Palliative Care: Pain Management

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Palliative CarePain Management End-of-Life
Care

• Winnie Hennessy, PhD, RN
• Palliative and Supportive Care

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Contacts

• Winnie Hennessy, PhD, RN
• Palliative and Supportive Care Consults
• 876-1121 (office) Pager ID 11132
• Karanne Campbell, APRN
• Pain and symptom Management Consults
• 792-3356 (office) pager ID 11719
• Palliative Care Service
• Attending on call

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Changing Demographics

• In 1900 - 1/2 of all deaths were under the age of
  16, and died in the home
• In 2000, 2/3 of all deaths were over the age of
  65 and died in an institution
• 90 of all Americans will die of a disease that
  they have greater than 3 months to think about
• lt15 of all Americans have an advance directive
  (still true in 2002)

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Culture

• America is a death denying society
• In America, death is viewed as a matter of
  choice, rather than the natural, necessary and
  inevitable end-point of medical care
• When in doubt, do something
• Myths regarding addiction and physiological
  dependence
• Health Care is a visual culture
• Callahan, D., (1993). Pursuing a Peaceful Death,
  Hastings Center Report (3)

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Palliative Care

• Interdisciplinary care that aims to relieve
  suffering and improve quality of life for
  patients with advanced illness and their
  families.
• It is offered simultaneous with all other
  appropriate medical treatment.
• (2003 Center to Advance Palliative Care, Meier,
  MD)

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Principles of Palliative Care

• Affirms life, regards dying as a normal process,
  neither hastens nor postpones death
• Fundamental purpose is to alleviate pain and
  suffering
• Focuses on treatment that enhances comfort and
  improves quality of life
• Dying is a process, not an illness

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What Do Patients With Serious Illnesses Want?

• Pain and symptom control
• Avoid inappropriate prolongation of the dying
  process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones

Singer et al, JAMA 1999
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Spiritual pearls

• Hospice Teachings
• Please forgive me
• I forgive you
• This is what you meant to me
• I will miss you
• Goodbye
• Reduce Fear Explain what dying looks like

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JCAHO Regulations End of Life

• RI 2.70- Patients have the right to refuse care,
  treatment and services in accordance with the law
  and regulation
• RI 2.80- The organization addresses the wishes of
  patients related to end-of-life decisions
• PC 8.70- Comfort and dignity are optimized during
  end-of-life care

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MUSC Death Data (2003)

• Adult ICU Deaths 197 (54.6)
• Adult Floor Deaths 164 (45.4)
• of patients, who died, per unit
• ICU 4STN (79) Floor 6E (11) 8E (34) 8MIC
  (49) 6W (6) 8W (38) 4MSI (28) 7E
  (19) 9PCU (19) 9CCU (26) 7W (6) 10W (11)
  4CTI (18) 10E (8)
• Additional areas
• T09C (7), T06E (2), 4E (1), 6ACU (1), PH3N
  (1)

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Pain Management

• We all must die. But if I can save him from days
  of torture, that is what I feel is my great and
  ever new privilege.
• Pain is a more terrible lord of mankind
• than even death himself.
• Albert Schweitzer, MD 1875 - 1965

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Myth busting Addiction

• A psychological dependence a pattern of
  compulsive drug use characterized by craving and
  the need to use a drug for effects other that
  pain relief.
• A psychologic and behavioral syndrome with 3
  distinguishing characteristics
• Loss of control over drug use
• Compulsive drug use
• Continued use despite harm
• DSM-IV Diagnostic Criteria

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Myth busting Physical Dependence

• An adaptive neuro-physiological response to the
  chronic presence of a drug
• Expect to occur is 2-3 days of repeated doses of
  an opioid
• Withdrawal or Abstinence syndrome
• Is a manifestation of physical dependence.
• Occurs when drug is abruptly stopped or
  antagonist is given
• Not an indicator of addiction
• Remove insulin from a insulin dependent diabetic,
  a withdrawal syndrome occurs.

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Myth busting Tolerance

• Tolerance A pharmacodynamic response at the
  neurophysiological level to chronic drug
  administration
• Evidence by a reduction in response or effect to
  a given dose of a drug after repeated
  administration.
• Tolerance to some of the effects of opioids, is
  expected (sedation, respiratory depression)
• Not an indicator of addiction
• Tolerance develops to the effects of many classes
  of drugs, e.g. Corticosteroids

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Definition of Pain

• An unpleasant sensory and emotional stimulus
  associated with actual or potential tissue damage
  or described in terms of such damage.
  (International Association for the study of Pain,
  1979)
• Pain is whatever the experiencing person says it
  is, existing whenever he/she says it does.
  (McCaffery 1968)

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Did you know

• Pain is the most common reason individuals seek
  medical attention but only 1 in 4 receive proper
  treatment for their pain.
• Unrelieved pain has adverse physical and
  psychological effects (APS, 1999)
• Over 75 million Americans suffer with pain each
  year (APS, 2000).
• ? Approximately 50 million Americans suffer
  with chronic pain each year.
• ? About 25 million Americans have acute pain
  from injury or surgery.

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Basic Types of Pain

• Acute Relatively brief, pain that subsides as
  healing takes place.
• Characterized bydefined onset, self-limiting,
  tells you something is wrong, serves a purpose.
• Chronic Can persist for months, serves no
  purpose, no change in vital signs
• Malignant (cancer)
• Non-malignant (non-cancer)
• Combination Chronic with acute exacerbations

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Basic physiology of pain

• Nociceptive Pain
• Results from ongoing activation of primary
  afferent neurons by noxious stimuli (intact
  nervous system)
• Somatic Arises from bone, joint, muscle, skin,
  or connective tissue
• normally opioid sensitive
• Visceral Arises from visceral organs, such as GI
  tract or pancreas.
• normally opioid sensitive

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Basic physiology of pain

• Neuropathic
• Abnormal processing of sensory input by
  peripheral or central nervous system (lesion or
  dysfunction).
• Proposed mechanism peripheral nervous system
  damaged in some way.
• Relatively opioid resistant.
• Treatment should include adjuvant analgesics.

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JCAHO pain standards

• The hospital addresses care at the end of life
  (RI.1.2.8.)
• Hospital framework provides for Managing pain
  aggressively and effectively
• Effective pain management is appropriate for all
  patients, not just dying patients
• Patients have the right to appropriate assessment
  and management of pain (RI.1.2.9)

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JCAHO pain standards

• Pain is assessed in all patients (PE.1.4)
• Each patient is reassessed at points designated
  in hospital policy (PE.2)
• Reassessment occurs at regular intervals in the
  course of care (PE.2.1)
• Reassessment determines a patients response to
  care (PE.2.2)
• Significant change in a patients condition
  results in reassessment (PE.2.3)

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JCAHO pain standards

• Patients are educated about pain and managing
  pain as part of treatment, as appropriate
  (PF.3.4)
• The organization collects data to monitor its
  performance (PI.3.1)
• The appropriateness and effectiveness of pain
  management

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MUHA Pain Committees

• MUHA Pain PI structure
• Posted on MUSC Intranet along with membership and
  contact names
• MUHA Pain PI Committee
• MUHA Pain Resources Nurses (PRN) Committee

TEAM
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MUSC Policies Pain and EOL care

• Pain Policy (C-64)
• Patient Controlled Analgesia (C-55)
• Separate orders (Primary service may order)
• Subcutaneous infusion
• Epidural Analgesia (C-54)
• Separate orders (Anesthesia writes orders)
• Peripheral Nerve Block (upcoming)
• End of Life Care policy C-50 (being revised)

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The END