Palliative Care, End-of-Life Decision Making, and Pain Management
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[edit] Palliative Care, End-of-Life Decision Making, and Pain Management
Timothy E. Quill
Robert V. Brody
Excellent patient care requires that physicians recognize and respond appropriately to the inevitability of death. Medical training concentrates on the pathophysiologic manifestations of disease; physicians are much less prepared for the psychologic, social, spiritual, and symptomatic aspects of incurable illness.
The goal of both palliative medicine and hospice is to achieve the best possible quality of life for patients and their families.[1][2] Excellent management of pain and other discomforting physical symptoms is followed by addressing the psychologic, social, spiritual, and existential dimensions of the patient's and family's suffering. In the United States, hospice is further defined by legislation as an organizational arrangement devoted to caring for terminally ill patients who (1) accept that they are dying, (2) are expected to live 6 months or less, and (3) are willing to forego invasive, disease-driven therapy. Hospice also emphasizes multidisciplinary, coordinated care to support the patient and family at home if possible, giving them the opportunity to find peace and acceptance before death.[3][4]
Hospice also implies a capitated Medicare benefit that reinforces supportive care at the end of life but militates against expensive, intrusive, complicated interventions, including hospitalization. In contrast, palliative medicine has no particular organizational arrangement or reimbursement scheme. It incorporates highly technical and invasive approaches when appropriate and does not require that patients forego aggressive, disease-driven therapy. Palliative medicine is recognized as a subspecialty in the United Kingdom and Canada but not in the United States. The goals and values of palliative medicine and hospice are relevant to the treatment of all severely ill patients, including those who want to continue complex treatment.[5] Expert pain and symptom management and exploration of other dimensions of suffering are essential medical skills for all physicians who care for severely ill patients.
[edit] EPIDEMIOLOGY OF DYING
People in Western populations are living longer but are also experiencing increasing disability and dependence before death, including loss of decision-making capacity. The probability of facing ethically complex end-of-life decisions is therefore increasing, including whether to use highly technical, invasive treatments (e.g., cardiopulmonary resuscitation, dialysis) or even relatively noninvasive treatments (e.g., antibiotics, artificial feeding) with profound potential effects.
The hospice Medicare benefit is based on a prognostic model that requires death to be predicted with relative certainty within 6 months. This prognostic requirement may apply to some cancers (e.g., metastatic colon cancer) but is not well suited for other cancers with more uncertain prognoses (e.g., chronic hematologic malignancies) or for other common causes of death (e.g., congestive heart failure, chronic obstructive lung disease, dementia, stroke). Many of these patients would welcome a palliative approach that emphasizes enhancing quality of life, but they also want to continue some or all of their disease-driven treatments. Therefore new models of care are needed that allow for a hospicelike benefit for those who have a more uncertain prognosis (50% chance of dying within 6 months but 25% chance of being alive in 2 years, as with severe congestive heart failure), as well as for those who simultaneously want to keep open the options of aggressive treatment, including hospitalization with invasive procedures, if indicated.[5]
Undertreatment of pain by primary care physicians and specialists in a variety of settings is well documented, even when patients are severely ill and near death, despite clear agreement among experts about what constitutes adequate care.[1][6][7] Physician barriers include lack of proper training, unrealistic concern about opioid addiction, fear of review by regulatory agencies, and worries about hastening death. Similarly, many physicians avoid talking with their patients about the possibility of death and continue burdensome, unwanted medical technologies beyond any chance of success.[8] About 80% of deaths now occur in hospitals or chronic care facilities, often far removed from caring families and familiar surroundings. The same medical technology that can save and prolong meaningful life can, paradoxically, prolong the process of dying.[9] Physicians report that they frequently use too much medical technology at the end of life, but they often do not know how to stop. Hospice care tends to be offered late, if at all. In this context, primary care physicians are in a unique position to take an active role in informing, caring for, treating, and advocating for their severely ill and dying patients.
[edit] BASIC END-OF-LIFE ETHICAL PRECEPTS
Despite gaps between principle and practice, considerable ethical and legal progress has improved care options for severely ill and dying patients. There is widespread ethical and legal agreement about the domains discussed next.
[edit] 1. Right to full disclosure.[1][10][11]
Physicians have a clear obligation to help patients understand their clinical condition, including prognosis, and their options for disease-driven and palliative treatments. Although truth telling, even about terminal illnesses, is the standard of care in the United States, physicians should allow for special circumstances when a patient may choose not to have some information or for a family who may want to protect a vulnerable patient because of special cultural or personal circumstances. Physicians should critically explore these unusual circumstances, keeping the patient's values and interests in the center of these discussions.
[edit] 2. Right to refuse treatment.[1][11]
Patients have the right to make informed decisions about matters that affect their bodies, including the right to accept or reject potentially effective treatment according to their values and beliefs. The right to refuse effective, lifesaving treatment applies even when death is certain without treatment and when the patient's goal is to die. When a patient's decision is at odds with the physician's recommendations, the reasons for the discrepancies should be fully explored. Final decisions, however, rest with patients. This right has been extended to surrogate decision makers when the patient is mentally incapacitated and when the surrogates are acting according to the patient's expressed values or best interests.
