Introduction

03  PAIN MANAGEMENT

Cancer Pain Management

To many people, the word cancer means pain and death. Sadly, there is much to support that point of view. One study found that 30% of patients experience pain at the time of diagnosis, 30% to 50% experience pain while undergoing therapy, and 70% to 90% experience pain as the cancer advances and overcomes its victims (Portenoy & Lesage, 1999). Yet in 1996 the World Health Organization (WHO) reported that 90% of cancer patients could receive adequate pain relief with the relatively simple drugs that were available at that time (WHO, 1996). Since then, many more pain-relieving interventions have been developed. To achieve the goal of providing adequate pain relief for people with cancer and for those who are dying, caregivers need to know the types and causes of pain and effective strategies to manage pain at the end of life.

Cancer pain is more than a physical symptom. It is a reminder of one’s mortality, a harbinger of death. It may interfere with normal routines, degrade the quality of life, and rob one of rest, creativity, joy, and peace. Cancer pain adds anxiety and stress to its sufferers, their friends, and family. For this reason, professional caregivers:

·                 Take pain seriously, recognizing that only the person who is suffering knows how it feels.

·                 Provide information and resources for pain control.

·                 Communicate with genuineness, accurate empathy, and nonpossessive warmth.

·                 Encourage sufferers to share their feelings and network with other survivors.

·                 Respect cultural norms and wishes of sufferers, maximizing their control of pain.

·                 Encourage release of energy through joy-producing activities.

·                 Monitor pain medications, effectiveness, and adverse effects.

·                 Suggest patients keep a pain-relief record, including date, time, pain rating, medication amount, side effects, and comments (Haylock & Curtiss, 1997).

Cancer is treated with both traditional and nontraditional healing measures. Traditional measures include pharmacologic and nonpharmacologic therapies. Pharmacologic remedies include nonopioid analgesics, opioid analgesics, and co-analgesics/adjuvants (drugs that add to the effect of an analgesic, such as a sedative). Unlike postoperative or post-trauma pain, cancer pain may go on for months and years, adding to other sources of pain. As the patient undergoes treatment or the cancer invades other tissue, the intensity of their pain may increase. It is vital for the treating physician to know the name and dosage of all medications being taken by patients, including over-the-counter drugs and herbal supplements.

TYPES AND CAUSES OF CANCER PAIN

Cancer pain is complex, interactive, and ever-changing. It is caused by the cancer itself and the many different measures used to diagnose and treat it.

Pain Due to the Cancer Itself

As cancer cells invade healthy tissue, visceral and somatic pain receptors called nociceptors sense tissue damage and send impulses to the brain, where the person perceives pain. Nociceptor pain may be localized at the cancer site or referred to a remote area. Not only do sensory impulses inform the person of tissue injury, they initiate the release of neuromodulators, which produce localized inflammation and generate even more pain.

As nervous tissue is infiltrated by tumor growth or damaged by its treatment, neuropathic pain results, often persisting long after the initial insult. In some circumstances, secondary pain further complicates the situation. Although secondary pain results from tumor growth, it is not the direct cause of pain. For example, a space-consuming tumor in the brain increases intracranial pressure, which produces severe headaches.

In addition to physical pain, people with cancer and their families experience the psychogenic pain of anticipatory grief, fear, and other negative emotions such as anger and revulsion. In summary, cancer causes nociceptor, neuropathic, secondary, and psychogenic pain.

·                 Nociceptor pain is pain that is transmitted over intact visceral and somatic nerve fibers from damaged tissue caused by cancerous invasion of bodily tissue, radiation therapy, chemotherapy, and the sticks and jabs of diagnostic procedures. Nociceptor pain may be sharp and stabbing, throbbing and aching, constant or dull.

·                 Neuropathic pain is pain that is transmitted over damaged nerve fibers due to the abnormal processing of sensory information and is caused by infiltration of nervous tissue by cancer cells, radiation therapy, and chemotherapy. Neuropathic pain is burning, searing, tingling, and migratory.

·                 Secondary pain is the result of tumor growth but not necessarily the direct result of the invasion of healthy tissue by cancer cells. For example, a space-consuming brain tumor increases intracranial pressure and causes severe headaches.

·                 Psychogenic pain is caused by the emotional response people have to cancer and death, such as anger, fear, sadness, disgust, shame, guilt, and blame. Negative emotions increase stress and decrease the effect of pain-relieving measures.

·                

The degree of pain experienced by an individual depends on the site of a cancerous lesion and the extent of its growth. Caregivers can expect cancer pain syndromes (clusters of symptoms) to produce the following typical pain:

Pain Due to Diagnostic Procedures

Diagnostic procedures can cause considerable discomfort and outright pain. They may be performed on a regular, preventive basis, such as colonoscopies and mammograms, or on the occasion of a suspicious symptom of cancer. To determine the presence of a cancerous lesion, a biopsy must be obtained and the cells examined under the microscope.

