Palliative care and pain



Palliative care and pain


D. Oxenham



Principles of palliative care


Palliative care is the active total care of patients with far advanced, rapidly progressive and ultimately fatal disease. Its focus is quality of life rather than cure, and it encompasses a distinct body of knowledge and skills that all good physicians must possess to allow them to care effectively for patients at the end of life. In palliative care, there is a fundamental change of emphasis in decision-making away from a focus on prolonging life towards decisions that balance comfort and the individual’s wishes with treatments that might prolong life. There is a growing recognition that the principles of, and some specific interventions developed in the palliative care of patients with cancer are equally applicable to other conditions. The principles of palliative care may therefore be applied not only to cancer but also to any chronic disease state.


Palliative care is often seen as a means of managing distress and symptoms in patients with cancer, where metastatic disease has been diagnosed and death is seen as inevitable. In other illnesses, the challenge is recognising when patients have entered this phase of their illness, as there are fewer clear markers and the course of the illness is much more variable.


Different chronic disease states progress at different rates, allowing some general trajectories of illness or dying to be defined (Fig. 12.1). These trajectories are useful in helping decision-making in individual patients and also in planning services.


image
Fig. 12.1 Archetypal trajectories of dying. From Murray, et al. 2005 – see p. 292.

Traditionally, palliative care has been associated with cancer because the latter is typified by a progressive decline in function which was more predictable than in many other diseases. This ‘rapid decline’ trajectory is the best-recognised pattern need for palliative care and many traditional hospice services are designed to meet the needs of people on this trajectory: for example, motor neuron disease, or AIDS where antiretroviral therapy (ART) is not available. With the improvements in management of malignant disease, this is no longer so true for all patients with cancer, whose illness may follow an erratic or intermittent decline trajectory.


Many chronic diseases, such as advanced chronic obstructive pulmonary disease (COPD) and intractable congestive heart failure, carry as high a burden of symptoms as cancer, as well as psychological and family distress. The ‘palliative phase’ of these illnesses may be more difficult to identify because of periods of relative stability interspersed with acute episodes of severe illness. However, it is still possible to recognise those patients whose care may benefit from a palliative approach. The challenge is that symptom management needs to be delivered at the same time as treatment for acute exacerbations. This leads to difficult decisions as to the balance between symptom relief and aggressive management of the underlying disease. The starting point of need for palliative care in these conditions is the point at which consideration of comfort and individual values becomes important in decision-making, often alongside management of the underlying disease.


The third major trajectory is categorised by years of poor function and frailty before a relatively short terminal period; it is exemplified by dementia, but is also increasingly true for patients with many different chronic illnesses. As medical advances extend survival, this mode of dying is being experienced by increasing numbers of people. The main challenge lies in providing nursing care and ensuring that plans are agreed for the time when medical intervention is no longer beneficial.


In a situation where death is inevitable and foreseeable, palliative care balances the ‘standard textbook’ approach with the wishes and values of the patient and a realistic assessment of the benefits of medical interventions. This often results in a greater focus on comfort, symptom control and support for patient and family, and may enable withdrawal of interventions that are ineffective or burdensome. Commonly, the outcome is less certain. In many cases, there is a substantial risk that the patient will die but there may be a small chance of improvement with further treatment. In these circumstances, it is often (but not always) correct and helpful to share this information with the patient so that better decisions can be made about further care.


The principles of palliative care are being used increasingly in many different diseases so that death can be managed effectively and compassionately. Palliative management of the most common symptoms is discussed in the next section.



Presenting problems in palliative care


Pain


The International Association for the Study of Pain (IASP) has defined pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. It follows that each patient’s experience and expression of pain are different, and that severity of pain does not correlate with the degree of tissue damage. Effective pain treatment facilitates recovery from injury or surgery, aids rapid recovery of function, and may minimise chronic pain and disability. Unfortunately, the delivery of effective pain relief is often impeded by factors such as poor assessment and concerns about the use of opioid analgesia.



Pain classification and mechanisms


Pain can be classified into two types:



• Nociceptive: due to direct stimulation of peripheral nerve endings by a noxious stimulus such as trauma, burns or ischaemia.