[edit] 3. Right to have treatment withdrawn once started.[12][11]
Some clinicians are more reluctant about stopping life-sustaining treatments once started (e.g., ventilator, feeding tube, dialysis) than about not starting them. The experience of withdrawing treatment may be difficult for physicians partly because of the proximity of the physician's action to the patient's death. The patient may also need intensive treatment of subsequent symptoms, such as severe shortness of breath when a respirator is discontinued.[12] Nonetheless, this option allows patients to undergo limited trials of life-sustaining treatment without being obligated to continue them indefinitely. It also allows the patient's goals, circumstances, and choices to change over time. Competent patients or surrogate decision makers if patients are incapacitated should be supported in their rights to have unwanted ongoing treatment stopped, even if that treatment is life sustaining.
[edit] 4. Substituted judgment for incompetent patients.[13]
When a patient has lost the mental capacity to make decisions, caregivers should attempt to reconstruct the patient's values and philosophies to make decisions as the patient would if able to comprehend the medical situation and options available. Since only about 10% of Americans have formally expressed their end-of-life philosophy through an advance directive (health care proxy or living will), such determinations are often approximations at best. The proxy decision maker's role is not to express what they would want for the patient or for themselves but what the patient would want. Only when no clue exists to what the patient would have decided should a generic view of the patient's “best interests” be invoked.
[edit] 5. Right to adequate pain management.[14][6][7]
The vast majority of pain in severely ill patients can be managed using basic step care protocols (see later discussion). Good pain management not only improves the patient's quality of life but also may increase length of life and reduce unnecessary hospitalization. Potent opioid analgesics should be used to relieve the patient's pain, even if the high dosages required could inadvertently or indirectly contribute to the patient's death. The possible unintended contribution to the patient's death is justified under the principle of double effect (actions initiated with good intentions can have unintended bad consequences but can still be ethically and morally appropriate). Patients who fear physical pain should be reassured that the physician will diligently and aggressively work with them to find a regimen that effectively manages their pain.
[edit] 6. Right to palliative care.[14]
The 1997 U.S. Supreme Court decision denying a constitutionally protected right to physician-assisted suicide suggested that patients have a protected right to treatments directed at relieving pain and suffering. Palliative care is best delivered in hospice programs, which utilize the resources of a multidisciplinary team, including nurses, social workers, clergy, health aides, volunteers, and others, to help relieve uncomfortable symptoms and to help the patient prepare for death. Although clearly relevant when a patient is in the terminal stages of illness, palliative care approaches are also important for severely ill, suffering patients who want to continue some disease-driven therapies but have a significant but less certain likelihood of dying in the near future. Offering patients the hospice philosophy of care should not depend on their acceptance into a formal program, since it can be implemented in virtually any setting.
[edit] 7. Duty not to abandon.[15]
Since any dying patient's course is uncertain, a physician's most significant commitment is not to abandon. This implies an obligation to be available to the patient until death, to continue to problem solve, to support the caregivers (both family and professional), and to be helpful regardless of the circumstances. This commitment can take some of the fear out of this profound process. A continued clinical presence is at the core of providing humane care for dying patients.
[edit] COMMON END-OF-LIFE DECISIONS
[edit] 1. Advance directive discussions.[13]
The living will involves setting out a person's philosophy and specific directives toward health care should that person lose decision-making capacity in the future (Fig. 9-1). The health care proxy involves naming an individual to represent the patient for health care decisions should the patient lose decision-making capacity in the future (Fig. 9-2). Both have gained substantial ethical and legal standing throughout the United States. In some states the durable power of attorney for health care can be used for both functions.
Only 10% to 15% of the population have completed such documents. Barriers include the inherent difficulty defining an end-of-life philosophy and contemplating one's death, conflicts within families, the complexity of the forms and concepts, and the sustained effort needed to complete the document. Physicians should initiate discussion as part of routine care for all patients, as part of a physical examination, when considering health maintenance, or when the issue of severe illness arises. These discussions can be more difficult and frightening if considered for the first time when the patient is severely ill and at immediate risk for losing decision-making capacity. The discussion is crucial, however, if the patient's values are to remain central to health care decisions.
If the patient has trusted family or friends, many favor the health care proxy over the living will because of its increased flexibility to deal with unanticipated conditions. Proxies who are uninformed about patient wishes, however, may have a difficult time remaining true to the patient's values. The living will has the advantage of being a direct expression of the patient's philosophy; the disadvantage is that it may not explicitly cover the patient's actual condition. The safest approach may be for the patient to complete both documents or the durable power of attorney for health care.
Advance directives have no relevance to the care of competent patients, since these persons can directly participate in their own medical decision making. Advance directives are activated only when patients lose this capacity.
[edit] 2. “Bad news,” ineffective treatment, uncertainty about future.[10][11]
Physicians regularly encounter patients who are working through these crises. There is no preset formula about how to proceed, except to say that telling the truth, even in the face of uncertainty or a poor prognosis, is usually critical to informed decision making. Whenever possible, the physician should follow the patient's lead about how rapidly and in what detail to convey the medical situation. Sometimes the process must be accelerated because of the immediacy of the patient's condition and the need for rapid decision making, but more often time can be allowed to enable the patient to integrate enough information to make a good decision. Attention should be paid to each patient's unique emotional responses, information needs, and support.
