___________________________________________ Palliative Care and Pain Management at the End of Life
Massage, which can be broadly defined as stroking, compres- sion, or percussion, has led to significant and immediate improvement in pain in the hospice setting [273]. Both mas- sage and vibration are primarily effective for muscle spasms related to tension or nerve injury, and massage can be carried out with simultaneous application of heat or cold. Massage may be harmful for patients with coagulation abnormalities or thrombophlebitis [227]. Focused relaxation and breathing can help decrease pain by easing muscle tension. Progressive muscle relaxation, in which patients follow a sequence of tensing and relaxing muscle groups, has enabled patients to feel more in control and to experience less pain and can also help provide distraction from pain. [227]. This technique should be avoided if the muscle tensing will be too painful. Acupuncture typically provides pain relief 15 to 40 minutes after stimulation. Relief seems to be related to the release of endorphins and a susceptibility to hypnosis [227]. The efficacy of acupuncture for relieving pain has not been proven, as study samples have been small. However, acupuncture has been found to be of some benefit for cancer-related pain when the therapy is given in conjunction with analgesic therapy [274]. Other nonpharmacologic interventions that have been help- ful for some patients but lack a strong evidence base include manipulative and body-based methods (such as application of cold or heat, and positioning), yoga, distraction, and music or art therapy. The application of cold and heat are particularly useful for localized pain and have been found to be effective for cancer-related pain caused by bone metastases or nerve involvement, as well as for prevention of breakthrough inci- dent pain [227]. Alternating application of heat and cold can be soothing for some patients, and it is often combined with other nonpharmacologic interventions. Cold can be applied through wraps, gel packs, ice bags, and menthol. It provides relief for pain related to skeletal muscle spasms induced by nerve injury and inflamed joints. Cold application should not be used for patients with peripheral vascular disease. Heat can be applied as dry (heating pad) or moist (hot wrap, tub of water) and should be applied for no more than 20 minutes at a time, to avoid burning the skin. Heat should not be applied to areas of decreased sensation or with inadequate vascular supply, or for patients with bleeding disorders. Changing the patient’s position in the bed or chair may help relieve pain and also helps minimize complications such as decubitus ulcers, contractures, and frozen joints. Members of the healthcare team as well as family members and other informal caregivers can help reposition the patient for comfort and also perform range-of-motion exercises. Physical and occu- pational therapists can recommend materials, such as cushions, pillows, mattresses, splints, or support devices.
Hatha yoga is the branch of yoga most often used in the medi- cal context, and it has been shown to provide pain relief for patients who have osteoarthritis and carpal tunnel syndrome but it has not been studied in patients at the end of life. Yoga may help relieve pain indirectly in some patients through its effects on reducing anxiety, increasing strength and flexibility, and enhancing breathing [275]. Yoga also helps patients feel a sense of control. Methods to provide distraction from pain come in a wide variety of methods, including reciting poetry, meditating with a calm phrase, watching television or movies, playing cards, visiting with friends, or participating in crafts. Music therapy and art therapy are also becoming more widely used as nonpharmacologic options for pain management. Listening to music has been shown to decrease the intensity of pain and reduce the amount of opioids needed, but the mag- nitude of the benefit was small [276]. Research suggests that art therapy contributes to a patient’s sense of well-being [277]. Creating art helps patients and families to explore thoughts and fears during the end of life. An art therapist can help the creators reflect on the implications of the art work. Art therapy is especially helpful for patients who have difficulty expressing feelings with words, for physical or emotional reasons. FATIGUE Fatigue is a subjective feeling of tiredness, weariness, and lack of energy. Fatigue is often accompanied by a feeling of weak- ness (asthenia), which can be either generalized or localized. The National Comprehensive Cancer Network (NCCN) defines fatigue as “a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion… that is not proportional to recent activity and interferes with usual functioning” [278]. Fatigue associated with life-limiting diseases is further characterized by the disproportionate relationship to recent activity and the lack of recovery follow- ing additional sleep [279]. Persistent fatigue has a significant impact on the quality of life by negatively affecting functional status, interfering with normal activities, and contributing to emotional distress [278]. Fatigue may also cause distress for a patient’s family members, who may interpret this symptom as a sign of the patient “giving up.” As is the case with pain, fatigue is underreported, underdiagnosed, and undertreated [279]. Studies have indicated that approximately half of patients do not report fatigue to their healthcare team, and the primary reasons were that they did not think effective treatments were available and their physicians did not offer interventions [280]. Fatigue is often part of a cluster of symptoms that may also include pain, depression, sleep disturbances, and anxiety/ depression, especially at the end of life [278; 281; 282; 283; 284]. Analysis of 25 symptoms among 922 patients with advanced cancer demonstrated seven clusters. One of those clusters, referred to as the fatigue/anorexia-cachexia cluster, was
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