fundamentals
Symptoms During a Fatal Illness
Pain
Most people fear pain as they confront dying. However, nearly all people can be made more comfortable, and most can also remain awake and involved in the world. However, aggressive pain therapy may sometimes unavoidably cause sedation or confusion. The doctor’s choice of pain reliever (analgesic) depends largely on the intensity of the pain and its cause, which the doctor determines by talking with and observing the person.Aspirin,acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving mild pain. However, many people need more powerful pain relievers such as opioids to treat moderate to severe pain. Opioids given by mouth, such asoxycodone,hydromorphone,morphine, andmethadone, or under the tongue, such asfentanyl, can relieve pain conveniently and effectively for many hours. If a person cannot take opioids by mouth or under the tongue, opioids are given via skin patch, injection under the skin or into a muscle, rectum, or continuous infusion into a vein. Adequate drug therapy should be given early, rather than held off until the pain is intolerable. There is no usual dose. Some people need only small doses, whereas others need much larger doses for the same effect. If a lower opioid dose is no longer effective, doctors should increase the dose, often by doubling it. Drug dependence may result from regular opioid use but causes no problems in dying people except the need to avoid sudden withdrawal and its uncomfortable symptoms. Drug addiction simply is not a concern when a person is close to death. Opioids may cause side effects such as nausea, sedation, confusion, constipation, or slow or shallow breathing (respiratory depression). Most of these side effects, except for constipation, usually resolve over time or when another opioid is substituted. Constipation can often be minimized by starting laxatives even before opioids are given. Opioids may occasionally cause delirium and seizures. People who have severe or persistent side effects or inadequate pain relief often benefit from treatment by a pain specialist. Using other drugs in addition to opioids often increases comfort and reduces the opioid dosage and side effects. Corticosteroids (such asprednisoneormethylprednisolone) can reduce the pain of inflammation and swelling. Antidepressants (such asnortriptylineanddoxepin) orgabapentinhelps manage pain caused by abnormalities in the nerves, spinal cord, or brain. Some antidepressants such asdoxepincan be given at night to help people sleep as well. Benzodiazepines (such aslorazepam) are useful for people whose pain is worsened by anxiety. For severe pain located in one spot, a local anesthetic injected into or around a nerve (a “nerve block”) given by an anesthesiologist (a doctor with special training in managing pain and supporting people during surgery) may provide relief with few side effects. Overview of Integrative, Complementary, and Alternative Medicine (such as guided imagery, hypnosis, acupuncture, relaxation, and biofeedback) help some people. Counseling for stress and anxiety may be very helpful as well as may spiritual support from a chaplain. Most of the distressing symptoms that occur near death can be relieved, at least to a large extent. 