When the news is overwhelming (e.g., new, unexpected diagnosis of cancer or HIV), it is prudent initially to develop a “miniplan” to cover the first few hours or days (how to tell close family members, where to go from the office, how to handle fear) before making major treatment decisions or learning about the illness. When the patient has integrated the relevant medical information and is ready to make medical decisions, all reasonable treatment options should be explored, from the most aggressively curative to those that emphasize comfort and symptom relief. Physicians should share their own opinions, biases, and recommendations while reinforcing that the final decision rests with the patient. Early in the patient's course, primary care physicians must convey their commitment to work with the patient through the illness no matter what choices are made.
Sometimes family members and even physicians believe that telling the truth when the prognosis is poor may deprive the patient of hope. Most providers and ethicists in the United States believe that physicians should fully inform unless a compelling reason exists not to inform. Frequently, protective secrets tend to isolate family members from the patient and may deprive the patient of the opportunity to make informed medical decisions, to settle affairs, or to say goodbye. Since medical treatment is only one avenue for finding hope, the patient may also be deprived of the opportunity to seek it in other domains (e.g., spirituality or religion). The physician should respectfully explore the reasons for not telling a patient the truth but ultimately should follow the patient's lead in deciding whether and in what detail to inform.
[edit] 3. Do not attempt resuscitation (DNAR).[16]
Although this decision technically applies only to attempting cardiopulmonary resuscitation (CPR), it often represents a complex amalgam of decisions and meanings. DNAR discussions may be the first open acknowledgment to the patient and the family that treatment is not working and that death is likely in the near future. Since CPR is usually ineffective in patients with metastatic cancer and other noncardiac multisystem diseases, patients and families should not anguish over resuscitation decisions. Some institutions have changed the default resuscitation order, requiring physicians to write an order to resuscitate any patient hospitalized more than 24 hours. Others allow the patient and physician to decline specific parts of CPR, such as indicating “no chest compression” or “no intubation.”
Unfortunately, DNAR emphasizes what will not be done and says nothing about what treatment will be tried. Therefore the DNAR decision is often confused by patients, families, and medical personnel with abandonment (“do nothing”). To avoid this confusion, discussions about resuscitation must also include an explanation of what treatments will be provided. For some patients this might include all curative and pathophysiologically directed treatments except CPR (potentially including antibiotics, fluids, chemotherapy, blood products, radiation, and even intensive care or surgery), whereas for others a more exclusively palliative approach is appropriate. The treatment plan should be individualized, tailored to the patient's values, goals, and medical condition.
[edit] 4. Choosing hospice care.[1][17][4]
Referral to a formal hospice program is frequently offered to patients only after all possible medical interventions have been exhausted and death is imminent. Physicians should discuss palliative care and potential hospice referral as possibilities much earlier in the course of a patient's illness, especially when the chances of effective treatment diminish or when treatment burdens outweigh expected benefits. The potential of palliative care and hospice should also be explored when patients raise fears about dying, reassuring them about the possibility of a more humane and less technologically dominated approach. Hospice care should not be equated with giving up. Instead, hospice care is an alternative medical approach emphasizing intensive caring for patients and an explicit focus on relieving suffering and symptoms rather than treating disease.
[edit] 5. Opportunities for growth and healing at the end of life.[3][9]
Although the end of life is frequently associated with loss and grief, opportunities for life closure can also make the process emotionally rich and personally meaningful for patient, family, and caregivers. For some patients, spiritual and religious issues predominate; others see it as an opportunity for families to come together and achieve closure. Physicians or other members of the health care team should explore these areas in an open-ended way with the patient and family and refer them to people with appropriate interest and expertise as appropriate. Sometimes the simple process of life review, where patients recount their life story from childhood to the present into a tape recorder as part of a family archive, can be meaningful. As always, the patient should decide whether and to what depth to implement this exploration.
[edit] 6. Wanting to die.[18]
Relatively few severely ill patients actually choose to intentionally end their lives, but many have transient or sustained wishes for death during intense suffering. The physician is in a unique position to lessen the isolation and despair that often accompany such feelings and to explore their underlying origins. Sometimes physicians are asked about their willingness to help patients die, now or in the future. Rather than responding with a “yes” or “no” based on assumptions about what the patient might actually be asking, the physician should explore the request in detail, including a consideration of why it is occurring at that particular time. Special attention should be paid to underlying depression, anxiety, or pain and to the emergence of unaddressed psychologic, social, or spiritual issues.
Sometime in their careers, physicians may encounter patients whose suffering is intolerable, whose request is rational, and for whom palliative care alternatives are ineffective or unacceptable. Physicians' responsibilities in caring for such patients are currently under intense debate in the United States (see next section). An open discussion of the issue when raised by a patient and a wide-ranging search for palliative care alternatives are essential and uncontroversial. Thoroughly exploring a patient's request for a physician-assisted death does not imply an obligation for the physician to accede. Physicians must consider their own values, the status of the law, and their relationship with the patient before responding.
