California Physician Ebook Continuing Education

ESSENTIAL DRUGS FOR QUALITY CARE IN DYING PATIENTS

Effective management of symptoms at the end of life is challenging but often can be achieved with fewer than for six key medications. Clinicians can help support patients and family by using these medications judiciously with the assurance that it will provide a

death that is as safe, dignified, and comfortable as medically possible. Table 5 summarizes the most common EOL medication classes. Later sections of this activity will explore some of these options in greater detail.

Table 5. Common medications in a “hospice comfort kit” 36

Medication class

Example medications Haloperidol or risperidone

Common indications Delirium, agitation

Antipsychotics

Antipyretics

Acetaminophen (oral or suppository) Lorazepam, alprazolam, diazepam

Fever

Benzodiazepines

Anxiety, nausea

Opioids

Morphine, oxycodone, hydrocodone

Dyspnea, Nociceptive pain (not generally effective for neuropathic pain)

Secretion medications Hyoscyamine, atropine

Excessive oropharyngeal secretions

Laxatives

Docusate, lactulose, senna with docusate Constipation PAIN MANAGEMENT AT THE END OF LIFE

The following is an overview of the treatment of pain as it applies to the end of life. More detailed information regarding pain management in general will be covered in later sections. Although pain relief is often considered—and may sometimes be—an end unto itself, it is particularly important for clinicians to recognize that, at the end of life, pain management and control of symptoms may be more appropriately viewed as means of achieving the more primary goal of improving or maintaining a patient’s overall quality of life. The meaning of “quality of life” varies, not just from patient to patient, but even between the phases of an illness experienced by a single patient. A focus on quality of life is important because sometimes a patient may have priorities that compete with, or supersede, the relief of pain. For example, the end of life can be an extremely important and meaningful time. 37 For some patients, mental alertness sufficient to allow maximal interactions with loved ones may be more important than physical comfort. Optimal pain management, in such cases, may mean lower doses of an analgesic and the experience, by the patient, of higher levels of pain. The point is that, at the end of life, decisions about pain relief must be more than usually balanced with a mindful consideration of the patient’s own values and desires. The types of pain syndromes arising at the end of life include most of the acute and chronic pain syndromes clinicians confront in other patients, and many of the Assessing Pain at the End of Life The end of life is often characterized by a reduced level of consciousness or complete lack of consciousness. This can make assessments of pain very challenging. If a patient is not alert enough to communicate, then nonverbal signs or cues must be used to determine if the patient is experiencing pain and to what degree an analgesic approach is effective.

same diagnostic and therapeutic strategies and skills are the same or similar. But pain management at the end of life does raise some unique clinical and ethical issues and, hence, these issues are appropriate for a focused consideration. In addition, the prospect of severe, unrelieved pain at the end of life ranks very high among patient fears. Indeed many people consider the experience of severe pain to be worse than death, which underscores the importance of a thorough clinical understanding this issue. 38 Managing pain and other symptoms at the end of life is just one component of a wider effort to relieve suffering and help a patient cope with the emotional and psychological aspects of dying. Nonetheless, a failure to manage pain and other symptoms may make it impossible for the patient to attend to these important dimensions. Uncontrolled pain can push all other priorities aside and sap a person’s energy and motivation to focus on potentially positive goals or meaningful experiences. A patient’s perception that his or her pain cannot be controlled may also contribute to a broader feeling that he or she has lost control over their lives in general, which can precipitate a downward spiral of depression and/ or hopelessness. Effective pain control, on the other hand, not only directly reduces suffering but may allow a patient the energy and positive attitude needed to engage with the emotional and psychological aspects of dying. In general, even ambiguous signs of discomfort should usually be treated, although caution must be exercised in interpreting such signs. 39 Patients who are actively dying may groan or grunt in ways that suggest they are in pain, although such sounds may, in fact, be the normal expressions attendant to the last moments or hours of life.

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Book Code: CA23CME

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