A 58-year-old male with colon cancer metastatic to the liver and lungs presents with vomiting, dyspnea, and abdominal pain. His disease has progressed through third-line chemotherapy and his care is now focused entirely on symptom management. He has not had a bowel movement in five days and he began vomiting two days ago.
The majority of patients in the United States die in acute-care hospitals. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT), which evaluated the courses of close to 10,000 hospitalized patients with serious and life-limiting illnesses, illustrated that patients’ end-of-life (EOL) experiences often are characterized by poor symptom management and invasive care that is not congruent with the patients’ overall goals of care.1 Studies of factors identified as priorities in EOL care have consistently shown that excellent pain and symptom management are highly valued by patients and families. As the hospitalist movement continues to grow, hospitalists will play a large role in caring for patients at EOL and will need to know how to provide adequate pain and symptom management so that high-quality care can be achieved.
Pain: A Basic Tenet
A basic tenet of palliative medicine is to evaluate and treat all types of suffering.2 Physical pain at EOL is frequently accompanied by other types of pain, such as psychological, social, religious, or existential pain. However, this review will focus on the pharmacologic management of physical pain.
Pain management must begin with a thorough evaluation of the severity, location, and characteristics of the discomfort to assess which therapies are most likely to be beneficial (see Table 1).3 The consistent use of one scale of pain severity (such as 0-10, or mild/moderate/severe) assists in the choice of initial dose of pain medication, in determining the response to the medication, and in assessing the need for change in dose.4
Opioids are the foundation of pain management in advanced diseases because they are available in a number of formulations and, when dosed appropriately, they are effective and safe. Starting doses and equianalgesic doses of common opioids are presented in Table 2. Guidelines recommend the use of short-acting opioids for dose titration to gain control of poorly controlled pain.3 If a patient is experiencing mild pain on a specific regimen, the medication dose can be increased up to 25%; by 25% to 50%, if pain is moderate; and 50% to 100%, if severe.5 When the pain is better-controlled, the total amount of pain medication used in 24 hours (24-hour dose) can be converted to a long-acting formulation for more consistent pain management. Because there is a constant component to most advanced pain syndromes, it is recommended that pain medication is given on a standing basis, with as-needed (prn) doses available for exacerbations of pain.3 Prn doses of short-acting medication (equivalent to approximately 10% of the 24-hour dose of medication) should be available at one- or two-hour intervals prn (longer if hepatic or renal impairment is present) for IV or PO medications, respectively.