 7.5
Lorcet Plus 7.5
Percocet 5
500mg
650mg
750mg
500mg
650 mg
325mg
8
6
5
8
6
12
Risk of GI Ulcer decreases 15% after 3
months continuous care
 For long term use, protect with
misosprostol (Cytotec), omeprazole
(Prilosec), lansoprosole (Prevacid) or
pantoprazole (Protonix)
OR
 Use Cox-2 inhibitor
celecoxib (Celebrex) or rofecoxib (Vioxx)
meloxicam (Mobic)
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Hydrocodone and Oxycodone
combination products
(Lortab, Tylox, Percocet, Vicoprofen,
Percodan)
All have ceilings due to acetaminophen,
aspirin or ibuprofen content
Considerations: skip this step and add
acetaminophen, aspirin or ibuprofen
separately
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BEST CHOICE◦ Morphine, oxycodone, hydromorphone (Dilaudid)
◦ No ceiling
◦ Morphine and oxycodone come in tablet, liquid,
concentrate and suppository form
Morphine Formulation
Half-life (t ½ )
Typical Dosing
Analgesia
Immediate release (IR)
2-3.5, q4h
Onset: 0.5-1h
Peak: 1.5-2h
Duration: 3-5h
Sustained-release (SR) 2-4* q12h
*Terminal elimination half-life for morphine SR
Onset: 1.5h
Peak: ~ 4h
Duration: 8-12h
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Used for occasional moderate to severe
pain
Used PRN to determine long acting dose
(add amount needed in 24hrs, divide by
2, give q 12)
Initially uses 80mg Oxylr in 24hrs, Oxtcontin 40mg q
12hrs with 10mg Oxylr q 4 hrs for breakthrough pain
Current Oxycontin dose 40mg q 12hrs, Used 40mg
Oxylr in last 24hrs. New Dose- Oxycontin 60mg q 12
hrs. New breakthrough dose- Oxylr 15-20mg q 4hrs.
Used to control pain that breaks through longacting dose (dose should be 1/3 -1/4 12 hr
dose)
SEDATION
ANALGESIA
PAIN
1
2
3
4
5
6 7 8
9
10
11
12
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ONLY TO BE USED FOR CONTINUOUS PAIN,
NEVER GIVEN PRN
◦ M.S. Contin, OxyContin, Oramorph SR
 12 hour relief
 Cannot be crushed or cut
◦ Kadian
 24 hour relief
 Time-released sprinkles
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Duragesic (fentanyl patch)
Lasts 72 hours
Takes up to 24 hours to peak
Must have subcutaneous tissue to
absorb
Fevers cause rapid absorption
Cost prohibitive
Slow and careful titration necessary
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By percentage
After peak effect
Morphine resistant pain versus psychological
component
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Oral
Mucosal
Rectal
Transdermal
Topical
Parenteral
◦ Intravenous
◦ Subcutaneous
◦ Intramuscular
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Determining equal doses when changing
drugs or routes of administration
Use of morphine equivalents
DRUG
Morphine
Codeine
recommended)
Fentanyl
Hydrocodone
Hydromorphone
Levorphanol
Methadone
Oxycodone
PARENTERAL ROUTE
10mg
130mg
*see below
not available
1.5mg
2mg acute
1mg chronic
10mg acute
2-4 mg chronic
not available
ENTERAL ROUTE
30mg
200mg (not
OTFC available
30mg
7.5mg
4mg acute
1mg chronic
20mg acute
2-4 mg chronic
20-30 mg
Fentanyl 100 mcg patch = 200mg oral morphine/24hrs = 4mg IV morphine/hour. To convert
from Fentanyl 100mcg/hour patch to IV Fentanyl, begin at 100mcg/hour IV and titrate as
needed
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Sedation, light-headaches, nausea,
vomiting, itching, dry mouth, urinary
retention, constipation and respiratory
depression
Most side effects diminish 3 days after
opioid started or increased
Minimal side effects noted if dose is
correct
Bowel protocol should be initiated at
the beginning of opioid therapy
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Mild vegetable laxative and softener
routinely (Senekot S)
Stronger laxative if no BM by the end of
the 2nd day (Senekot Xtra)
Increase as needed to achieve soft, form
BM q 2-3 days
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Nausea and Vomiting
◦ Use an anti-emetic prophylactically in patient
who:
 Currently has nausea and vomiting
 Has nausea and vomiting from a weak opioid
 Experienced nausea and vomiting in past with
strong opioid
◦ Always rule out obstruction
◦ Haldol, Reglan, vestibular
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Catch up on sleep
Other medications
Other medical problems
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If opioid is at steady state, then think of other
causes:
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Dehydration
Infections
CNS event
Other medications
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A change in rate or depth
Sedation precedes respiratory depression
Level 3 – drifts off to sleep during
conversation
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Immediate hypersensitivity
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In general, all strong opioids have similar side
effects
◦ Strategies:
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Different route
Different opioid
Decrease dose, increase frequency
Add a second drug
Adjuvant medication are not analgesics,
but have properties that either assist
in blocking pain impulses or
potentiates the effects of analgesics.
