● Consent is obtained from the patient or his/her proxy ● The withdrawal of food and water is discussed ● Families are informed that the patient will likely not regain consciousness and will die ● Causing death is not the intention even though it may not be possible to achieve adequate symptom control except at the risk of shortening the patient’s life The degree to which palliative sedation is used, and the manner in which it is used, must, in the end, be a matter of clinical judgment on the part of individual physicians.
Although palliative sedation may bring intolerable suffering to an end and allow people to die peacefully, it nonetheless can be challenging to put into practice and has been criticized as “slow euthanasia.” 93 Acknowledging the inherently complex and subjective nature of decisions about palliative sedation, guidelines have nonetheless been developed to help guide responsible use of this alternative. Many guidelines state that palliative sedation should only be considered when: 94,108 ● The patient is terminally ill ● Death is expected within hours or days ● The patient is suffering acute symptoms unresponsive to therapy
PALLIATIVE/END-OF-LIFE CARE CONCLUSIONS
Compassionate care for patients who are dying requires clinicians to employ the full range of their therapeutic skills to holistically care for the physical, psychological, and emotional needs of both their patients and loved ones. This is a time when diagnostic skills and medical knowledge may be less important that emotional intelligence and communication skills. It may also entail a shift away from previous goals of aggressive treatment with advanced medical technology, and toward a realistic assessment of what such technology can actually provide in terms of comfort, dignity, and peace of mind at the end of life. Ongoing pain assessment is critical in order to detect changes in pain such as the development of painful bone metastasis, resolution of treatable causes such as infections, or worsened neuropathic or visceral pain due to tumor growth. Careful refinement of pain management regimens is often required at the end of life and may include changes in the route of analgesics if patients can no longer take oral medications, the
need to rotate opioids, or the addition of adjunctive or integrative therapies. Clinicians should seek expert consultation from pain services or palliative care teams for complex cases or when pain appears to be refractory to all efforts. Early referral to hospice care may allow time for a carefully planned pain regimen to ensure comfort at the end of life. The other symptoms that can accompany the end of life, such as dyspnea, agitation, delirium, and anxiety, each need to be carefully assessed and treated with coordinated interventions. Fortunately, a wide array of analgesics, interventional strategies, adjuvant medications, varied routes of administration, and complementary and alternative therapies exist that, if used cooperatively and effectively, can greatly improve the chances that patients and their families will experience death without trauma, suffering, or unrelieved pain.
INTRODUCTION TO PAIN MANAGEMENT
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.” 110 Pain can be characterized as either acute or chronic pain. Acute pain typically has a sudden onset and a specific cause and is often described as sharp pain. Acute pain typically lasts for a short period, less than three months, and goes away when there is no longer an underlying cause for the pain. 111,112 Chronic pain is ongoing and typically lasts longer than three to six months, or past the amount of time needed for normal tissue healing. 113 Common causes of chronic pain include lower back pain, nerve pain, arthritis, and fibromyalgia. Chronic pain can affect many aspects of a patient’s life, causing adverse effects that include depression, fatigue, worsened comorbid conditions, and negative effects on social relationships. 114 Pain disorders, exclusive of cancer or end-of-life pain, are often referred to collectively as chronic noncancer
pain (CNCP). Chronic pain is one of the most common reasons that adults seek medical care in the United States, and is associated with poor mental health, decreased quality of life, and opioid dependence. The 2019 National Health Interview Survey found that in the previous three months, 20.4% of adults experienced chronic pain, and 7.4% had chronic pain that limited their work or life activities, known as high- impact chronic pain. The incidence of both chronic pain and high-impact chronic pain increased with age, with the highest prevalence in people over the age of 65. Incidence was also higher in rural areas, and among women as compared to men. 115 Pain is a highly subjective and personal experience that can be effectively described only by the person who is experiencing pain. Recognizing and accepting the subjectivity of pain are significant challenges of treating pain that must be overcome to provide appropriate care. 110
Book Code: CA23CME
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