Is the elimination of pain at the end of life always possible?

[drscholls]

I've been having an interesting debate regarding physician assisted death and as part of this debate the question of end of life conditions for terminal patients has come up.

A long time heathcare provider (an RN) has asserted that it is possible to completely eliminate pain in patients during the final days of their life. My own experience and conversations with a few physicians have suggested otherwise. I thought this would be the place to come for some more focused opinions.

Is it possible to completely eliminate the pain associated with diseases like cancer as patients the patients enter the final transition into death.

---

Members don't see this ad.

 

[Boogie Man]

Is it possible to completely eliminate the pain associated with diseases like cancer as patients the patients enter the final transition into death.

Depends on a lot of factors I guess... based on what I've seen it appears that death itself is the only thing that brings complete relief of pain.

 

[cpants]

If your goal is comfort only, you can keep turning up the morphine until the patient appears comfortable. Opioids are drugs with unlimited dosing, and when I've seen comfort care done well, even patients with advanced cancers can be relatively pain free. The nice thing about pain and opioids is they have counteracting effects. It's not really possible to have someone go apneic from opioids if they are in tons of pain. Pain stimulates you to breathe. It's just a question of titration.

Also using adjunct medications helps. Is the person really in pain, or is it just agitation from delirium?

It also depends on patient goals. If they want to be lucid and interacting with family members, it may not be possible for them to be pain free. You have to work with them on goals.

 

[VentJockey]

I have seen times when the mu receptors appear to be saturated, and there is no apparent effect of further escalation of narcotic dosages. Its not like that's the end of the line, you can add benzos and sedate them, but pain management is a genuine challenge in some patients and despite best efforts still the patient suffers until the end.

 

[deleted185747]

If your goal is comfort only, you can keep turning up the morphine until the patient appears comfortable. Opioids are drugs with unlimited dosing, and when I've seen comfort care done well, even patients with advanced cancers can be relatively pain free. The nice thing about pain and opioids is they have counteracting effects. It's not really possible to have someone go apneic from opioids if they are in tons of pain. Pain stimulates you to breathe. It's just a question of titration.

Also using adjunct medications helps. Is the person really in pain, or is it just agitation from delirium?

It also depends on patient goals. If they want to be lucid and interacting with family members, it may not be possible for them to be pain free. You have to work with them on goals.

You are wrong about not being able to go apnic if in pain. Chronic pain downregulates the mu receptors on the peripheral C-fibers and thus creates opioid insensitive pain. You can titrate the patient's dose to sedation and apnea and the second your patient wakes up will say they hurt. You have to use other medications and procedures to block pain but this depends on the source of pain.

Don't fool yourself and think opioids are safe if the patient is in pain.

 

[loveoforganic2]

In the case of intractable pain, it can be an option to do palliative sedation with something like midaz. The emphasis on complete lack of pain I don't find meaningful though - as a healthy 24 year old, I experience daily pains of some sort. It's a matter of keeping pain at tolerable levels

 

[VentJockey]

I would add that you can occasionally have a paradoxical response to opoids, which acutally results with increasing pain with increasing dose. This is so very complex to manage, let's get away from the idea that we can just titrate up away from terrible pain. Sometimes death is hideous despite our best efforts. It is a sad reality and sobering reminder of the limitations of our current abilities.

 

[brimcmike]

Short of palliative sedation to unconsciousness, think first about rational trials of medications to treat neuropathic pain (there is a neuropathic component in bone pain, tumor pain and ischemic pain). You can consider anti-epileptic drugs (AEDs), e.g., gabapentin, pregabalin, carbamazepine, as well as SNRIs (duloxetine, venlafaxine). Also, consider NMDA-receptor antagonists, ketamine and methadone. Interestingly, tramadol has weak activity on serotonin, norepinephrine, NMDA receptors as well as weak mu antagonism. I had a patient with a large sarcoma, at home on hospice with gabapentin 900 mg TID, scheduled methadone 60 mg PO Q6H and hydromorphone PCA at 7 mg Q10ming with 24-hour hydromorphone doses >300 mg and actually approaching 400 mg - awake, alert, oriented, no myoclonus and experiencing fair pain control. That patient did not get there over night, but still...

As stated in the thread above, various blocks and epidurals should be considered as well.

Also, consider ketamine and lidocaine infusions
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_132.htm
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_180.htm

If you've really tried everything, and the patients is at end-of-life, experiencing severe suffering then palliative sedation to unconsciousness can be considered.
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_106.htm
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_107.htm

 

[europeman]

Hello.

