special subjects
Symptom Relief for the Dying Patient
Pain
About half of patients dying of cancer have severe pain. Yet, only half of these patients receive reliable pain relief. Many patients dying of organ system failure and dementia also have severe pain. Sometimes pain can be controlled but persists because patients, family members, and physicians have misconceptions about pain and the drugs (especially opioids) that can relieve it, resulting in serious and persistent underdosing. for severe pain (see Treatment of Pain ). In dying patients, oral opioid therapy is convenient and cost-effective. Sublingual administration is also convenient particularly because it does not require patients to swallow. In the unusual case where opioids cannot be given orally or sublingually, they can be given rectally, or by injection (IM, IV, or subcutaneously). Long-acting opioids are best for long-lasting pain. Physicians should prescribe opioids in adequate dosages and on a continuous basis and make additional, short-acting opioids available for breakthrough pain. Concerns by the public and by health care practitioners about addiction may unreasonably limit appropriate use of opioids in dying patients. Pharmacologic dependence may result from regular use but causes no problems in dying patients except the need to avoid inadvertent withdrawal. Prescription opioid risk mitigation strategies, such as prescription drug monitoring programs and opioid reversal drugs likenaloxone, are not usually necessary for dying patients. Adverse effects of opioids include nausea, sedation, confusion, constipation, and respiratory depression. Opioid-induced Constipation should be treated prophylactically. Patients usually develop substantial tolerance to the respiratory depressant and sedative effects of When a stable opioid dose becomes inadequate, increasing the dose by 1½ to 2 times the previous dose (eg, calculated based on daily dose) is reasonable. Usually, serious respiratory depression occurs only if the new dose is much more than twice the previously tolerated dose. ) help manage Neuropathic Pain ; For severe localized pain, regional nerve blocks given by an anesthesiologist experienced in pain management may provide relief with few adverse effects. Various nerve-blocking techniques may be used. Indwelling epidural or intrathecal catheters can provide continuous infusion of analgesics, often mixed with anesthetic drugs. Pain-modification techniques (eg, Guided Imagery , 