For example, a maotices blood in his stool and reports it to his physician, who schedules a colonoscopy. During the colonoscopy, a suspicious polyp is found and removed, and its cells are examined to determine if they are cancerous. In another situation, a womaotices a lump in her breast and reports it to her physician, who schedules a biopsy, either by needle or surgical excision. Cells from the lump are examined to determine their status.

A multitude of other procedures are performed to obtain specimens for examination. All such measures create physical pain as well as emotional pain, as follows:

Pain Due to the Treatment of Cancer

Although a great deal of research is being conducted to find less invasive ways to treat cancer, at the present time the primary treatments used to rid the body of cancer are chemotherapy, radiation, and surgery. All of these modalities are potentially dangerous, and none of them guarantee success. They destroy healthy cells as well as cancer cells and cause nociceptor, neuropathic, secondary, and psychogenic pain. Sweeder estimated that 20% to 25% of cancer pain is directly related to its treatment (2002). Typical pain of common cancer treatments are listed in the following table.

EFFECTIVE STRATEGIES TO MANAGE CANCER PAIN

To manage cancer pain, nurses and other caregivers use a process that includes assessing pain, diagnosing it, setting goals to manage the pain, planning appropriate actions, intervening, evaluating the effectiveness of interventions, and communicating with both the sufferer and caregivers.

Interventions for the Management of Cancer Pain

PHARMACOLOGIC INTERVENTIONS

Three groups of drugs are used to treat cancer pain: nonopioid analgesics, opioid analgesics, and co-analgesics or adjuvants.

Nonopioid Analgesics

Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammation. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.

 

With the exception of acetaminophen (Tylenol), most nonopioids are potent anti-inflammatory agents. They are especially effective when the primary cause of pain is inflammation, as occurs in bone cancer. When tissue is damaged, a series of biochemical events lead to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes—cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2)—play an important part in this biochemical process. Drugs that inhibit their action, especially COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified. The following table lists some commoonopioid analgesics.

Opioid Analgesics

Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names, typically denoted by Greek letters such as mu (μ), kappa (κ), and sigma (σ). Many of the characteristics of particular opioids relate to the receptor to which they bind. For example, morphine binds to μ receptors and follow μ receptor control.

Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control—an “agonist effect.” Full agonists include such drugs as morphine (Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl (Duragesic patch, Fentanyl oralets), oxycodone hydrochloride (OxyContin), and hydromorphine (Dilaudid).

 

Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin) and butorphanol tartrate (Stadol). An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.

The primary action of opioids (narcotics) is to alleviate moderate to severe pain. Many of the unwanted side effects of this class of drugs are related to their actions on other than the central nervous system (CNS), causing such effects as constipation and respiratory depression. The following table lists some common opioid side effects and preventative measures.

Some medications combine nonopioid with opioid analgesics in one tablet to offer two different levels of pain relief—acting both on peripheral nerve endings at the injury site and at the level of the central nervous system. Acetaminophen with codeine is such a medication.

Drug Tolerance and Dependence

Drug tolerance is a physiologic condition in which humans require larger and larger doses of a drug to provide the same effect as the original dose. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may help overcome tolerance. However, drug tolerance is not the only reason drugs become ineffective. They may be less effective because of advancing cancer growth and tissue damage and thus greater pain.

Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. Other such needs include drug-to-drug interaction, drug-to-food interaction, increased physical activity, changes in opioid formulation, and psychological dependence (addiction).

Physical dependence is a physiologic adaptation of tissues to a drug. If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response, including excessive yawning, nausea, vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. By slowly reducing the dose of an opioid analgesic, physical withdrawal symptoms can be reduced or eliminated.

Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for the drug’s nonanalgesic emotional effects. Opioids with an affinity for both μ and σ receptor sites produce euphoria and hallucinations. Thus, these drugs are the most frequently abused narcotics. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues.

Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly “drug-seeking” but “relief-seeking.” Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or inadequate doses spaced too far apart.

Adjuvant Analgesics

Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain but have been found to enhance the effects of analgesics. Caregivers need to remember that these are “helper drugs,” not substitutes for analgesics. Clients in pain still need analgesics. The following table describes some common adjuvant analgesics.

Placebos

 

A placebo is a “sugar pill,” an inactive substance prescribed as if it were an effective dose of a medication. Research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000). This so-called “placebo effect” has been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and gadgets to people in pain. Because their purpose is to deceive and strip clients of the right to make informed decisions, legitimate medical practice does not use placebos. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is when subjects give prior consent for the possible use of placebos in research studies.

