What do you consider end of life pain care for non cancer patients?

[OMMFellow06]

We had an interesting discussion after a journal club last night regarding end of life pain control.

Alot of talked about in regards to control pain when a patient has cancer and how it is sometimes acceptable if a patient has an adverse reaction or even death when it was attributed to pain control.

What was brought up last night was in regards to NON CANCER pain control in patients who have debilitating and possibly terminal diagnoses like severe cardiomyopathy, severe COPD, kidney failure on dialysis etc. where the patient comes to you as a pain doc and would like adequate pain control. What is considered proper pain care for these patients? They don't have a "terminal" diagnosis like in some cancer patients, but some of them are quite debilitated from their medical conditions and concomitently have pain disorders. And quite possibly, their medical conditions will cause them to die.

What we all discussed is of course the psychosocial aspects of their care, but what we really didn't have any concensus answer to was their pain control with meds. I think one of the concerns addressed was the medicolegal side of this.

This was an interesting topic and wanted hear your thoughts on this and how you handle their pain.

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[Tenesma]

hospice is hospice is hospice... if you are going to die in the next 3-6 months, the edge gets blurred anyway... unfortunately, the death is less predictable and most of these "end of life" patients can live another 5-9 years and usually are admitted over and over again due to opioid induced side effects (constipation, obstruction, urinary retention, mental status changes/delirium)...

 

[PMR 4 MSK]

Life is terminal. No one gets out alive.

Why are opioids magical for end-of-life? There are other meds that can relieve pain also without the side effects.

I think it short-sighted to say "well, he's dying, so addiction is not a concern." It's not about that. It's about treating the underlying diagnosis, relieving symptoms and improving function. Opioids have significant side effects, especially in the elderly.

I still maintain that they are a drug of last resort.

I've had cancer patients come to me on opioids, supposed to die in a few months and still be there several years later, on ever-escalating doses. I've caught cancer patients going to multiple docs for pain pills, while they told me everything was perfect. Some have tested positive for MJ, told me they would quit, only to be positive again later.

 

[Tenesma]

when I was a med student on an oncology rotation there was a sweet older (mid-60s) lady with metastatic breast ca on Oxycontin 320mg (40mg tablets) TID.... she was on medical assistance... one of the nurses noticed that she was driving a brand-spanking new Mercedes S class... they did a drug screen --- no narcotics... it turns out she had been selling her oxycontin for YEARS and was managing her pain just fine with motrin...

clearly, this is the rarer story.... but it is amazing how how our practice mentality changes with the word "cancer" "end-of-life"...

i completely agree with PMR 4 MSK

i get tons of consults on end-of-life patients for pain management, and MOST of them and their families want to get OFF of narcotics --- 1) Constipation is miserable 2) cognitive impairment/sedation is sad way to end your time with your loved-ones...

 

[schiener]

hospice is hospice is hospice... the edge gets blurred anyway...

Well the patient will never know if they are staying at the ritz, etc.

 

[lobelsteve]

when I was a med student on an oncology rotation there was a sweet older (mid-60s) lady with metastatic breast ca on Oxycontin 320mg (40mg tablets) TID.... she was on medical assistance... one of the nurses noticed that she was driving a brand-spanking new Mercedes S class... they did a drug screen --- no narcotics... it turns out she had been selling her oxycontin for YEARS and was managing her pain just fine with motrin...

clearly, this is the rarer story.... but it is amazing how how our practice mentality changes with the word "cancer" "end-of-life"...

i completely agree with PMR 4 MSK

i get tons of consults on end-of-life patients for pain management, and MOST of them and their families want to get OFF of narcotics --- 1) Constipation is miserable 2) cognitive impairment/sedation is sad way to end your time with your loved-ones...

Ask Terry....

http://www.time.com/time/magazine/article/0,9171,998901,00.html

 

[Jcm800]

Ask Terry....

http://www.time.com/time/magazine/article/0,9171,998901,00.html

this is why i dont prescribe it...

 

[Tenesma]

what i am tired of are the self-pay patients that fork over BIG CHECKS for their initial eval... then walk out on me when they realize they won't score oxycontin... what pisses me off even more is when their checks bounce and I get assessed a FEE from my bank

My exposure
1) I wasted 30-40 minutes of my life
2) I exposed myself to litigation, internet complaints, board of medicine complaints, hospital complaints, long crude voice mails left after-hours with veiled threats
3) time spent answering those complaints
4) Now I am responsible for $10 fee to my bank...

So now, all self-pay patients have to pay cash (there is an ATM down the hallway) - and they sign a form before hand stating that the money is not refundable regardless of whether they like my advice or not...

outcome: i have only seen one self-pay patient in the last 6 months... who turned out to be dying of cancer (he had back pain due to spine mets - breaking through his skin) - i refunded him the money...

 

[lobelsteve]

I do not see self pay patients.

Unless:

I have been treating them and they lost their job and are now w/o insurance.
They are stinking rich and and genuinely nice people (could this violate HIPPA as there are so few of these folks in my practice). I did an SCS explant for a self-pay patient- 2 EON's and 4 octrodes- and no- I did not implant her.

 

[Aether2000]

The end of life issues are very interesting. If opioids are perceived by the medical community to have hastened their demise even if they had been on unchanged doses for years, the doctors are chastised for prescribing them. Death is indeed unpredictable....one of my patients was told five years ago by his pulmonologist that he had less than 6 months to live due to critical COPD. Pump placed to avoid respiratory depression....became infected 3 years later due to pneumonia, pump removed, and he remains on high dose oral opioids 2 years later without any sedation or apparent side effects, and the blood gasses are identical to when he was on intrathecal fentanyl. Go figure....