DEFINITION & SCOPE OF PALLIATIVE CARE
The focus of palliative care is to improve symptoms and quality Of life at any stage of any serious illness, to support the patient’s family and loved ones, and to help align patients’ care with their preferences and goals. At the end of life ) palliative care often becomes the sole focus of care, but palliative care alongside cure-focused treatment is beneficial throughout the course of a serious illness, regardless of prognosis, whether the goal is to cure disease or manage it. Palliative care includes management of pain, dyspnea, nausea and vomiting, constipation, and agitation; emotional distress, such as depression, anxiety, and interpersonal strain; and existential distress, such as spiritual crisis. While palliative care is a medical subspecialty recognized by the American Board of Medical Specialties, all clinicians should possess the basic skills to be able to manage pain; treat dyspnea; identify possible depression; communicate about important issues, such as prognosis and patient preferences for care; and help address spiritual distress. Advanced certification in palliative care is offered by the Joint Commission to hospitals providing high-quality palliative services. During any stage of illness, symptoms that cause significant suffering are a medical emergency that should be managed aggressively with frequent elicitation, continuous reassessment, and individualized treatment. While patients at the end of life may experience a host of distressing symptoms, pain, dyspnea, and delirium are among the most feared and burdensome. Management of these common symptoms is described later in this chapter. The principles of palliative care dictate that properly informed patients or their surrogates may decide to pursue aggressive symptom relief at the end of life even if, as a known but unintended consequence, the treatments preclude further unwanted curative interventions or even hasten death, although increasingly palliative care has been shown to prolong the life.
Quill TE et al. Generalist plus specialist palliative care-creating a more sustainable model. N Engl J Med. 2013 Mar 28;368(13 ): 1173-5. [PMID: 23465068}. · ·. . Rabinow M et al. Moving upstre~Jll: a review of the evidence of the impact of outpatient ·. · palliative ·• care. J • Palliat Med. 2013 Dec; 16( 12): 1540~9. [PMID: 24225013] ·
Smith TJ et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into CJ standard oncology care. J CJin Oncol. 2012 Mar 10;30(8):880-7_ [PMID: 22312101] Temel JS et al. Early palliative care for patients with metastatic non-smal1-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. [PMID: 20818875]
PRINCIPLES OF PAIN MANAGEMENT
The experience of pain includes the patient’s emotional reaction to it and is influenced by many factors, including the patient’s prior experiences with pain, meaning given to the pain, emotional stresses, and family and cultural influences. Pain is a subjective phenomenon, and clinicians cannot reliably detect its existence or quantify its severity without asking the patient directly. A useful means of assessing pain and evaluating the effectiveness of analgesia is to ask the patient to rate the degree of pain along a numeric or visual pain scale. General guidelines for the management of pain are recommended for the treatment of all patients with pain. Clinicians should ask about nature, severity, timing, location, quality, and aggravating and relieving factors of the pain. Distinguishing between neuropathic and nociceptive (somatic or visceral) pain is essential to proper tailoring of pain treatments. The goal of pain management is properly decided by the patient. Some patients may wish to be completely free of pain even at the cost of significant sedation, while others will wish to control pain to a level that still allows maximal functioning. Chronic severe pain should be treated continuously. For ongoing pain, a long-acting analgesic can be given around the clock with a short-acting medication as needed for ((breakthrough” pain. Whenever possible, the oral route of administration is preferred because it is easier to administer at home, is not painful, and imposes no risk from needle exposure. Patient-controlled analgesia (PCA) of intravenous medications can achieve better analgesia faster with less medication use and its principles have been adapted for use with oral administration.
The underlying cause of the pain should be diagnosed and treat~d: balancing the burden of diagnostic tests or therapeutic IC Interventions with the patient’s suffering. For example, radiation therapy for painful bone metastases or nerve locks for neuropathic pain may obviate the need for ongoing treatment with analgesics and their side effects. Regardless of decisions about seeking and treating the underlying cause of pain, every patient should be offered prompt relief
PAIN MANAGEMENT FOR PATIENTS WITH SERIOUS ILLNESS
Definition and Prevalence :
Pain is a common problem for patients with serious illnesses. Up to 75% of patients dying of cancer, heart failure, COPD, or other diseases experience pain. Pain is what many people say they fear most about dying and is routinely undertreated. Joint Commission reviews of healthcare organizations now include pain management standards.