World Health Organization Pain Management Ladder

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended a three-step pain management ladder based on the intensity of pain.

1.            Mild pain (intensity 1–3 on the 0–10 standard): Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists, then administer…

2.            Mild to moderate pain (intensity 4–6): Use combination medications such as oxycodone and acetaminophen and adjuvants. If pain persists, then administer…

3.            Moderate to severe pain (intensity 7–10): Use potent opioids such as morphine, fentanyl, methadone, and adjuvants.

4.           

To prevent under-treatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant cancer pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at the lower level (Jackson & Stanford, 2003).

Routes of Administration

Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.

ANALGESIC DRUG ADMINISTRATION
Route	Indications	Contraindications
Oral (per os = PO)	Preferred route due to lower cost and convenience; may be prepared as powders, tablets, capsules, liquids, or lozenges	Gastrointestinal irritation; inability to swallow; need for more potent analgesic
Rectal (R)	Inability to take oral drugs; can be self-administered; longer duration than oral	Anal or rectal lesions, diarrhea, thrombocytopenia
Intramuscular (IM)	Acute, short-term pain relief	Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly
Intravenous (IV) bolus	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; gives only brief pain relief when prolonged relief is needed
Continuous intravenous (IV) infusion	Gives constant opioid blood level when other methods are ineffective	Requires infusion pumps with alarms and close monitoring
Patient-controlled analgesia (PCA)	Allows predetermined IV bolus of analgesic when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous (SC) opioid infusion	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; potential site irritation
Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular	Intractable pain when client cannot tolerate systemic opioids by other routes	Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Regional nerve blocks	Continuous or single dose analgesic for acute and chronic pain; used for trauma, burns, and labor	Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Topical (cream-laden anesthetic)	Analgesic for needle sticks, venipuncture, dermatitis, and insect stings	Must be applied 30–60 min in advance of need
Transdermal skin patch	Continuous dose of opioid; allows home use	Absorption is accelerated when body temperature is over 102°F; costly
Nasal sprays	Alternative to IV, IM, and oral opioid administration; rapid onset of action	Nasal exudates or mucosal swelling may prevent consistent absorption

NONPHARMACOLOGIC INTERVENTIONS

Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately, there are many nondrug interventions to reduce pain, especially when used in conjunction with effective drugs. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of nursing practice. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater sense of control, and are considered holistic nursing practice.

Physical Interventions

Comfort measures such as clean and smooth sheets, soft and supportive pillows, warm blankets, and a soothing environment have been used by caregivers throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical well-being of patients.

Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is bodily movement to health, an entire profession has developed specializing in physical therapy. However, caregivers need not wait for a specialist to offer these important pain-relieving interventions.

Acupuncture

One of the oldest pain management techniques is the Chinese practice of acupuncture. Acupuncture uses tiny needles, placed in specific points along the body, to help alleviate chronic pain. One large study of people with knee osteoarthritis found that acupuncture provided significant pain relief when medications couldn’t. But the study did find that acupuncture must be used long-term for the maximum effect; most of the time, it took at least 14 weeks to appreciate the results.

Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic nursing care, backrubs offer an important noninvasive way to relieve pain and provide comfort.

 

Physical Therapy

 

Physical therapy teaches you how to gently move and stretch your muscles and work your joints to strengthen them, which will help alleviate pain. Unlike medication, physical therapy can actually help treat the underlying source of your pain, whether it’s arthritis or another condition, and will help chronic pain improve over time. Physical therapy may include water therapy, such as working muscles in a pool or whirlpool. Physical therapy also includes regular exercise, and working with pain specialists trained in physical therapy can teach you the right way to exercise to alleviate pain, not increase it. A January 2012 article in Annals of Internal Medicine found that doing home exercises taught by physical therapists was more helpful for neck pain than drugs.

Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decreases blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are an important means of providing comfort.

Cognitive-Behavioral Interventions

Relaxation exercises are effective ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, yoga, and other such interventions may relieve pain. One such exercise involves controlled breathing. A coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. The coach suggests the subject locate an area of muscle tension, contract the muscles in that area, and then relax them. As the subject relaxes, pain perception and anxiety diminish.

Guided imagery is similar to relaxation exercises in that a coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.

Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. Distraction alone does not work for cancer pain and chronic, long-term pain.

Complementary and Alternative Medicine (CAM)

An increasing number of people in the United States are also turning to theories and practices outside the realm of conventional Western medicine to relieve pain. In 1991, the federal government established the Office of Alternative Medicine. In 1998, the agency became the National Center for Complementary and Alternative Medicine (NCCAM), making the center one of 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services. NCCAM defines CAM as “a group of diverse medical and healthcare systems, practices, and products that are not currently part of conventional medicine” (NCCAM, 2009a).

