Chapter 70 Management of Pain at End of Life Flashcards
KEY POINTS 1. All physicians, regardless of specialty, are responsible for care of patients with life-threatening illnesses. 2. Assessment of pain and other symptoms at end of life requires knowledge of common syndromes, as well as skill to conduct a thorough history and physical examination, with particular attention to the neurologic evaluation. 3. Complex pain syndromes require novel drug therapies, in addition to standard nonopioid, opioid, and adjuvant analgesics. 4. Adequate pain contr
Palliative care
the “active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. Palliative care affirms life and regards dying as a normal process
Hospice care goals
Goals include attention to alleviation of physical and emotional suffering, along with focus on the patient and family as the unit of care.
Cancer pain syndromes can be grouped in a variety of
categories:
acute versus chronic, somatic versus neuropathic,
and disease versus treatment related
Acute pain
generally due to invasive procedures, such as diagnostic or surgical interventions, and is not unlike the experience of patients with nonmalignant disease
Chronic pain syndromes often include
involvement of bone, soft tissue, the viscera, and the nervous system. Bone metastases are common sources of pain, particularly in patients with breast, lung, or prostate cancers.
Visceral pain
may arise from involvement of tumor within the liver, intestine, kidney, peritoneum, bladder, or other organs.
Acute Cancer Pain Syndromes- Chemotherapy
Arthralgia and myalgia induced by paclitaxel
Cold allodynia induced by oxaliplatin
Headache due to methotrexate or L-asparaginase
Mucositis commonly due to pre-transplant chemotherapy regimen
Pain due to infusion of chemotherapy into peritoneum or bladder
Acute Cancer Pain Syndromes Growth Factors Hormonal Therapy Flare syndrome Immunotherapy
Growth Factors: Myalgia, bone pain, fever, headache
Hormonal Therapy
Flare syndrome (myalgia, arthralgia, and headache) in prostate or breast cancer
Immunotherapy: Myalgia, arthralgia, and headache due to interferon
Acute Cancer Pain Syndromes- Radiation
Bone pain flare (due to radionuclides)
Enteritis and proctitis
Mucositis
Myelitis when spinal cord is irradiated
Chronic Neuropathic Pain Syndromes Seen at
End of Life
Cancer-Related
Brachial, cervical, or sacral plexopathies Chemotherapy-induced neuropathy Cisplatin Oxaliplatin Paclitaxel Vincristine Vinblastine Cranial neuropathies Postherpetic neuropathy Postradiation plexopathies Surgical neuropathies Phantom pain Postmastectomy syndrome Post-thoracotomy syndrome
Chronic Neuropathic Pain Syndromes Seen at
End of Life
Noncancer Causes of Neuropathies
Alcohol-induced neuropathy Brachial plexus avulsion (trauma) Carpal tunnel syndrome Complex regional pain syndrome Diabetic neuropathy Fabry’s disease Failed back syndrome Guillain-Barré syndrome HIV-associated neuropathy Viral involvement Antiretrovirals Poststroke pain Trigeminal neuralgia Vitamin deficiencie
critical to ascertain for pain
Intensity, location (or often, multiple locations), quality, temporal nature of the pain, and factors that alter the pain
Assessment of pain
thorough history is followed by a comprehensive
physical examination, with particular emphasis
on the neurologic evaluation.16 Radiographic, laboratory, and other diagnostic techniques may be indicated, although in caring for those at the end of life, treatment decisions may be made empirically to avoid uncomfortable scans or invasive procedures.