[edit] END-OF-LIFE CHALLENGES AND CONTROVERSIES
Two main public policy challenges remain to be solved in the care of dying patients. These issues are interrelated, but both are essential if physicians are to reassure patients that they will die with as much comfort, dignity, and meaning as possible.
[edit] 1. Improving access to and delivery of palliative care for all dying patients.[1][14][3][5]
Palliative care is the standard of care for dying patients, including pain and symptom management, patient and family support, and the opportunity for life closure. Multidisciplinary hospice programs are the models against which other systems of care should be measured, but they are underused among eligible patients and are only available to those who will likely die within 6 months. Although much is made about the potential cost savings of using hospice and avoiding deaths in the acute hospital setting, these savings are mainly in the last 2 months of life, and costs of palliative care increase relative to traditional care the longer the patient is in the program. New models of palliative care must be developed that can coexist with continued disease-driven care and must be used for patients whose prognosis is longer and more uncertain, such as those with congestive heart failure, chronic obstructive pulmonary disease, stroke, amyotrophic lateral sclerosis, and dementia.
Palliative care and hospice promote a multidisciplinary team to support the patient and family in the last phase of the patient's life. Unfortunately, physicians are often the weakest link in this team, in part because of inadequate education about available palliative measures to relieve pain and other forms of suffering, and in part because they are inadequately trained in the complex communication issues involved in end-of-life care. There is considerable momentum nationally to remedy this situation, but many challenges remain. Since comprehensive palliative care is the standard of care for dying persons, all physicians who care for severely ill patients must learn how to communicate with patients and families and then deliver what has been agreed on.
[edit] 2. Expanding the range of options available when palliative care is failing and patients are ready to die.[17][9][19]
What are the options if the patient's suffering is intolerable, palliative care alternatives have been exhausted, and the patient is requesting a hastened death? If the problem is severe pain or shortness of breath, legal and ethical experts generally agree that opioid pain relievers can be increased until the symptom is relieved or the patient is sedated. The purpose of this intervention is primarily to relieve the patient's symptoms, not to hasten death, even though that may be what the patient is requesting. If the patient is receiving life-supporting treatments, such as mechanical ventilators, dialysis, feeding tubes, or dexamethasone for brain swelling, these can be discontinued even if the patient's wish is to hasten death.
If these options are unavailable, the physician can consider providing terminal sedation to relieve other severe symptoms of suffering. The patient is sedated to unconsciousness with a benzodiazepine or barbiturate infusion to relieve the symptoms consistent with the double effect, then life-prolonging interventions such as artificial hydration and nutrition are withheld. The Supreme Court suggested that terminal sedation would be legally permitted. Its ethical status is currently being debated, but the practice is supported by hospice and geriatrics groups as a last-resort alternative to physician-assisted suicide. As an additional possibility, the patient can choose to stop eating and drinking, even though physically capable; the physician's role is passive, ensuring informed consent and that the patient is competent and all alternatives exhausted.
Physician-assisted suicide, in which the physician provides a potentially lethal prescription at the patient's request that the patient may then independently take, could also be an option. As of 2000, the practice is illegal in the United States except in Oregon. Although physician-assisted suicide is supported by a majority of people in public opinion polls, its ethical status as an intervention of last resort remains controversial. If considering this type of assistance, the physician should be aware of the law, carefully assess the patient, and speak with experienced and trusted colleagues to ensure that all alternatives have been explored. Safeguards for any of these interventions include a careful assessment of the patient's mental capacity, a full understanding of the patient's suffering including what makes it intolerable, and a careful search for standard palliative care alternatives.[19] If any question remains about the patient's mental capacity, second opinions by palliative care specialists, by those with experience in caring for dying patients, and by mental health professionals are essential.
[edit] PAIN MANAGEMENT
All physicians must become skilled at pain and symptom management to care for severely ill and dying patients. Although pain specialists are available at many major medical centers to help with unusual or intractable problems, pain can usually be managed using basic principles and techniques by the primary treating physician. These include caregiver continuity and commitment, careful assessments over time, and individually tailored treatment regimens that often combine pharmacologic and psychosocial/behavioral techniques (Box 9-1).
| Box 9-1 - Goals of Pain Management |
|
[edit] Pain Assessment
The patient's pain is always subjective, usually experienced by the person as an integrated biologic, psychologic, and social experience. Physicians should attempt to assess its multiple dimensions simultaneously. The patient's report of pain is the most reliable information available.
Pain has consequences. In addition to the unnecessary suffering, patients with unrelieved pain become catabolic, respond less well to other treatments, have greater complication rates, show more emotional disturbance, and sometimes die sooner. Cultural and psychologic factors influence the expression of and tolerance for pain. Factors that aggravate pain include insomnia, fatigue, nausea, anxiety, fear, misunderstanding, anger, shame, sadness, depression, memory of past pain, and expectation that pain will recur. Conversely, pain may be lessened with sleep, rest, sympathy, understanding, diversion, relief of other symptoms, and around-the-clock pain medication.