The mission of NCCAM is to explore “complementary and alternative healing practices in the context of rigorous science…and [to] disseminate authoritative information to the public and professionals” (NCCAM, 2007). In this context, “complementary” describes practices used in conjunction with or to supplement conventional medical treatments, and “alternative” means those that are used independently or in place of conventional medicine. Practitioners of such techniques and practices often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit.

The major categories of complementary and alternative medicine are:

·            Biologic (herbal mixtures; macrobiotic diets; orthomolecular, such as megadoses of vitamins, magnesium, melatonin, etc.)

·            Energy fields (acupuncture, therapeutic touch, pulse fields, Reiki, etc.)

·            Manipulative and body-based (chiropractic, lymphatic drainage, reflexology, aromatherapy, deep-muscle massage, shiatsu, etc.)

·            Mind-body (biofeedback, hypnosis, art therapy, prayer, etc.) (Diluzio & Spillane, 2002)

Biologic. Plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When prepared in a purified form, the dose is more precise than it can be from a plant. Some common active chemicals originally derived from plants are: digitaloid found in the foxglove plant (digitalis), saponins found in sarsaparilla (irritant laxatives), alkaloids found iightshades (atropine), and alkaloids found in the opium poppy (morphine) (McGuigan & Krug, 1942).

Energy fields. Such healing measures are based on theories about unseen forces in the human body. Acupuncture, for instance, is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When these forces are out of balance, pain and illness result. There are at least 350 acupuncture points by which energy flows are accessible. The theory posits that by stimulating these points with very fine needles, the energy flow can be rebalanced and pain relieved (Mayo Clinic, 2009; NCCAM, 2009b).

Manipulative and body-based. These are healthcare approach that focuses on the relationship between the body’s structure and its functioning. Chiropractic care primarily focuses on back, neck, and headache pain. Reflexology, aroma therapy, and shiatsu may be employed to improve the emotional state of cancer patients. Ongoing research is looking at effects of these approaches, how they work, and conditions for which they may be most helpful (NCCAM, 2009c).

Mind-body. These healing measures include biofeedback, hypnosis, art therapy, and prayer. Though they have been used throughout human history to effect healing and pain relief, only recently have they been subjected to scientific study (Diluzio & Spillane, 2002).

Evaluating the Effectiveness of Interventions

Evaluation is a critical phase of managing cancer pain. It tells the degree to which an intervention did, in fact, reduce pain and, if so, how much and at what cost to the patient.

To find out, we gather data from the best source of information, the client, and to some degree the client’s caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, data is gathered about adverse effects of an intervention, such as an allergic reaction, hypotension, constipation, or respiratory depression.

Communicating and Documenting

Communication about pain and the response of patients to interventions is facilitated by accurate and thorough documentation. This communicatioeeds to be conveyed from caregiver to caregiver and shift to shift. Various tools have been devised to facilitate this communication, including pain flow sheets, running diaries, and bedside computer charting, called “point-of-care.” When communicating information about pain, it is important to describe the time and exact nature of an intervention, including details such as the level of pain before and after intervention, specific analgesic and dose, and adverse effect, such as respiratory depression. The more specific and timely a report, the more effective the evaluation will be.

Because pain is a potent motivator for change, people who suffer are vulnerable to all manner of fake gadgets and magical cures. It is the responsibility of healthcare professionals, especially nurses, to give patients accurate information about medications, devices, physical activities, and psychological strategies in clear, understandable ways. Such teaching empowers those who suffer and demonstrates genuine concern, accurate empathy, nonpossessive warmth, and respect.

PART II: Pain Management at the End of Life

The focus of pain management at the end of life is to provide support and comfort rather than cure for the dying and those they leave behind. To do this, caregivers need to understand the concepts, guidelines, ethical concerns, and legal issues associated with the end of life.

PALLIATIVE CARE AND HOSPICE

Palliative care is the active, total care of clients with a goal of providing comfort rather than cure (WHO, 2000). It addresses pain control, symptom management, and social, emotional, spiritual, and financial concerns of people at the end of life.

In 1968 Cicely Saunders—nurse, social worker, and physician—opened St. Christopher’s Hospice in England to care for people who were dying alone and in pain. She developed the concept of enhancing the quality of life through palliative care rather than curative treatment. In 1970 the philosophy of palliative care for dying patients was brought to the United States. Since that time it has spread throughout the nation, addressing the needs of people whose lives are ending.