I'm an ICU doc.

I often have to deal with end of life pain.

Few options besides just titration up the narcotic to crazy doses.

Of course maximize Tylenol, neuroleptics, possibly NSAIDs. Fine maybe add in some benzos fine.


But what works amazing is dexmeditomidine. It doesn't suppress respirations. It allows them to rest, but if stimulated they can wake up and interact just fine (converse with family..... Eat.... Whatever.). Can be given through peripheral IV. It has some analgesic properties but not much.... What it does do though is drastically potentiate the analgesic properties of the other drugs. None down side.... It's expensive and causes Bradycardia.


As another option is IV ketamine. Again doesn't suppresses breAthjng. amazing drug. The negative psychotropic effects of the drug Are drastically over stated. Down side is that at high enough doses they are essentially completely dissociated and (and while not in pain.... They are also essentially under anesthesia) and you can't interact with them. That said it's all dose dependent.


If you aren't using dex (which is an alpha 2 agonist), there is a lot of good stuff out there regarding adding on clonidine

 

[Trogghunter]

Hello.

I'm an ICU doc.

I often have to deal with end of life pain.

Few options besides just titration up the narcotic to crazy doses.

Of course maximize Tylenol, neuroleptics, possibly NSAIDs. Fine maybe add in some benzos fine.


But what works amazing is dexmeditomidine. It doesn't suppress respirations. It allows them to rest, but if stimulated they can wake up and interact just fine (converse with family..... Eat.... Whatever.). Can be given through peripheral IV. It has some analgesic properties but not much.... What it does do though is drastically potentiate the analgesic properties of the other drugs. None down side.... It's expensive and causes Bradycardia.


As another option is IV ketamine. Again doesn't suppresses breAthjng. amazing drug. The negative psychotropic effects of the drug Are drastically over stated. Down side is that at high enough doses they are essentially completely dissociated and (and while not in pain.... They are also essentially under anesthesia) and you can't interact with them. That said it's all dose dependent.


If you aren't using dex (which is an alpha 2 agonist), there is a lot of good stuff out there regarding adding on clonidine

Precedex is ICU only though, correct?

 

[2Pints]

Precedex is ICU only though, correct?

At my hospital, if we can't get a pt off Precedex they can't transfer out of the ICU.

 

[Medschoolornah]

no it is not always possible.

 

[PinkLithe]

I don't think it's possible to completely eliminate pain, unless the patient is very sedated (palliative sedation). Pain is very complex, with spiritual, psychological and personal aspects, which are not treated effectively with medications. The goal for pain management should always be to find a level that is tolerable, rather than aim to eliminate it completely.

 

[Kahreek]

from what i've heard personally from hospice docs, i would say no.

Hello.

I'm an ICU doc.

I often have to deal with end of life pain.

Few options besides just titration up the narcotic to crazy doses.

Of course maximize Tylenol, neuroleptics, possibly NSAIDs. Fine maybe add in some benzos fine.


But what works amazing is dexmeditomidine. It doesn't suppress respirations. It allows them to rest, but if stimulated they can wake up and interact just fine (converse with family..... Eat.... Whatever.). Can be given through peripheral IV. It has some analgesic properties but not much.... What it does do though is drastically potentiate the analgesic properties of the other drugs. None down side.... It's expensive and causes Bradycardia.


As another option is IV ketamine. Again doesn't suppresses breAthjng. amazing drug. The negative psychotropic effects of the drug Are drastically over stated. Down side is that at high enough doses they are essentially completely dissociated and (and while not in pain.... They are also essentially under anesthesia) and you can't interact with them. That said it's all dose dependent.


If you aren't using dex (which is an alpha 2 agonist), there is a lot of good stuff out there regarding adding on clonidine

WHat about IV lidocaine, wouldnt it be similar to dexmeditomidine

 

[Kahreek]

If your goal is comfort only, you can keep turning up the morphine until the patient appears comfortable. Opioids are drugs with unlimited dosing, and when I've seen comfort care done well, even patients with advanced cancers can be relatively pain free. The nice thing about pain and opioids is they have counteracting effects. It's not really possible to have someone go apneic from opioids if they are in tons of pain. Pain stimulates you to breathe. It's just a question of titration.

Also using adjunct medications helps. Is the person really in pain, or is it just agitation from delirium?

It also depends on patient goals. If they want to be lucid and interacting with family members, it may not be possible for them to be pain free. You have to work with them on goals.

from the first to the last breath, it is kind of romantic and ironic how pain and respiratory pathways correlate.