Acute pain has a well-defined temporal onset and may be associated with autonomic nervous system activity such as tachycardia, diaphoresis, elevated blood pressure, pallor, and pupil dilation. It may serve as a warning or protective purpose. Acute pain is best treated by recognizing and addressing the underlying cause directly and by using analgesics, which should be both administered around the clock to maintain steady analgesic blood levels and supplemented as needed for breakthrough pain. Acute, episodic pain that is associated with procedures (e.g., chest tube insertion or removal, dressing changes, bone marrow aspiration or biopsy, lumbar puncture) can be anticipated and treated prophylactically.
Chronic pain may not have a well-defined temporal onset, may last months to years, and frequently has no signs of autonomic nervous system hyperactivity. Instead, chronic pain is often associated with the signs and symptoms of depression, including hopelessness, helplessness, anhedonia, appetite and weight changes, sleep disturbances, and decreased social interaction. The underlying causes may not be treatable and in some circumstances not clearly identifiable. Chronic pain should be prevented whenever possible and treated aggressively once identified.
The assessment of pain and pain therapy requires regular, accurate measurement. Pain can be followed over time on a 10-point numeric scale, with 0 being no pain and 10 being the worst imaginable pain (Fig. 9-3). After any therapeutic intervention, one needs to learn how much relief was achieved (i.e., where did the pain rating move on the scale) and how long the relief lasted. Intervals between analgesic dosages are adjusted so that the analgesic effect is uninterrupted. The goal of pain management is not necessarily complete absence of pain, but rather a maximally functional patient. The patient is the ultimate arbitrator of whether pain relief goals have been achieved.[1][6][7]
[edit] Treatment
Pain treatment almost always involves a combination of pharmacologic and psychosocial/behavioral techniques.
[edit] Psychosocial and Behavioral Approaches.[7][11][4]
Meditation, self-hypnosis, distraction, humor, psychotherapy, spiritual exploration, hobbies, biofeedback, music, art, and many other approaches can be very effective and helpful in treating pain. The choice of technique depends on the patient's interests and condition and the presence of skilled practitioners or partners. For some patients, pain may be very tolerable when in the presence of others but intolerable when alone. Therefore, although pharmacologic approaches are vitally important and effective, other psychosocial factors might influence a patient's pain.
[edit] Pharmacologic Treatments.[2][6][7][4]
Medications are generally effective provided they are used skillfully, with knowledge of the underlying pharmacokinetics and without unnecessary fear or restraint. Table 9-1 shows an analgesic ladder of progressively stronger medications in the management of chronic pain; the higher the step, the greater the analgesic effect, while adverse reactions also become more likely. To treat any chronic pain, analgesics should be taken around the clock. Chronic pain should not be managed solely with as-needed dosing, although such dosages should be provided for breakthrough pain between regular dosing intervals. The initial drug dosage and interval are determined by the pharmacologic properties of the specific drug, but the final regimen of any drug should be individualized. Onset, peak effect, and duration of analgesia may vary from person to person because of differences in absorption, organ dysfunction, or tolerance.
Table 9-1 Analgesic Ladder for Pain Management
| Drug | Equianalgesic dose (mg) | Usual starting doses (mg) | Half-life (hours) | Duration (hours) | Comments | ||
|---|---|---|---|---|---|---|---|
| IM/IV | PO | IM/IV | PO | ||||
| Step 1: Drug equivalents for mild pain† | |||||||
| Acetaminophen (Tylenol, Datril, Panadol) | ✢ | 650 | ✢ | 650 q4-6h | 2 | 4 | No antiinflammatory effect; does not inhibit platelet function; avoid in liver failure. |
| Aspirin, ASA | ✢ | 650 | ✢ | 650 q4-6h | 3-12 | 2-4 | Avoid during pregnancy, in hemostatic disorders, in GI or GU bleeding, preoperatively, and in patients under age 18; may precipitate asthma. |
| Nonsteroidal antiinflammatory drug (NSAID) (various) | ✢ | Varies | ✢ | Varies | ✢ | ✢ | As with ASA; also useful with opiates for pain of bone metastases; upper GI toxicity common. |
| Ketorolac (Toradol) | 30 | 10 | 30 q6h | 10 q6h | 4-7 | 6-8 | IM preparation with all NSAID side effects; expensive; reduce dose with renal insufficiency. |
| Celecoxib (Celebrex) | ✢ | 200 | ✢ | 200 qd | 11 | 24 | Cox 2 inhibitor-antiinflammatory effect similar to NSAID, but less GI toxicity; expensive. |
| Rofecoxib (Vioxx) | ✢ | 25 | ✢ | 25 qd | 17 | 24 | Cox 2 inhibitor-antiinflammatory effect similar to NSAID, but less GI toxicity; expensive. |
| Step 2: Drug equivalents for moderate pain‡ | |||||||