Suffering is a highly personal experience that depends on the meaning of an event, such as an illness or loss. One can suffer without physical pain, and one can have physical pain and not necessarily suffer. The founder of the modern hospice movement described suffering as “total pain,” an experience of fear of physical distress and dying, concerns about relationships, changing self-perception, and memory of another person’s suffering (Panke, 2002).

The word quality refers to a measure or a grade of services or products. Quality of life refers to the state or condition of one’s being. If people are physically comfortable and emotionally satisfied, we say their quality of life is good. If they are in pain, under stress, alone, sad, or distressed, as many people are, we say their quality of life is poor. The goal of hospice and palliative care is to enhance the quality of life of dying clients.

Pain Control Guidelines

To help caregivers provide better care to individuals in pain and at the end of life, Paice and Fine (2001) suggest the following guidelines:

1.       Assess a client’s pain and evaluate its effects on the individual’s quality of life. Titrate analgesics according to goals of care, pain, severity, need for supplemental analgesics, severity of adverse side effects, measurements of functional abilities (such as interaction with others, mobility, and sleep), emotional state, and effects of pain on quality of life.

2.       For continuous pain relief, use sustained-release formulations and around-the-clock dosing.

3.       Treat breakthrough pain with immediate-release formulations.

4.       Monitor the client’s status frequently, especially during dose titration.

5.       Anticipate adverse effects and prevent or treat them as necessary.

6.       Be aware of possible drug-drug and drug-disease interactions.

7.       Reassess pain regularly. Determine what level of pain is acceptable to the client. If pain is not relieved adequately, don’t give up. Consult resources outside your institution, including nursing colleagues and experts in related disciplines.

8.       Differentiate pain from other symptoms such as delirium or multi-system failure.

9.       Use sedation selectively to relieve intractable pain when other pain-relieving measures have failed and there is a do-not-resuscitate (DNR) prescription.

10.  If the client is unable to communicate verbally, consult with caregivers and use nonverbal behaviors to evaluate pain.

Ethical and Legal Issues at the End of Life

Ethical principles guide caregivers at every stage of life, including its end. Ethical and legal issues and end-of-life care are often intertwined (Scanlon, 2003). This is especially true because pain frequently accompanies terminal illnesses.

BASIC ETHICAL PRINCIPLES

Caregivers follow these basic ethical principles (Hamilton, 2009):

·                 Respect for human life and dignity. Demonstrate respect for the dying person’s beliefs, values, privacy, and physical and psychological needs.

·                 Beneficence. Give care with gentleness, kindness, and a generosity of spirit.

·                 Autonomy. Respect the wishes of the individual and encourage family members to do the same.

·                 Justice. Give equal care to the poor, the rich, the young, the old, the addict, the psychotic, the criminal, the righteous, and the self-righteous.

·                 Honesty. Speak truthfully, with openness and candor, creating a culture of frankness for the dying person and the family.

ADVANCED DIRECTIVES

 

It is vital for all healthcare facilities to anticipate potential conflicts and see that advance directives are in place. When they are not, healthcare professionals may believe they are legally required to continue medically provided nutrition and hydration even when a client no longer benefits.

To resolve this conflict, all fifty states and the District of Columbia have enacted statutes to comply with the Client Self Determination Act (Omnibus Budget Reconciliation Act of 1990). The federal law requires that all healthcare institutions receiving Medicare and Medicaid funding must inform clients in writing about their right to accept or refuse medical or surgical treatment before they become incapacitated. Legal forms called advance directives facilitate this law. (Instructions and forms for each state are available without charge at http://www.caringinfo.org/stateaddownload/.)

There are two basic types of advance directives:

·                     Living will (treatment directive): written document that directs treatment in accord with the client’s wishes.

·                     Durable power of attorney for healthcare (appointment directive): also called a medical power of attorney for healthcare or healthcare proxy; a written document that designates a spokesperson (agent, proxy, surrogate) to represent the person in decision making (Partnership for Caring, 2009).

Despite legislation, Last Acts found that only 15% to 20% of the general population had an advance directive. They also found that decision making was skewed by circumstances at the moment, and that nurses play a vital role in helping families come to terms with the impending death of a loved one because nurses may be the first to recognize signs of approaching death (2002).

Communication Strategies

Caregivers can use three communication strategies to help terminally ill clients and their families accept the reality of death and make decisions about end-of-life care. They are:

·            Use clear, unambiguous words, such as dying and death.

·            Do not use words like hope because of the many meanings such words can convey.

·            Collaborate with other providers to enforce evidence of failing health and the need to have an advance healthcare directive (Norton and Talerico, 2001).

In sum, pain management at its best provides maximum pain relief and minimal harm to individuals at every stage of life, including its end.