A psychosocial assessment is indicated, directed towards
the meaning of the pain as well as the effect of pain on the patient and their caregiver. The findings of this assessment may suggest the need for education, to mediate fears of addiction, for example. The results of this questioning may also prompt referral to social workers, chaplains, or others who are trained to address the existential distress or suffering
experienced by the patient or their family
Pain does not exist in isolation and symptom clusters are
common, particularly at end of life. Several instruments
have been designed to measure clinically multiple symptoms, including
Edmonton Symptom Assessment Scale(ESAS),
the M.D. Anderson Symptom Inventory (MDASI) ,
the Memorial Symptom Assessment Scale (MSAS), and others. Another tool, the Distress “Thermometer,”
is a vertical visual analog scale designed to look
like a thermometer, with 0 meaning “no distress” and 10
(at the top of the thermometer) indicating “extreme distress
Brief Hospice Inventory (BHI)
addresses the specific needs of people enrolled in hospice. assess outcomes of hospice patients, including physical and psychological symptoms, patient’s perceptions of hospice care, as well as ratings of their quality of life. Each statement is measured using an 11-point scale
Cardiovascular Disease Cardiomyopathy Congestive heart disease Peripheral vascular disease Pain Syndromes
Pain Syndromes
- Chest pain
- Ischemia
Cirrhosis
Pain Syndromes
- Abdominal pain due to portal
- hypertension, esophageal varices
Debility
Pain Syndromes
- Myalgias due to immobility
- Painful pressure ulcers
- Abdominal pain due to constipation,impaction
- Suprapubic pain due to distended bladder
End-Stage Renal Disease
Pain Syndromes
- Painful pruritus
HIV
Pain Syndromes
- Abdominal pain due to infectious
- gastrointestinal disorders
- Chest pain from pneumocystis pneumonia
- Headaches
- Herpetic neuropathy
- Myalgia
- Neuropathies due to antiretrovirals and the virus
Neuromuscular Disorders
ALS
Multiple sclerosis (MS)
Spinal cord injury
Pain Syndromes
- Painful spasticity
- Lower extremity dysesthesias
- Periorbital pain and trigeminal neuralgia (MS)
Pulmonary Disease
Embolism
Infection
Pneumothorax
Pain Syndromes
- Chest pain
- Dyspnea
a small percentage of patients will experience complex syndromes that do not respond to traditional approaches, such as
bone pain, intractable neuropathic pain, or malignant bowel obstruction, or will develop severe opioid-induced toxicity.
Bone pain is often difficult to treat, in that patients may
obtain good relief of movement-associated pain from
higher-dose opioid therapy, yet will be extremely sedated when they stop moving or placing pressure on the bone
Patients at risk of malignant bone pain
those with cancers that frequently metastasize to bone, including breast, lung, prostate, or multiple myeloma
Managment of Malignant Bone Pain
Dexamethasone 8–20 mg PO, IV, SQ every morning (not to be used in conjunction with NSAIDs)
Opioids
Bisphosphonates such as pamidronate or zoledronic acid
Radiation therapy (may be given as single fraction in some cases)
Radionuclides such as strontium-89
Orthotics for braces or slings
Physical or occupational therapy for assistive devices
INTRACTABLE NEUROPATHIC PAIN
Standard therapies include opioids and adjuvant analgesics, including corticosteroids. Additionally, nerve blocks and other interventional techniques can be useful. In more refractory cases intravenvous lidocaine infusions are used to treat intractable pain. Using techniques and protocols originating from pain clinics, intravenous lidocaine1 to 2 mg/kg is given over 15 to 30 min. If effective a continuous infusion of 1 to 2 mg/kg/hr is started. The analgesic effects can be as prolonged as weeks of relief
Intractable Neuropathic Pain Managment
Dexamethasone 8–20 mg PO, IV, SQ every morning (not to be used in conjunction with NSAIDs)
Opioids can be effective but higher doses are indicated (methadone may provide additional benefit over other opioids)
Anticonvulsants
Antidepressants, including novel or atypical agents such as venlafaxine
Local anesthetics (e.g., LidoDerm patch, intraspinal infusions in combinations with opioids or parenteral infusions)
Malignant Intestinal Obstruction management
Dexamethasone 8–20 mg PO, IV, SQ every morning to reduce inflammation and nausea (not to be used in conjunction with NSAIDs)
Opioids
Octreotide 20 mg/hr IV or SQ to decrease intestinal secretions; increase dose as needed
Scopolamine transdermal patches (1.5 mg, up to 2 patches) may reduce secretions
Nasogastric tube or venting gastrostomy if consistent with patient goals
neuroexcitatory effects of opioids include
myoclonus, hyperalgesia, delirium, and grand mal seizures. These toxicities have been reported in association with morphine, hydromorphone, hydrocodone, fentanyl, methadone, and oxycodone.
implicated as contributing to these neuroexcitatory
effects
3-glucuronide metabolites
Both morphine-3-glucuronide (M3G) and hydromorphone-3-glucuronide (H3G) are believed to produce
myoclonus and seizures
The treatment of mild myoclonus generally includes
switching to another opioid, lowering the dose of the opioid, and adding a benzodiazepine. Clonazepam 0.5 mg
orally twice daily with upward titration may be effective.
