It takes flexibility to manage end-of-life pain
When medication doesn’t succeed, trial, trial again
The goal of pain management is the same, whether patients are at the end stage of life or are recovering from surgery.
"In all instances, the goal for pain management should be to help the patient be as comfortable as possible while keeping the patient as safe as possible," says Ann Quinlan-Colwell, RN, MS, CHPN, HNC, advanced practice nursing team leader for the pain/stress/palliative care team at Duke University Health Systems in Durham, NC.
However, pain management is very individualized. Some people don’t want any pain; others want some so they know they are still alive or want to be comfortable but alert. "I like to tell hospice patients that they are the directors and we are the supporting cast, and our goal is to help them to live every day the best and most comfortable that they can," Quinlan-Colwell says.
While the goal may be comfort, often it takes more than medication to ease the pain at the end of life. Psychological and spiritual issues can compound the suffering, says Justin Engleka, MSN, CRNP, CHPN, nurse practitioner in the palliative care and chronic pain service at the University of Pittsburgh Medical Center. "Anxiety, worries, and concerns about death itself or loved ones left behind all add to the whole component of suffering."
Therefore, while pain medicine is used to control the physical part of pain, spiritual counselors or clergy and experts from behavioral medicine also are involved in pain management because anxiety and worry can exacerbate pain.
To determine patients’ needs in these areas, they are asked about spiritual issues, such as what religion they are and its importance in their life during the initial screening. A symptom assessment scale touches on several psychological factors such as anxiety and depression. Sometimes, these issues come up in conversation as well, prompting a referral to the appropriate health care professional, Engleka says.
Individualize pain assessment
For end-of-life patients, the pain assessment must be very individualized with the frequency determined by the patient’s condition and needs. "End-of-life care is very fluid and needs to be flexible to meet the needs of the individual patient and family," Quinlan-Colwell says.
Generally, pain scales are used, and if the patient becomes noncommunicative, pain management goals are based upon what patients have previously established. Also, the care team pays close attention to the patient’s nonverbal communications such as facial expressions, hand movements, vital signs, and irritability, she says.
Pain assessment can be more difficult toward the end of life, not only when patients are less responsive but when they are concerned that medication may be used to slow down body functions and hasten death, says Linda E. Hood, RN, MSN, AOCN, oncology clinical nurse specialist at Duke University Health Systems.
Also, the assessment is complicated by other changes at the end of life. For example, patients may have some dementia or delirium that comes at end of life but can be attributed to the medications they are on as well. "It takes small trials and changes in medication to determine the cause," says Hood. If one change doesn’t work, another must be tried until it can be determined what is going on with the patient, she says.
Confusion also can result as a side effect of some medications, and family members usually want the patient to be as alert as possible. "This may require negotiating and adjusting medications. It also may mean using a combination of preparations to reduce the confusion with optimal analgesia," Quinlan-Colwell says. Often, nonpharmacological interventions can help ease pain and relieve confusion. They also complement a medication regimen to bring comfort. They might include relaxation exercises, progressive muscle relaxation, breathing strategies, touch therapies, and guided imagery.
Communication between the health care team and the patient is critical for pain control. "We teach patients that their pain should be treated. Often people feel they are complainers or they don’t want to be a bad patient, so they are reluctant to really communicate with their health care providers," says Engleka.
It’s also important for people to get teamed up with the person on the health care team that has expertise in treating pain but whom they feel comfortable with, he says. This could be the oncologist, a palliative care hospice specialist, or the patient’s primary care physician. This enhances communication.
It is possible to keep pain for terminally ill patients under control if there is frequent and open communication with the patient, family, care team, and physician, Quinlan-Colwell says.
[For more information, contact:
- Justin Engleka, MSN, CRNP, CHPN, Nurse Practitioner, Palliative Care and Chronic Pain Service, University of Pittsburgh Medical Center Care Service, 830 E. Montefiore Hospital, 200 Lothrop St., Pittsburgh, PA 15213. Telephone: (412) 692-4883. E-mail: [email protected].
- Linda E. Hood, RN, MSN, AOCN, Oncology Clinical Nurse Specialist, Duke University Health Systems, DUMC 3677, Duke North 9244, Durham, NC 27710. Telephone: (919) 684-1886. E-mail: [email protected].
- Ann Quinlan-Colwell, RN, MS, CHPN, HNC, Advanced Practice Nursing Team Leader, Pain/Stress/ Palliative Care Team, Duke University Health Systems, DUMC 3677, Duke North 9244, Durham, NC 27710. Telephone: (919) 970-6242. E-mail: [email protected].]
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