 

A model for pain management

The World Health Organization (WHO 1990) has devised a structure to assist nurses and other health-care providers in the management of cancer pain. The WHO principles for cancer can be used as a template for the management of other pain at the end of life. The recommendations include managing pain:

. ‘by the ladder’;

. ‘by the clock’; and

. ‘by the mouth’.

‘By the ladder’ refers to the WHO analgesic ‘ladder’—a stepwise approach to effective pain management (Figure 8.1, page 108). On the first step of the ladder, when pain is mild (‘1–4’ intensity), the best choice of medication is the non-opioid class of analgesics. If the pain is greater (‘5–6’ intensity), opioids for mild–moderate pain should be used. Finally, if the pain is severe (‘7–10’ intensity), opioids for strong pain are indicated. Adjuvant analgesics and nonopioids are used on each step of the ladder to optimise patient comfort.

‘By the clock’ refers to the administration of analgesics around the clock, rather than on an ‘as-needed’ basis. Around the clock dosing produces a steady therapeutic blood level of opioid, rather than a ‘peak-and-trough’ effect in which periods of relief alternate with painful peaks in pain. Additional doses should be used for breakthrough pain.

‘By the mouth’ refers to the administration of an analgesic by the oral route whenever possible. Other routes of administration, such as the rectal or transdermal routes can also be used.

 

Analgesics at the end of life

Non-opioid analgesics

The non-opioid analgesics include paracetamol (known as ‘acetaminophen’ in the USA) and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin. Paracetamol (acetaminophen) is the drug of choice for mild pain and should be considered as a primary treatment or as an adjuvant for various types of mild musculoskeletal pain. Hepatotoxicity is the most significant potential side-effect of paracetamol, and the dose should not exceed 4000 mg in 24 hours. Patients with cirrhosis, hepatitis, and liver metastases are especially sensitive to the hepatotoxic effects of the drug, even at daily doses of less than 4000 mg (Shiodt et al. 1997).

The NSAIDs work by blocking the production of prostaglandins, thus inhibiting inflammation. The NSAIDs are categorised into two classes, each with distinctive side-effects. The older NSAIDs, including aspirin, block two types of enzymes and can therefore cause effects other than the desired antiinflammatory effect. They can thus cause gastrointestinal ulceration, renal dysfunction, and platelet inhibition. Examples include ibuprofen (Brufen), naproxen (Naprosyn), ketoprofen (Orudis), and indomethacin (Indocid). The newer NSAIDs, such as celecoxib (Celebrex) and rofecoxib (Vioxx), are more selective and block only the enzyme responsible for inflammation and tissue injury, thus resulting in fewer episodes of gastrointestinal and renal dysfunction (Cryer & Feldman 1998). There is concern, however, that these ‘COX-2 inhibitors’, as they are known, might contribute to thrombo-embolism (and related cardiovascular events).

 

Opioid analgesics

Choice of opioids

Opioid analgesics are the mainstay of pain management at the end of life. In choosing an opioid, it is important to consider the efficacy of the agent, its halflife, its duration of action, the delivery and dosing options, and potential sideeffects.

In addition, the patient’s age, comorbidity factors, and previous opioid use should be considered. It should also be noted that some opioids should not be used chronically because of their metabolites and ceiling doses (APS 1999). These include pethidine, propoxyphene (Doloxene, Digesic), buprenorphine (Temgesic), and pentazocine (Fortral).

Suitable opioid options for the management of pain at the end of life include morphine, oxycodone (Endone), fentanyl, hydromorphone (Dilaudid), and methadone.

Dosage regimens

Because pain at the end of life is often constant, it is best to choose an opioid that is controlled-release or long-acting. A variety of suitable opioids (including some of those listed above) can be given by continuous intravenous infusion with bolus doses for breakthrough pain.

It is important to continue the opioid analgesics throughout the dying process, even when the patient is sedated or unresponsive. Restlessness and agitation can indicate increased pain, and doses might have to be increased to maintain adequate analgesia. If the patient cao longer take the prescribed opioid orally, an alternative route should be selected. If the opioid is stopped abruptly, the patient will experience withdrawal (Elliott 1997).

Side-effects of opioids

The most common side-effects of opioids include constipation, nausea and vomiting, sedation, confusion, and pruritus. Myoclonus (muscle spasm) can occur if opioids are used in high doses. Constipation is a major problem, and is the most common side-effect reported. Some patients even say that they would ‘Opioid analgesics are the mainstay of pain management at the end of life.’rather be in pain than suffer from severe constipation. Prophylactic bowel management can assist in managing this common problem. An overview of the most common opioid-related side-effects and management strategies is shown in Table 8.2 (below).

