Effective pain management in terminally ill requires Understanding of pain control strategies Ongoing assessment Diagnosis of pain Breakthrough pain relief Fine adjustment of medications Opioid rotation Unresolved psychosocial or spiritual issue can be great impact to pain management

1. PAIN MANAGEMENT
AS PART OF
“PALLIATIVE
CARE”
P. Chaudakshetrin M.D., FFPMANZCA(Hon.)
Pain & Palliative Care, Samitivej Sukhumvit Hospital
Bangkok. THAILAND
How I do it

2. Staff tea
room
Rest room
Rest room
Conference room
CS 5 CS 7
CS 4
CS 3 CS 6
CS 2
Treatment
roomCS 1
Counseling
room
Rest room
Rest room
Palliative
care
office
Pain
clinic
office
Patient
waiting
area
Entrance

3. Symptom control has to precede
spiritual support. A person can not
think about meaning of his life while
he has pain or keeps being sick.

4. that improves the quality of life
of patients & their families
facing the problems associated with
life-threatening illness,
through the prevention & relief of suffering
by means of early identification &
impeccable assessment & treatment
of pain & other problems,
physical, psychosocial and spiritual.
World Health Organization 2002
Palliative Care is an approach

5. CA breast with lymphedema pain, Rt upper extremity

6. Advanced Rectal cancer s/p palliative colostomy,
large pelvic mass involved bony structure,
incarcerated peri-anal erosion + multiple lymph
node metastasis. fecal incontinence,
• Stocking like dysesthesia,
• Diminished pinprick sensation
• Slight motor weakness

7. Palliative Care
Principles
Symptom
control
Disease
manage
ment
Psycho-
social
care
• High quality
• Cost effective care
• Person oriented,
not disease
oriented
• Holistic in approach
• Multidisciplinary
team

8. Approach To Pain Control in Palliative Care
1. Thorough assessment by skilled and knowledgeable
clinician
– History
– Physical Examination
2. Pause here - discuss with patient/family the goals of
care, hopes, expectations, anticipated course of illness.
This will influence consideration of investigations and
interventions
3. Investigations – X-Ray, CT, MRI, etc - if they will affect
approach to care
4. Treatments – pharmacological and non-pharmacological;
interventional analgesia (e.g.. Spinal)
5. Ongoing reassessment and review of options, goals,
expectations, etc.

9. Be prepare to breaking bad news !
• Disease Diagnosis
• Prognosis
It’s our responsibilities !

10. Breaking Bad News:
The SPIKES Approach
• Setting up
• Perception
• Invitation
• Knowledge
• Emotions
• Strategy and summary
Baile WF, Buckman R, Lenzi R, et al. Oncologist 2000; 5: 302-11

11. Symptom Management - General Approach
WHY is the patient having this
symptom?
In the light of your assessment,
Make a TREATMENT plan
Try to treat the cause at the same
time as treating symptomatically
Liaise with the team, patient & family
Explain, educate and support
Document discussion/decisions/plans
REVIEW / FOLLOW-UP

12. Pain Assessment
• Listen carefully: What are the words used?
– May deny pain but will admit to having “discomfort”,
“aching” or “soreness”
– Do you hurt anywhere?
– Are you uncomfortable?
– How does it affect you?
• Believe the patient “pain is what the patient says
hurts….the best judge of a patient’s pain is the
patient” Bonica
• Assess for other symptoms: Portenoy: Study of 243 cancer
patients- Average of 11.5 symptoms
12

13. PRINCIPLES OF SYMPTOM MANAGEMENT
– When possible, choose a drug treatment that targets
the likely underlying cause
– Nausea and vomiting, for example, can be secondary to
gastric outlet obstruction, hypercalcemia, increased
intracranial pressure, esophagitis, opioid use, or
constipation
Try to understand the pathophysiology
behind the symptom

14. PAIN PROBLEMS HAS TO BE
DIAGNOSED AND
DIFFERENTIAL DIAGNOSE
DInflammation
from IV site
A Fracture from bone
metastasis
B Pressure sore
CConstipation colic