• Neuropathic: due to dysfunction of the pain perception system within the peripheral or central nervous system as a result of injury, disease or surgical damage, such as continuing pain experienced from a limb which has been amputated (phantom limb pain). This should be identified early (Box 12.1) because it is more difficult to treat once established.



image 12.1   Features of neuropathic pain




The pain perception system (p. 1147) is not a simple hard-wired circuit of nerves connecting tissue pain receptors to the brain, but a dynamic system in which a continuing pain stimulus can cause central changes that lead to an increase in pain perception. This plasticity (changeability) applies to all the peripheral and central components of the pain pathway. Early and appropriate treatment of pain reduces the potential for chronic undesirable changes to develop.



Assessment and measurement of pain


Accurate assessment of the patient is the first step in providing good analgesia.



History and measurement of pain

A full pain history should be taken, to establish its causes and the underlying diagnoses. Patients may have more than one pain; for example, bone and neuropathic pain may both arise from skeletal metastases (Box 12.2).



image 12.2   Types of pain






































Type of pain Features Management options
Bone pain Tender area over bone Possible pain on movement
Increased intracranial pressure Headache, worse in the morning, associated with vomiting and occasionally confusion
Abdominal colic Intermittent, severe, spasmodic, associated with nausea or vomiting
Liver capsule pain

Neuropathic pain See Box 12.1
Ischaemic pain

Incident pain Episodic pain usually related to movement or bowel spasm Intermittent short-acting opioids Nerve block


image



A diagram of the body on which the patient can mark the pain site can be helpful. When asked to score pain, patients consistently rate it higher than health professionals and should, if able, always be asked to rate pain themselves. Methods include:



Regular recording of formal pain assessment and patient-rated pain scores improves pain management and reduces the time taken to achieve pain control.



Psychological aspects of chronic pain

Perception of pain is influenced by many factors other than the painful stimulus, and pain cannot therefore be easily classified as wholly physical or psychogenic in any individual (Fig. 12.2). Patients who suffer chronic pain will be affected emotionally and, conversely, emotional distress can exacerbate physical pain (p. 240). Full assessment for symptoms of anxiety and depression is essential to effective pain management.


image
Fig. 12.2 Components of pain.


Examination

This should include careful assessment of the painful area, looking for signs of neuropathic pain (see Box 12.1) or bony tenderness suggestive of bone metastases. In patients with cancer, it should not be assumed that all pains are due to the cancer or its metastases.




Management of pain


Many of the principles of pain management apply to any painful condition. There are, however, distinct differences between management of acute, chronic and palliative pain. Acute pain post-surgery or following trauma should be controlled with medication without causing unnecessary side-effects or risk to the patient. Chronic, non-malignant pain is more difficult and it may be impossible to relieve completely. In the management of chronic pain there is a greater emphasis on non-pharmacological treatments and on enabling the patient to live with pain. Strong opioids may help chronic pain but need to be used with caution after full assessment. They are used more readily in patients with a poorer prognosis.


Two-thirds of patients with cancer experience moderate or severe pain, and a quarter will have three or more different pains. Many of these are of mixed aetiology and 50% of pain from cancer has a neuropathic element. Careful evaluation to identify the likely pain mechanism facilitates appropriate treatment (see Box 12.2). It is vital that the patient’s concerns about opioids are explored. Patients should be reassured that, when they are used for pain, psychological dependence and tolerance are extremely rare (Box 12.3).



image 12.3   Opioid myths




















Myth Fact
Pain is inevitable in cancer and many other diseases Pain can usually be controlled
Opioids should be avoided because of dangerous side-effects Opioids can cause side-effects and sometimes the therapeutic window is narrow. However, side-effects are treatable and reversible
The use of opioids commonly leads to addiction Addiction is very rare in patients who have pain and no previous history of addiction
Taking opioids leads to more rapid decline and earlier death Opioids do not cause organ damage or other serious harm when used appropriately

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Apr 9, 2017 | Posted by in GENERAL SURGERY | Comments Off on Palliative care and pain

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