| Codeine | 120 | 200 | 30 q3-4h | 30-60 q3-4h | 3 | 4-6 | Often used in combination with acetaminophen or ASA (325 mg); analgesic effect plateaus in adults receiving more than 120 mg q4h. |
| Hydrocodone (Hycodan) | ✢ | 30 | ✢ | 5-10 q4-6h | 3.3-4.5 | 4-6 | Combined with acetaminophen (500 mg) (Vicodin). |
| Oxycodone (Roxicodone) | ✢ | 30 | ✢ | 10 q4-6h | No data | 4-6 | Used in combination with ASA (Percodan, Roxiprin) or acetaminophen (Percocet, Tylox, Roxicet); upper limit of dosing not defined except for combination preparations. |
| Meperidine (Demerol) | 75-100 | 300 | 75 q2-3h | NR | 3-4 | 2-4 | Short acting (about 2 hr); toxic metabolite causes irritability and seizures with repeated dosing; parenteral dose ⅓ oral dose; NR. |
| Propoxyphene (Darvon) | ✢ | 100 | ✢ | NR | 6-12 | 4-6 | Opiate with potentially toxic metabolite; used with acetaminophen (Darvocet-N); does not inhibit platelet function or cause GI upset or bleeding; may be habituating; NR. |
| Step 3: Drug equivalents for severe pain‡ | |||||||
| Morphine | 10 | 30 (60 if opiate naïve) | 5-10 q3-4h | 15-30 q3-4h | 1.5-2 | 3-7 | Standard against which all other analgesics are judged; available as several different preparations.§ |
| Hydromorphone (Dilaudid) | 1.5 | 7.5 | 1-2 q3-4h | 4-8 q3-4h | 2-3 | 4-5 | As with morphine; duration of action 3-4 hr; 2-, 3-, 4-, 8-mg tablets, 3-mg rectal suppositories, and 1-, 2-, 4-, 10-mg/ml parenteral solutions available. |
| Methadone (Dolophine) | 10 | 20 | NR | 5-10 q12h | 15-30 | 4-6 | Give q6-8h for pain, not qd; will accumulate with repeated dosing; equianalgesic dosage may cause unacceptable persistent sedation, so should be reduced on the third or fourth day of titration; inexpensive. |
| Fentanyl (Duragesic) | 100 μg (single dose) 200 μg (continuous infusion) | 100 μg/hr; transdermal patch equivalent to 180 mg morphine/24 hr | 100 μg IV q1-2h | 25-mg transdermal patch q72h | 12 (transdermal) | 48-72 (transdermal) 1-2 (IV) | 25-, 50-, 75-, and 100-μg patches (Duragesic); 25-μg patch approximates 10 mg morphine PO q4h; with transdermal patch, steady state reached only after 24 hr, so other analgesics needed in interim; replace q72h at different site; fever may lead to increased levels; skin reservoir causes long half-life (50% 17 hr after removal), so careful monitoring required; most useful in stable chronic pain situations. |
| IM/IV, Intramuscular/intravenous; PO, oral; q4-6h, every 4 to 6 hours; qd, daily;GI, gastrointestinal; GU, genitourinary;NR, not recommended. | |||||||
| Concentrated oral solution (Roxanol, OMS concentrate, MSIR concentrate), 20 mg/ml, absorbed sublingually when patient has no oral intake or difficulty swallowing; used when higher doses indicated. | |||||||
| Sustained-release (SR) tablet (MS Contin, Oramorph SR); 15, 30, 60, 100 mg; lasts 8-12 hr instead of 3-4 hr; titrate first with rapid-acting preparations for 24 hr, then divide into 2-3 doses for around-the-clock administration of SR tablet; continue short-acting preparation as needed for breakthrough pain; may be used rectally; do not crush tablet. | |||||||
| Immediate-release tablet (MSIR tablets), 15 and 30 mg, short acting. | |||||||
| Rectal suppositories (MS/S or RMS), short acting; 5, 10, 20, 30 mg per suppository. | |||||||
| Also indicated for intractable dyspnea; no upper limit to morphine dosing but relatively ineffective for neuropathic pain. | |||||||
✢Not available or not applicable.
†Equianalgesic dose: approximate comparisons with other step 1 drugs.
‡Equianalgesic dose: equivalent to 10 mg of parenteral morphine.
§Morphine preparations: Oral solution (MSIR), 2-4 mg/ml, when low doses needed.
The biologic half-life of the analgesic agent must be considered when adjusting the dosage and interval. The maximum effect of a given dose may not be seen until the drug has been administered over four or five half-lives. In addition, the duration of analgesia may be shorter than the half-life, which may be prolonged in renal or hepatic failure, when short-acting agents usually are administered at longer intervals.
Oral medications are preferred. Physicians should also be familiar with unique routes of administration (e.g., highly concentrated oral solutions, transdermal patches, subcutaneous infusions) that may be effective in special situations. Subcutaneous, intravenous, and intramuscular injections should be avoided if possible to enhance patient comfort and to minimize the risk to caregivers. Patient-controlled analgesia (within professionally established limits) has been shown to lessen postoperative pain, decrease complications, lead to earlier discharge, and lessen the overall opiate level consumed. This concept has been applied most frequently to parenteral pumps but also reinforces active patient participation in the selection, assessment, and control of analgesic regimens.
With step 2 and step 3 drugs (see Table 9-1), side effects must be anticipated. Constipation is predictable and should be treated prophylactically (Table 9-2). Box 9-2 outlines guidelines for analgesic use.