15. What is the cause of this pain ?
• Cancer-related
– Bone
– Nerve compression/infiltration
– Soft tissue infiltration
– Visceral
– Muscle spasm
– Lymphoedema
– Raised intracranial pressure
• Treatment related
– surgery: postoperative scars
/adhesions
– Radiotherapy: burns/ fibrosis
– Chemotherapy: neuropathy
• Associated with cancer/
debility
– Constipation
– Pressure sores
– Bladder spasms
– Stiff joints
– Post-herpetic neuralgia
• Unrelated to cancer
– Arthritis
– Angina
– trauma

16. Attention to “Total P.A.I.N.”
hysical Distress (physical
pain/discomfort)
ffective Distress (anger, anxiety,
depression)
nterpersonal Distress (relationships)
ormative Distress (spiritual,
existential)

17. Examination
It is in itself a powerful, non-verbal message.
“ I am interested in you, and this is how I am
going to care for you.” and opportunity for
positive comments
( which need to be true)

18. Pain management

19. Challenges in Cancer Pain Management
• Bone Pain
• Neuropathic Pain
• Gastrointestinal pain / obstruction
• Mixed Pain
• Treatment related neuropathy
• / arthropathy
• The Role of tumor factors
• “ extra layer” local / systemic

20. Progression of cancer pain
• Turning in bed
• Limb movement
• Coughing
• spontaneous
Intermittent pain
Constant pain
Episode of break through pain
Extreme pain associate with
normal activities

21. SPECIAL CONSIDERATIONS IN PALLIATIVE CARE
PATEINTS
• These people may:
• Be debilitated and cachexic
• Have other medical problems
• Not be able to tolerate side-effects of drugs
• Be on multiple medications +/- complementary
therapies
• Have multiple symptoms

22. Therapeutic limitations
 Lack of clinical characterization of pain
syndromes
 Unpredictable response to treatment
 Limited time to get it right
 Several pains in single patients
 Average of 6 non-pain symptoms
 General frailty / co-morbidities
 Drug side effects

23. Palliative Care
Not Just opiates

24. Address psychosocial problems
Specific therapies
Radiotherapy, chemotherapy,surgery
Co-analgesics
Drugs, nerve blocks, TENS, relaxation, acupuncture
Morphine
Fentanyl
Methadone
Codeine
TramalAspirin
Acetaminophen
NSAIDs

25. ‘Good enough’ Relief
• Re-frame goal
• Primary goal of pain management is
helping patients move from being
overwhelmed by their pain to
establishing mastery over the pain
25

26. Seizures,
Death
Opioid
tolerance
Mild myoclonus
(eg. with sleeping)
Severe myoclonus
Delirium
Agitation
Misinterpreted
as Pain
Opioids
Increased
Hyperalgesia
Misinterpreted
as Disease-Related Pain
Opioids
Increased
Spectrum of Opioid-Induced Neurotoxicity

27. The needs of the
dying
are different from
those
who are expected to
recover.
When FANTASY stops, the reality begins…
Changed focus of care helps the person
begin some of the tasks of life closure.

28. “When nothing can be done”
‘Caring is the result of an ongoing creativity process. If creativity
is arrested or stopped, caring and hope are not possible. You
have to restore creativity in order to restore hope”

29. Clinically, skilled psychosocial and
spiritual care can provide a way
out of pharmacologically
“intractable” pain without resort
to sedation.

30. Causes of terminal restlessness
– Uncontrolled pain and other symptoms
– Drugs
– Metabolic
– Infections
– Constipation
– Cerebral causes
– Postictal
– Anxiety
– Withdrawal

31. Terminal sedation
• Sedation should not be intended as a terminal
event
• All other options should have been explored
first
• The level of sedation is only that required to
relieve distress
• Sedation is achieved with sedatives, not
opioid

32. Effective pain management in
terminally ill requires
• Understanding of pain control strategies
• Ongoing assessment
• Diagnosis of pain
• Breakthrough pain relief
• Fine adjustment of medications
• Opioid rotation
• Unresolved psychosocial or spiritual issue can be
great impact to pain management

33. The greatest things in this world
can not be seen or touched. They
must be felt by the heart.”
Helen keller.