 

Adjuvant analgesics

Adjuvant analgesics are agents that: (i) have independent analgesic efficacy; or (ii) work synergistically with other agents to enhance comfort; or (iii) relieve symptoms associated with pain (such as anxiety). The adjuvants are used with each step of the WHO analgesic ladder (see page 108), and are often prescribed for specific somatic, visceral, and neuropathic pain symptoms.

The tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) are used as adjuvant therapy in the management of neuropathic pain, especially ‘burning’ pain associated with peripheral neuropathy. These drugs, which are usually administered orally, can produce anticholinergic side-effects (such as dry mouth). Anticonvulsants (clonazepam, carbamazepine, gabapentin) can also be used for neuropathic pain (especially shooting pain or radiating pain), but can produce sedation as an unwanted side-effect. Other drugs that can be used to assist in the management of neuropathic pain include local anaesthetics (mexiletine), calcitonin, capsaicin, and baclofen.

Corticosteroids (dexamethasone, prednisolone) are helpful as adjuvant therapy in the management of a range of problems, including cerebral oedema, spinal cord compression, bone pain, neuropathic pain, and visceral pain. These drugs can be administered orally, intravenously, or subcutaneously, depending on circumstances. Possible side-effects include ‘steroid psychosis’ and dyspepsia.

For the management of bone pain and hypercalcaemia related to metastatic bone disease, the bisphosphonates (pamidronate, zoledronic acid) are useful. However, these drugs can cause ‘aches and pains’ following administration. Calcitonin is also used to assist in the management of bone pain.

The bisphosphonates are especially noteworthy in pain management at the end of life. Initially indicated for the treatment of bone diseases such as osteoporosis and Paget’s disease, they are now recognised for their role in the management of metastatic bone pain. The two approved agents, pamidronate disodium (Pamisol, Aredia) and zoledronic acid (Zometa), work by inhibiting the osteoclastic activity of bone resorption and inflammation triggered by the tumour. Intravenous pamidronate reduces vertebral fracture, delays the onset of skeletal disease, and reduces radiation requirements. Moreover, patients have reported an improvement in quality of life while on the medication (Fulfaro et al. 1998).

Routes of administration

Approximately 75–85% of patients achieve pain control through simple routes of administration—such as oral, transdermal, or rectal administration. Another 5–20% require intravenous and subcutaneous drugs, and approximately 2–6% require intraspinal analgesics. It is important to begin with the simplest and least invasive method. A change in administration should be considered if the person has uncontrolled pain (despite aggressive titration) or unpleasant side-effects, or if the route is no longer intact (AHCPR 1994).

The rectal route, although simple, is disliked by many patients. However, rectal administration should be considered if oral administration is difficult because the patient has become unresponsive close to death. When using the rectal route, it should be noted that absorption is highly variable, but can be faster than the oral route with some drugs (Warren 1996).

Parenteral administration of opioids includes the intramuscular, subcutaneous, and intravenous routes. Intramuscular administration is not recommended because it is painful, difficult to use in the home situation, and can result in variable absorption (compared with subcutaneous or intravenous injection) (Elliott 1997). Subcutaneous injection can, however, provide rapid analgesic onset if intravenous administration is impractical. Intravenous administration provides rapid relief of pain, and most opioids peak within 10–15 minutes. For both subcutaneous and intravenous administration, individual requirements can be met with continuous infusion along with optional patient-controlled analgesia (PCA) bolus dosing for breakthrough and/or incident pain.

The intraspinal route (epidural and intrathecal) can be useful in patients whose pain does not respond to less-invasive measures. Local anaesthetics can be added to intraspinal opioids to produce additional analgesia. The route requires careful monitoring and expertise, and might not be suitable for home use (especially in rural settings) without careful assessment (AHCPR 1994).

Dosing and titration considerations

A decision on an initial opioid dose is based on the patient’s prior exposure to opioids. Patients should start with the lowest dose, and this can be titrated to a higher doses until a satisfactory analgesic effect is achieved. The titration should be aggressive enough to provide optimal pain relief in a short time without ausing profound side-effects. Some side-effects occur with initial dosing, but tolerance to side-effects usually develops over time.

Analgesics can be administered around the clock (ATC) or as required (prn). Patients with constant pain require ATC dosing to maintain a therapeutic blood level, and extra doses can given between long-acting doses for breakthrough or incident pain. In calculating such breakthrough doses, the following guidelines are useful (Derby 1999):

. for oral opioids, give 5–15% of the 24-hour dose every 2 hours as needed;

. for parenteral opioids, administer 25–50% of the hourly infusion rate.