Table 9-2 Opioid Side Effects and Treatment
| Side effect | Treatment | Comments |
|---|---|---|
| Constipation | Bisacodyl (Ducolax, 250 mg), senna (Senekot), or magnesium hydroxide (Milk of Magnesia, 30-60 ml) once or twice daily | Prophylaxis is better than as-needed dosing for steps 2 and 3 drugs (see Table 9-1); avoid bulk laxatives. |
| Sedation | Decrease dosage or increase interval of opiate; dextroamphetamine, 2.5-7.5 mg every 6 hours | Tolerance to sedation usually develops in 24-72 hr; sedation usually appears well before respiratory depression; avoid naloxone (Narcan) except in emergencies, as it will cause major withdrawal. If Narcan is needed, dilute 0.4 mg with 9 ml NS and give slowly to desired effect. |
| Nausea | Antihistamines, phenothiazines, butyrophenones, scopolamine, metoclopramide, steroids | Use trial-and-error approach: be sure nausea is not secondary to constipation; be aware of drug-specific side effects (e.g., dystonic reaction with phenothiazines or metoclopramide). |
| Box 9-2 - Analgesic Guidelines |
|
[edit] Special Patients
[edit] Loss of Ability to Swallow.[2][4]
As patients near death or when they develop complications, they may lose the ability to ingest medications that were adequately controlling their pain. The physician should change to an equianalgesic amount of the same or a different medication. The options include, in general order of preference, oral concentrate (can be absorbed through oral mucosa), transdermal patch, subcutaneous infusion, and transrectal suppository. The physician must choose the best available route of delivery, then calculate the equivalent amount of medication needed (see Table 9-1). The total dose equivalent is generally reduced by 25% to 30% (to allow for individual differences) and given around the clock at intervals determined by usual drug half-lives. Ten to fifteen percent of the total daily dose is made available on an as-needed basis every few hours (see Box 9-2). Physicians who are unfamiliar with dose conversions should seek guidance from palliative care or pain specialists or consult with a knowledgeable pharmacist.
[edit] Invasive Options.[2]
Intraspinal (epidural or intrathecal) opiates can provide analgesia at lower dosages and may reduce systemic side effects in special situations, but they tend to be invasive and expensive and require close monitoring. Nerve blocks, such as celiac block for the pain of pancreatic cancer, or other sympathetic or neurolytic blocks may also be useful when pain is well localized, especially when systemic analgesia fails because of unacceptable side effects. Anesthesiologists who specialize in pain management should be consulted if the patient might benefit from these approaches.
[edit] Neuropathic Pain.[6][7]
Neuropathic pain is characterized by burning, tingling, numbness, and electrical and pins-and-needles qualities. It accompanies many medical and surgical conditions, is often underdiagnosed, and may also coexist with other forms of pain. Neuropathic pain does not respond well to conventional analgesics. Tricyclic agents are useful because they have a specific analgesic effect lacking in other classes of antidepressants. Compared with the antidepressant effect, pain relief occurs at lower dosages (10 to 25 mg for pain vs. 150 to 300 mg for depression) and sooner (1 to 3 days vs. 2 to 4 weeks for depression). These drugs are usually started at a low dosage and titrated up to relief of neuropathic pain or the development of side effects. Dosing at night may help with sleeplessness. These drugs may treat coexisting depression, which can aggravate pain.
Anticonvulsants such as carbamazepine, phenytoin, valproic acid, gabapentin, and clonazepam are used to treat neuropathic pain. The analgesic dosage is usually the same as the anticonvulsant dosage but may be less. The physician should start low and follow blood levels until adequate analgesia or a therapeutic range is reached. Mexiletine, an orally administered form of lidocaine, and capsaicin, a topical substance P inhibitor derived from chili peppers, have also been used to treat neuropathic pain. Conventional analgesics may be used if these more specific approaches are neither effective nor tolerated.
[edit] Anxiety and Depressive Disorders.[2]
These conditions, often seen in the general population, are frequently associated with chronic pain or terminal diseases. Anxiety and depression contribute to considerable suffering, can aggravate chronic pain, and usually respond to treatment (see Chapter 48 ). It is important not to overnormalize (e.g., “Of course he's depressed, he's dying”) because even depression secondary to terminal illness may respond to treatment. On the other hand, not all sadness or anxiety that accompanies grief, loss, or the dying process is part of a disorder. Each patient's unique circumstances should be thoroughly explored with the hope of finding a way to lessen suffering.
[edit] Substance Abuse.[2]
Whether the substance is opiates, alcohol, or other chemicals, substance abusers present complex pain management dilemmas. The history should include the drug(s) of choice, route, dosage, and frequency of use, including time of last dose. Withdrawal must be recognized and treated. Because of physiologic tolerance, regular users of opiates require stronger analgesics and larger dosages to achieve the same analgesic effect. Effective pain management cannot occur until acute substance abuse issues, such as prevention and treatment of withdrawal, are addressed and brought under control. However, drug rehabilitation during an acute hospitalization for other major medical or surgical problems is seldom appropriate. Including substance abuse caregivers in the plan of care is usually helpful.
The patient in recovery from abuse who develops a chronic pain problem requires an open discussion regarding the risks and benefits of opioid analgesics, including the potential of addiction relapse. If opioids are needed, active and recovering substance users may best be treated with a long-acting oral preparation given at scheduled times. Needles can be the environmental trigger for drug craving and generally are avoided. Prescribing rules and contracts are often helpful, including mutually agreed amounts and dosages renewed at fixed, relatively frequent intervals and statements that lost or stolen medications will not be replaced except at these intervals.