If the patient is unable to swallow, midazolam or lorazepam
may be used.
When these more severe neurotoxicities occur, the
opioid dose should
be reduced by at least 50%
Naloxone in treatment of neurotoxicities
Naloxone appears to be ineffective in reversing this
toxicity.
In select cases, spinal delivery of analgesics can
be effective in
relieving pain and reducing systemic opioid exposure
Should seizures occur
first- and secondline therapies include phenytoin and benzodiazepines, such as diazepam or lorazepam.37 In some cases the seizures will progress in frequency and intensity, advancing to status epilepticus. Refractory status epilepticus treatment may require midazolam, barbiturates, and propofol.
Midazolam is particularly useful in palliative care due
to its
rapid onset and short duration, as well as its ability
to be given subcutaneously, intravenously, orally,
buccally, sublingually, or rectally. Furthermore, its
only known drug incompatibility is with corticosteroids,
particularly betamethasone, dexamethasone, and
methylprednisolone
The standard dose of phenobarbital in the management of seizures is
20 mg/kg intravenous infusion, with
a maximum rate of 50 to 100 mg/min.
The recommended dose of propofol to treat refractory
status epilepticus is
1 to 2 mg/kg via intravenous injection over 5 min and repeated if necessary. A maintenance intravenous infusion of 2 to 10 mg/kg/hr is then started, using the lowest dose needed to suppress seizure activity
OTHER SYMPTOMS COMMON AT END
OF LIFE
Dyspnea, anxiety, depression, and other symptoms are
common in the face of advanced illness. Palliation of these symptoms, which are frequently linked with pain, can result in improved pain control and enhanced quality of life.
Dyspnea, or air hunger, can occur as a result of a variety
of illnesses, including
cancer, congestive heart failure, or pulmonary diseases. Opioids are the first drug of choice, often in small doses that do not cause sedation. Short acting anxiolytics are indicated in the face of severe anxiety. Simple measures such as bedside fans can provide additional comfort.
many medications commonly used in palliative care, can result in motor restlessness and agitation.
corticosteroids, neuroleptics (including metoclopramide), bronchodilators, antihistamines, digitalis, and occasionally benzodiazepines (which can cause a paradoxical reaction in elderly patients
produce agitation
Abrupt withdrawal from alcohol, opioids, benzodiazepines, and nicotine. Hypoxia, pulmonary embolus, sepsis, hypoglycemia, thyroid abnormalities, and heart failure are associated with anxiety, as are certain tumors, including pheochromocytomas, and some pancreatic cancers. Primary or metastatic lung cancers and chronic cardiopulmonary conditions can lead to dyspnea, which can also produce
anxiety.
Pharmacologic treatment of anxiety usually consists
benzodiazepines, particularly lorazepam as it has a
short duration of action and produces fewer adverse
effects. A typical initial dosage is 0.5 to 2 mg orally 3 or
4 times daily. Lorazepam can be placed sublingually,
which is useful when patients have difficulty swallowing,
or given parenterally as a bolus or infusion. Haloperidol
is frequently used for short-term management of severe
anxiety and as an antipsychotic, with initial dosage
starting at 0.5 to 1 mg orally twice daily.
physical symptoms of depression
fatigue, anorexia, and sleep disturbance)
Psychological symptoms suggestive of depression
in the patient with life-threatening illness include
loss of selfworth, unremitting sadness and hopelessness, and suicidal ideation.
a simple screening question for depression
“Are you depressed?” or “Are you sad?” is the most valid
measure of a patient’s depression.
Management of Depression
Supportive psychotherapy may be of benefit, although limited life span may be a barrier. Antidepressant medications, such as serotoninspecific reuptake inhibitors (SSRIs), such as citalopram, fluoxetine, paroxetine, and sertraline, are usually well tolerated.
However, the 2 to 4 weeks required for the drug to take
effect is often too long for patients with advanced disease and a very short life span. Newer, “atypical antidepressants” (bupropion, mirtazepine, and venlafaxine) have a relatively rapid onset of action and few reported side effects. However, for patients with a very limited life span, stimulants such as methylphenidate and pemoline provide rapid relief, usually within hours to days