Acetaminophen & NSAIDs
Deficiencies in pain management in the seriously ill have limited training and clinical experience with pain management and thus are understandably reluctant to attempt to manage severe pain. Lack of knowledge about the proper selection and dosing of analgesic medications carries with it attendant and typically exaggerated fears about the side effects of pain medications, including the possibility of respiratory depression from opioids. Most clinicians, however, can develop good pain management skills, and nearly all pain, even at the end of life, can be managed without hastening death through respiratory depression. In rare instances, palliative sedation may be necessary to control intractable suffering as an intervention of last resort.
A misunderstanding of the physiologic effects of opioids can lead to unfounded concerns on the part of clinicians, patients, or family members that patients will become addicted to opioids. While physiologic tolerance (requiring increasing dosage to achieve the same analgesic effect) and dependence (requiring continued dosing to prevent symptoms of medication withdrawal) are expected with regular opioid use, the use of opioids at the end of life for relief of pain and dyspnea is not generally associated with a risk of psychological addiction (misuse of a substance for purposes other than one for which it was prescribed and despite negative consequences in health, employment, or legal and social spheres ). The Risk for problematic use of pain medication is higher .however in patients with a history of addiction or substance abuse .yet even patients with such history need pain relief, albeit with close monitoring.
Some patients who demonstrate behaviors associated with addiction ( demand for specific n1edications and doses, anger and irritability, poor cooperation, or disturbed interpersonal reactions) may have pseudo-addictions, defined as exhibiting behaviors associated with addiction but only because their pain is inadequately treated. Once pain is relieved, these behaviors cease. In all cases, clinicians must be prepared to use appropriate doses of opioids in order to relieve distressing symptoms for patients at the end of life. Harms from the use of opioid analgesics, including medication diversion or death from accidental or intentional overdose, are known and significant risks. Some clinicians fear legal repercussions from prescribing the high doses of opioids sometimes necessary to control pain at the end of life. The US Food and Drug Administration (FDA) released a Risk Evaluation and Management Strategy for long-acting and extended-release opioids to help inform physicians about appropriate prescribing and reduce abuse [http://www.fda.gov/Drugs/DrugSafety/Informationby-DrugClass/ucml 63647.htm]. Some states have special training, licensing, and documentation requirements for opioid prescribing. However, governmental and professional medical groups, regulators (including the FDA), and the US Supreme Court have made it clear that appropriate treatment of pain is the right of the patient and the fundamental responsibility of the clinician. Although clinicians may feel trapped between consequences of over or under prescribing opioids, there remains a wide range of practice in which clinicians can appropriately treat pain. Referral to Pain management or palliative care experts 1s appropriate whenever pain cannot be controlled expeditiously or safely by the primary clinician. In the field of chronic, non-malignant pain management, many clinicians are using pain medication contracts and urine drug testing to help decrease the chance of abuse and diversion ( see Box, Opioids for Chronic, Noncancer Pain). Clinicians who are caring for patients earlier in the course of life-threatening illness and are concerned that their patients may be misusing opioids ( with serious negative consequences) can conduct periodic urine toxicology screening to confirm that the patient is taking the medication as prescribed and not using other medications.
PHARMACOLOGIC PAIN MANAGEMENT STRATEGIES
In general, pain can be well controlled with opioid and nonopioid analgesic medications. For mild to moderate pain, acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) may be sufficient. For moderate to severe pain, opioids often are necessary. In all cases, the choice of analgesics must be guided by a careful consideration of the physiology of the pain and the benefits and risks of the particular analgesic being considered.
Acetaminophen & NSAIDs
Appropriate doses of acetaminophen may be just as effective, are an analgesic and antipyretic as NSAIDs but without the risk of gastrointestinal bleeding or ulceration.