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Prevent re-uptake of serontonin and
norepinephrine – block neuropathic pain
Amitryptyline (Elavil)S, doxepin
(Sinequan)S, desipramine (Norpramin)
Start with small dose, titrate to ½
therapeutic dose for depression
SSRI’s have less effect on neuropathic
pain but may be somewhat effective.
(Effexor)
Block nerve impulses by limiting sodium ions
 Carbamapezine (Tegretol) 200-1600 mg
qd
 Phenytoin (Dilantin) 300-600 mg qd
 Gabapentin (Neurontin) up to 3200 mg qd
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Clonidine (Catapres) 0.1 mg qd-tid
Decadron 4mg qd-tid or 100mg IM x 1
Donnatal 1-2 tabs bid-tid (GI spasms)
Baclofen (Lioresal) up to 80mg qd
Lorazepam (Ativan) 4-6mg qd
Hydroxyzine (Vistaril) 25-50 mg tid
Promethazine (Phenergan) 25-50mg q4 prn
Dextromethorphan up to 1000 mg qd
Ketamine 2% ointment tid
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Choose the adjuvant that will benefit the
patient’s other symptoms as well as the pain
For severe pain use, use an adjuvant out of
several different categories
Remember that often using adjuvant therapy
provides improved pain relief with smaller
doses of opioids and fewer side effects
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Addiction – Psychological craving for the
drug’s psychic effect
Dependence – Natural physical response
to continue use of an opioid
Tolerance – The body’s legitimate need
for larger doses of an opioid to produce
the same effect during an extended
period of use
Pseudo-addiction – drug seeking behavior
caused by poor pain management
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Pain relief is contingent on adequate
assessment and use of both drug and nondrug therapies
Pain extends beyond physical causes to either
causes of suffering and existential distress
Interdisciplinary care
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Physical –
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Decreased functional capability
Diminished endurance and strength
Nausea, poor appetite
Poor or interrupted sleep
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Psychological –
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Diminished leisure, enjoyment
Increased anxiety, fear
Depression, personal distress
Difficulty concentrating
Somatic preoccupation
Loss of control
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Social –
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Diminished leisure, enjoyment
Decreased sexual function and intimacy
Altered appearance
Increased caregiver burden
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Spiritual –
◦ Increase suffering
◦ Altered meaning
◦ Re-evaluation of religious
beliefs
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Physical – Movement, Thermal, Touch,
Relaxation, Environment, Aromatherapy,
Acupuncture
Psychological – Distraction, Meditation,
Visualization, Staying Attitude, Hope,
Spiritual Support
Palliative Treatments – Radiation Therapy,
Chemotherapy, Nerve Blocks, Surgery
Pharmacological – Analgesic and Adjuvant
Medications
All patients admitted to hospice will
receive the best level of pain control that
can be safely provided.
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Assessment –
◦ At time of admission, a comprehensive pain
assessment will be conducted, including use
of numeric pain rating scale
◦ When pain is identified as a problem,
individualized pain management goals will be
established (some patients find a level of 4
acceptable in order to remain awake and alert
while others wish to be pain free is possible).
◦ Pain assessments will be conducted on each
nursing visit with reassessments occurring
until pain goal is achieved.
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Interventions –
◦ If pain is scored at greater than 3 or if pain
level is unacceptable to patient, there will be
an intervention to reduce the pain.
◦ Follow up to determine the success of the
intervention MUST be done within 24 hrs of
the intervention. In many cases, follow up will
be necessary in a much shorter time frame
depending on the severity of the pain and the
interventions required. Nursing judgment is
crucial in determining the time frame. Follow
up may be done via telephone call or by visit
at the discretion of the nurse. Documentation
must be evident on the medical record.
