___________________________________________ Palliative Care and Pain Management at the End of Life
will substantially help in directing effective treatment. The risks, benefits, costs, and options for treating an underlying cause should be discussed with the patient and family and considered within the context of the patient’s culture, belief system, and expectations. An important contribution of palliative care is the commit- ment to explore sources of suffering other than merely the physical aspects. Serious illness inevitably leads to an array of thoughts, feelings, fears about the future, and an erosion of capacity for work and other activities that give life meaning and purpose. Thus, in addition to pharmacologic treatment of physical symptoms, nonpharmacologic strategies are needed to augment therapy and to address the sensory, cognitive, affec- tive, and functional components of illness [67]. The healthcare team should talk to the patient and family about priorities for pharmacologic versus nonpharmacologic treatments. Although data are limited on some nonpharmacologic interventions, many patients have benefited from these approaches. As research expands in the field of palliative care, other innova- tive strategies are being scientifically evaluated, and results are sometimes conflicting. Nonpharmacologic measures should be carried out in conjunction with pharmacologic management before medications fail to provide relief, as interventions, especially cognitive/behavioral techniques, are more effective when symptoms are acute and/or mild. Once the patient’s needs have been assessed, the palliative care team should work with the patient (and family) to develop priorities and goals of care [113]. Continual reassessment of symptoms and periodic review and documentation of the patient’s goals and care plan are necessary to ensure that his or her needs are met [113]. It may be helpful for patients or a family member to keep a pain or symptom diary to note which measures have or have not provided relief and the duration of relief. This information will help clinicians determine the efficacy of specific therapeutic options and modify the treat- ment plan as necessary. The discussion of interventions that follows focuses on the care of adults. Palliative care for children is addressed later in this course. PAIN Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understand- ing of effective pain management is well-documented [222]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [47; 126; 187; 207; 209; 217; 222; 223; 224; 225]. Issues in Effective Pain Management The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain
relief [226]. This reluctance is related to a variety of attitudes and beliefs [222; 226]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medica- tions • Fear that increasing pain means that the disease is get- ting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcom- ing these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversa- tions about pain management, especially regarding the use of opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [227]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fic- tion. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low [222]. It is also helpful to note the difference between addiction and physical dependence. There are several other ways clinicians can allay patients’ fears about pain medication: • Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe. • Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely and that some side effects will abate over time. • Explain that pain and severity of disease are not neces- sarily related. Encouraging patients to be honest about pain and other symptoms is also vital. Clinicians should ensure that patients understand that pain is multidimensional and emphasize the importance of talking to a member of the healthcare team about possible causes of pain, such as emotional or spiritual distress. The healthcare team and patient should explore psy- chosocial and cultural factors that may affect self-reporting of pain, such as concern about the cost of medication. Clinicians’ attitudes, beliefs, and experiences also influence pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [222; 223; 226; 228; 229; 230]. A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [226; 228; 230; 231]. As a result, many clinicians, especially primary care physicians, do not feel confident about their abil- ity to manage pain in their patients [226; 228].
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MDCA1525
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