Invasive procedures

Approximately 1–5% of patients require invasive interventions to control their pain. These include nerve blocks, palliative surgery, and ablative surgery.

One of the most successful interventions for people suffering from visceral abdominal cancer pain is a neurolytic coeliac plexus block. This procedure is recommended by the WHO Cancer Pain Relief Program, and is considered to be the most suitable invasive procedure in the palliative-care setting (WHO 1990). The block is performed by injecting alcohol into the coeliac plexus (during laparotomy or percutaneously). Lillimoe et al. (1993) reported that some patients lived 3.5 times longer if a block was performed, perhaps due to improved function and pain control. Overall, a coeliac plexus block is well tolerated and provides optimal quality of life for patients suffering intractable abdominal pain (Eisenberg, Carr & Chalmers 1995; Yamamuro et al. 2000).

Non-pharmacological pain management

It is important to recognise that pain is an emotional experience, as well as being a physiological phenomenon. Cognitive-behavioural approaches can assist in modifying a person’s perception of pain. Relaxation, distraction, music therapy, and hypnosis should be considered for incorporation in the plan of care. Although these are not the mainstay of therapy, they are complementary to pharmacological and procedural treatments.

 

 

 

 

 

 

 

Because pain management is so important to the provision of quality healthcare, many organizations have developed standards by which professional practice is measured. Four such organizations are the Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), the American Academy of Pediatrics (AAP), and the American Association of Occupational Therapy (AAOT).

Joint Commission

The Joint Commission is an independent organization that accredits and certifies more than 17,000 healthcare organizations and programs in the United States. It evaluates how well these healthcare providers meet published standards of care, including their management of pain. The federal government accepts Joint Commission–accredited facilities as qualified to participate in Medicare and Medicaid reimbursement programs.

Regarding pain management, the Joint Commission Resources states:

Each and every patient has a right to the assessment and management of pain. Hospitals must develop policies and procedures that address the organization’s expectations of pain management in support of their mission and philosophy of care. Patients and their families also need education regarding their role in pain management. Developing a comprehensive and coordinated pain management program can be made easier by accessing good practices. From policies and procedures for the different types of pain (acute, chronic, etc.) to training assistants (including pre- and post-tests) to assessment tools, good practices can assist your organization to provide a comprehensive approach to pain management that meets the intent of the standards and, at the same time, achieves positive outcomes for patient (Joint Commission Resources, 2009).

To meet the Joint Commission standards, accredited facilities must have policies in place to meet the following requirements:

Standard PC.01.02.07: The hospital assesses and manages the patient’s pain.

Rationale: Identification and treatment of pain is an important component of the plan of care. Patients can expect that their healthcare providers will ask them about whether they have pain. When pain is identified the individual is assessed based on his or her clinical presentation and in accordance with the care, treatment, and services provided by the organization.

Elements of Performance:

1.                     The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient’s condition.

2.                     The hospital uses methods to assess pain that are consistent with the patient’s age, condition, and ability to understand.

3.                     The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.

4.                     The hospital either treats the patient’s pain or refers the patient for treatment.

Accreditation Association for Ambulatory Health Care

The Accreditation Association for Ambulatory Health Care is the outpatient counterpart of the Joint Commission. It uses a similar model of standards, interpretive statements, and facility surveys to assure the quality of care delivered in other-than-hospital settings. As with TJC, AAAHC surveys can be used to qualify facilities to participate in Medicare and Medicaid reimbursement programs.

As part of a facility survey, a nurse and/or a physician surveyor will follow a patient from admission to discharge; this is called “tracer methodology.” The surveyors will note how care providers implement, among other things, the pain-related policies. To be considered in compliance with standards on pain management, AAAHC states: “The organization maintains a written policy with regards to assessment and management of acute pain” (AAAHC, 2012).

American Academy of Pediatrics

The American Academy of Pediatrics is a professional organization dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. As such, its committees develop guidelines, positions, and programs to support the mission of the organization. The AAP guidelines for pain management conclude with the strategies listed below.

1.                     Expand knowledge about pediatric pain and pediatric pain management principles and techniques.

2.                     Provide a calm environment for procedures in order to reduce distress-producing stimulation.

3.                     Use appropriate pain assessment tools and techniques.

4.                     Anticipate predictable painful experiences, intervene, and monitor accordingly.

5.                     Use a multimodal (pharmacologic, cognitive behavioral, and physical) approach to pain management and use a multidisciplinary approach when possible.

6.                     Involve families and tailor interventions to the individual child.

7.                     Advocate for child-specific research in pain management and Food and Drug Administration evaluation of analgesics for children.

8.                     Advocate for the effective use of pain medication for children to ensure compassionate and competent management of pain.