Follow up via telephone should generate a
progress note, while a visit should generate a
nursing note.
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Interventions cont’d –
◦ If pain is not improved, additional
interventions should be taken and
documented.
◦ Follow up within the determined time frame
will be conducted until pain goal is
achieved. NOTE: Follow up MUST be done
within 24hrs. Documentation of this must
be evident in the medical record.
◦ Alternative pain relief measures may be
implemented as well as pharmacological
interventions. (Massage, relaxation
techniques, guided imagery, etc.)
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Interventions cont’d –
◦ Unless pain is occurring occasionally, scheduled
analgesics are indicated with additional
medication available on demand for
breakthrough pain.
◦ Oral meds are the preferred routes
◦ Opioids are considered the analgesic of choice
for moderate to sever pain.
◦ Adjuvant therapies must be considered.
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Documentation –
◦ The initial pain assessment must be
completed at time of admission. Pain sites
are to be numbered with a designation of
the probable cause of the pain at each site.
◦ Subsequent assessments/reassessments
must be clearly documented
◦ Progress notes should clearly delineate the
plan and the rationale for treatment
All patients and their families admitted to
Hospice will receive the best level of
individualized care and personalized
service that may be safely provided,
regardless of the time of day. Hospice staff
is available 24 hours a day, 7 days a week,
365 days per year.
All calls made to Hospice will be promptly
answered. Those received after hours or
on-call, will be responded to within thirty
(30) minutes.
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Assessment –
◦ Once staff is notified by the service that a call
has been made, a response to the call MUST be
initiated within 30 minutes.
◦ If the call is of routine nature and at the staff’s
discretion can be handled safely and effectively
over the phone, it may be appropriate to do so.
◦ If a second call comes in regarding the same
patient or family, even if the subject of the call is
different, a visit must be made.
◦ If the on-call staff receive notification that the
patient is going to or is in the emergency room,
the staff member MUST either accompany the
patient to or meet them at the emergency room.
There should be no exceptions to this.
◦ All deaths will be attended without regard to
location.
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Interventions –
◦ All calls will be documented on the on-call
log and it should be notated if a visit was
made or of the situation was resolved via
telephone consultation
◦ If it was determined that the situation could
appropriately be handled via telephone call,
a Progress Note (if a non-clinical problem)
or an On Call Note should thoroughly
explain the reason for the call, the action
or intervention taken in response to the call
(keep a supply of Progress Notes and On
Call Notes with you).
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Interventions cont’d –
◦ Follow up to determine the outcome of the
intervention MUST be done within 24 hrs of the
intervention (requires passing off to next on-call
nurse). Follow up may be done via telephone call
or by visit at the discretion of the nurse.
Documentation must be evident on the medical
record.
◦ If it was determined that a visit be made, an On
Call Note should thoroughly explain the nature
of the call and all pertinent information
regarding the call should be documented. All
interventions should be documented, the
rationale for such interventions and a report of
the nursing assessment/observations that
prompted the intervention.
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Documentation –
◦ Follow up to ALL calls for a clinical nature
received during the on-call hours require
follow up within 24 hrs.
◦ Documentation of this must be evident in
the medical record.
“If we know that pain and suffering can be
alleviated, and we do nothing about it, then
we ourselves become the tormentors”
– Primo Levi
Meuser T, Pietruck C, Radbruch L, et al.: Symptoms
during cancer pain treatment following WHOguidelines: a longitudinal follow-up study of symptom
prevalence, severity and etiology. Pain 93 (3): 247-57,
2001.
Patrick DL, Ferketich SL, Frame PS, et al.: National
Institutes of Health State-of-the-Science Conference
Statement: Symptom Management in Cancer: Pain,
Depression, and Fatigue, July 15-17, 2002. J Natl
Cancer Inst 95 (15): 1110-7, 2003.
Bruera E, Willey JS, Ewert-Flannagan PA, et al.: Pain
intensity assessment by bedside nurses and palliative
care consultants: a retrospective study. Support Care
Cancer 13 (4): 228-31, 2005.
Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with
the analgesic regimen: a significant barrier to effective
cancer pain management. J Clin Oncol 19 (23): 4275-9,
2001.