Acetaminophen can be given at a dosage of 500-1000 mg orally every 6 hours, although it can be taken every 4 hours as long as the risk of hepatotoxicity is kept in mind. Hepatotoxicity is of particular concern because of how commonly acetaminophen is also an ingredient in various over the counter medications and because of failure to account for the acetaminophen dose included in combination acetaminophenopioid medications such as Vicodin or Norco. With a recognition that total acetaminophen doses should not exceed 3000 mg/d long-term or 2000 mg/d for older patients and for those with liver disease, the FDA is now letting the amount of acetaminophen available in combination analgesics
Commonly used NSAIDs and their dosages are listed. The NSAIDs are antipyretic, analgesic, and antiinflammatory. NSAIDs increase the risk of gastrointestinal bleeding by 1.5 times normal. “the risks of bleeding and nephrotoxicity from NSAIDs are both increased in elders. Gastrointestinal bleeding and ulceration may be prevented with the concurrent use of proton pump inhibitors (eg, omeprazole, 20-40 mg orally daily) or with the class of NSAIDs that inhibit only cyclooxygenase (COX)-2. Celecoxib (100 mg/d to 200 mg orally twice daily) is the only COX-2 inhibitor available and should be used with caution in patients with cardiac disease. The NSAIDs, including COX-2 inhibitors, can lead to fluid retention and exacerbations of heart failure and should be used with caution in patients with that condition. Unlike all other NSAIDs, naproxen has not been shown to increase the risk of major cardiovascular events and thus may be preferred in patients with coronary artery disease or at risk for cardiac disease. Topical formulations of NSAIDs (such as diclofenac 1.3% patch or 1 % gel), placed over the painful body part for treatment of musculoskeletal pain, are associated with fewer side effects than oral administration.
Formulations and Regimens
For many patients opioids are the mainstay of pain management Opioids are appropriate for severe pain due to any cause including neuropathic pain. Opioid medications are 1isted. Full opioid agonist such as morphine, hydromorphone, oxycodone methadone, fentanyl, hydrocodone, and codeine are used most commonly Hydrocodone and Codeine are typically Combined with acetaminophen or NSAIDs although acetaminophen in these combinations is restricted to 325 mg per unit dose due to the risk for toxicity Extended-release hydrocodone without acetaminophen is FDA approved Short-acting formulations of oral morphine sulfate ( starting dosage 4-8 mg orally ev~ery 3-4 hours; hydromorphone l-2 m.g orally every 3-4 hours or Oxycodone (5 mg orally every 3-4-hours) are useful for acute pain not controlled with other analgesics. These same oral medications. or oral transmucosal fentanyl ( 200 mcg oral dissolved in the mouth) or buccal fentanyl (100 mcg dissolved in the mouth), can be used for “rescue or “breakthrough” treatment for patients experiencing pain that breaks through long-acting medications.
For chronic stable pain, long-acting medications are preferred, such as oral sustained-release morphine (one to three times a day), oxycodone (two or three-times a <day), hydrocodone (two tin1es a day)> or methadone (three or four times a day). A useful technique for opioid management of chronic pain is equianalgesic dosing. The dosages of any full opioid agonists used to control pain can be co11verted into an equivalent dose of any other opioid. This approach is helpful in estimating the appropriate dose of a long-acting opioid based on the number of short-acting opioids required over the preceding days. For example, 24-hour opioid requirements established using short-acting opioid n1edications can be converted into equivalent dosages of long-acting medications or formulations. Cross-tolerance is often incomplete, however, so generally only two-thirds to three-quarters of the full, calculated equianalgesic dosage is administered initially when switching between opioid forn1ulations.
deserves special consideration among the long-acting opioids because it is inexpensive, available in a liquid formulation, and may have added efficacy for neuropathic pain. However, equianalgesic dosing is complex because it varies with the patient’s opioid dose and caution must be used at higher methadone doses (generally > 100-150 mg/d) because of the risk of QT prolongation. Baseline ECG is recommended before starting methadone except at the very end of life where comfort is the only goal. Given the complexities of management and the increasing prevalence of methadone overdose in the United States, consultation with a palliative medicine or pain specialist may appropriate.