Patients without a history of abuse almost never become addicted when opiates are prescribed for acute or chronic pain. Health care providers must not allow concern or ignorance about addiction to prevent patients in their care from receiving adequate analgesia. Some patients exhibit drug-seeking behavior because no physician has adequately assessed or provided treatment for their pain.
[edit] OTHER PHYSICAL SYMPTOMS
Nausea, vomiting, diarrhea, constipation, open wounds, confusion, incontinence, and other symptoms may develop in severely ill or dying patients. Alone or in combination, each may aggravate pain or suffering and may undermine quality of life.[2][4] Experienced hospice and palliative care physicians and nurses should be consulted when a patient has developed an intractable physical symptom. Although not all such symptoms can be relieved with available interventions, many can be improved or at least made tolerable.
[edit] FINAL RECOMMENDATIONS
Caring for dying patients and their families can be a uniquely rewarding facet of clinical practice. Although dying is physiologically destructive, it may be psychologically, socially, and spiritually constructive. Facilitating this growth can be enormously gratifying. Dying patients need a knowledgeable guide, witness, and friend who will commit to facing the unknown with them through the entire process. Having known the patient when healthy and weathered disease processes together, the primary care physician is often in an ideal position to assume this role.
To prepare for this responsibility, physicians should undertake several activities. First, they should articulate their own personal end-of-life philosophy in some form of written advance directive. Physicians who have not personally been through this process are often unpersuasive in encouraging their patients to complete their own advance directives, and they may be less open about their own beliefs and recommendations as they help those who are facing death. Second, all physicians caring for severely ill patients must become skilled in palliative care, including basic measures to relieve severe pain and other symptoms. Third, if a patient has been cared for by multiple physicians in the course of the illness and is moving to the terminal phase, a specific physician should be identified to work through this phase of illness with the patient and family. That physician must commit to working with the health care team to care for the patient and family regardless of the illness course until the patient's death. The promise not to abandon may be the most fundamental aspect of primary care physicians' commitment to their dying patients.
[edit] REFERENCES
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 American Board of Internal Medicine Caring for the dying: identification and promotion of physician competency Philadelphia: American Board of Internal Medicine; 1996:
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 D Doyle GWC Hands N MacDonald Oxford textbook of palliative medicine. ed 2. New York: Oxford University Press; 1998:
- ↑ 3.0 3.1 3.2 I Byock: Dying well: the prospect for growth at the end of life New York: Riverhead Books; 1997:
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 KA Wallston, C Burger, RA Smith,et al.: Comparing the quality of death for hospice and nonhospice cancer patients. Med Care 1986; 26:177.
- ↑ 5.0 5.1 5.2 J Lynn: Caring at the end of our lives. N Engl J Med 1996; 335:201.(editorial)
- ↑ 6.0 6.1 6.2 6.3 6.4 K Foley: The treatment of cancer pain. N Engl J Med 1985; 313:84.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 A Jacox, DB Carr, R Payne,et al.: Management of cancer pain, Clinical practice guideline no 9, ACHPAR pub no 94-0592 Rockville, Md: Agency for Health Policy and Research, Public Health Service, US Department of Health and Human Services; 1994:
- ↑ MZ Solomon, L O'Connell, B Jennings,et al.: Decisions near the end of life: professional views on life-sustaining treatment. Am J Public Health 1993; 83:14.
- ↑ 9.0 9.1 9.2 TE Quill: A midwife through the dying process: stories of healing and hard choices at the end of life Baltimore: Johns Hopkins University Press; 1996:
- ↑ 10.0 10.1 R Buckman: How to break bad news: a guide for health care professionals Baltimore: Johns Hopkins University Press; 1992:
- ↑ 11.0 11.1 11.2 11.3 11.4 TE Quill: Bad news: delivery, dialogue and dilemmas. Arch Intern Med 1990; 151:463.
- ↑ 12.0 12.1 H Brody, ML Campbell, K Faber-Langendoen,et al.: Withdrawing intensive life-sustaining treatment: recommendations for compassionate clinical management. N Engl J Med 1997; 336:652.
- ↑ 13.0 13.1 G Annas: The health care proxy and the living will. N Engl J Med 1991; 324:1210.
- ↑ 14.0 14.1 14.2 RA Burt: The Supreme Court speaks: not assisted suicide but a constitutional right to palliative care. N Engl J Med 1997; 337:1234.
- ↑ TE Quill, CK Cassel: Nonabandonment: a central obligation for physicians. Ann Intern Med 1995; 122:368.
- ↑ T Tomlinson, H Brody: Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988; 318:43.
- ↑ 17.0 17.1 TE Quill: Death and dignity: making choices and taking charge New York: WW Norton; 1993:
- ↑ TE Quill: “Doctor, I want to die Will you help me?”. JAMA 1993; 270:841.
- ↑ 19.0 19.1 TE Quill, B Lo, D Brock: Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide and voluntary active euthanasia. JAMA 1997; 278:2099.
