Lectures 15 & 16 Pain Management in Palliative Care PDF

Lectures 15 & 16 Pain Management in Palliative Care and at End of Life Chapter 11  OBJECTIVES Know the definition, rationale for and goals of palliative care across the life span. Recognize that palliative care relieves pain and sufferin...

Lectures 15 & 16 Pain Management in Palliative Care and at End of Life Chapter 11  OBJECTIVES Know the definition, rationale for and goals of palliative care across the life span. Recognize that palliative care relieves pain and suffering for patients with malignant and non-malignant incurable diseases. Understand that optimal communication skills and symptom control are the core principles of palliative care. Understand the role of nursing in addressing patient and family care needs.  Palliative Care The term ‘palliative’ is derived from the latin ‘palliare’, meaning ‘to cloak’. The primary aim of palliative care is to achieve optimal pain and symptom control for the patient to allow maximum quality of life to the end of his or her life. As pharmacological and nonpharmacological treatments improve patients to live longer, sometimes with symptoms which require long-term palliation to maintain optimal quality of life and functionality.  Palliative Care The World Health Organization (2002) defines palliative care as to improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement.. The Role of Nursing in Palliative Care Palliative care stems from the recognition of the potential at the end of life for discovering and for giving, a recognition that an important dimension of being human is the lasting dignity and growth that can continue through weakness and loss. The basic assumption of palliative nursing is ‘a whole person philosophy of care implemented across the lifespan and across diverse settings, where the patient and the family is the unit of care  Internationally Recognized Goals of Palliative Nursing To promote quality of life along the illness trajectory through the relief of suffering, including care of the dying and bereavement. To follow up for the family and significant others in the patient's life. To relieve suffering and enhance quality of life, including providing effective pain and symptom management. To address the psychosocial and spiritual needs of the patient and family. To incorporate cultural values and attitudes into the plan of care. To support those who are experiencing loss, grief and bereavement. To promote ethical and legal decision-making. To advocate for personal wishes and preferences. To use therapeutic communication skills. To facilitate collaborative practice. Roles and Functions of the Palliative Care Team Members The nurse's role, together with the physician's, comprises the core palliative care team. They provide access to the essential psychosocial services. A healthcare team can be described as an identified collective in which members share common team goals and work interdependently in planning, problem solving, decision making and implementing and evaluating team related tasks. Roles and Functions of the Palliative Care Team Members The Advanced Nurse Specialist (Practitioner) in palliative care is the nurse clinician, educator, researcher and consultant to the interdisciplinary team. The Clinical Nurse Specialist/Palliative Care Nurse educates and supports the nursing team in their roles with the holistic patient and family care, acts as a resource for pain management and symptom control, combines nursing science with ethics and philosophy to foster standards for best quality clinical practice in palliative care, Roles and Functions of the Palliative Care Team Members The Palliative Care Physician provides expertise, collaborating and communicating with the interdisciplinary team members, particularly with regard to pain management and treatment and care decisions. The Social Worker provides supportive interventions for and refers families to social services if required. The Chaplain (Shaikh) assesses and helps the patient and family address spiritual issues relating to the meaning and purpose of life, death , and loss. Roles and Functions of the Palliative Care Team Members The Bereavement Counsellor provides bereavement counselling and referral services for families who have lost loved ones or family members who are anticipating the loss of a loved one. The Physiotherapist and Occupational Therapist work with patients receiving palliative care to maximize functionality, quality of life and remaining time, with input as required from the Pharmacist and Speech and Nutritional Therapists. Roles and Functions of the Palliative Care Team Members Complementary therapists offer diverse therapies, such as massage, aromatherapy, reflexology, relaxation, art and music therapies, which patients often find helpful for reducing stress associated with pain, treatments and the illness experience. Volunteers have a major role in the hospice setting, providing companionship and support for patients and families, and support for palliative care programmes. Model for Integration of Palliative Care  Palliative Care and Cancer-Related Pain and Suffering The etiology of pain in advanced cancer is through tissue and/or nerve destruction as a consequence of tumor burden, treatment side-effects such as chemotherapy- induced neuropathic pain and metastases. Secondary bone metastases are a common pain problem in palliative care, along with secondary tumors of the lung and liver. Effective end- of-life palliative treatment of cancer- induced bone pain may require any of a combination of interventions comprised of corticosteroids, bisphosphonates, radiotherapy or radioactive isotopes, long-acting opioids and stabilization of the skeletal structure. Assessment in Palliative Care and at End of Life Comprehensive biopsychosocial assessment of the patient's pain and distress is essential at the first consultation Regular measurement of pain as the fifth vital sign, using patient-appropriate pain tools in hospital and hospice care settings, and asking the patient to keep a pain diary if he or she is living in the community contributes to quality care. Documentation and frequent communication among the interdisciplinary palliative care team help to ensure consistent standards of care, optimal pain control for the patient and prevent duplication of patient interviews.  The Memorial Delirium Assessment Scale (MDAS) Patients with advanced cancer may suffer from a diverse range of problems comprising pain, other symptoms and emotional distress, combined with delirium, and/or dementia and/or the neurological side-effects of cancer manifesting as changes in mental status, sensory and motor deficits, as well as treatment side- effects. The Memorial Delirium Assessment Scale (MDAS) is a 10- item clinician-administered assessment that evaluates the areas of cognition most sensitive to impairment with delirium. – These are arousal, level of consciousness, memory, attention, orientation, disturbances in thinking and psychomotor activity. Scores range from 0 to 30, and a score of 13 or above suggests delirium.  The Brief Pain Inventory (BPI) The relief of suffering and discomfort requires measurement to understand the impact on the patient. A numerical or verbal assessment can give pre- and post-pain treatment feedback and help with medication adjustment to achieve optimal pain control. The Brief Pain Inventory (BPI), asks patients to circle a number from 0 to 10 that signifies the severity of their pain, with zero labelled as ‘no pain’ and 10 labelled ‘pain as bad as you can imagine’. Following the pain ratings, patients are asked to report the medications or treatments they receive for pain, the percentages of relief these medications or treatments provide and patients’ belief about the cause of their pain. Finally, patients are asked to rate how much pain interferes with mood, relations with other people, walking ability, sleep, normal work and enjoyment of life, using a Number Rating Scale. The Hospital Anxiety and Depression Scale (HADS) The Hospital Anxiety and Depression Scale (HADS) is a 14-item tool. – Seven items assess anxiety and seven items assess depression. – The severity of the symptoms suggests the possibility that the patient may have clinical depression or anxiety, which is then confirmed by clinical diagnostic interview by the trained palliative care physician or psychiatrist. – The HADS may be the most widely used tool to assess mood disorders in patients with cancer.  Communication at the End of Life Hope for the control of pain is a vital aspect of the relief of suffering Suffering is linked also to the experience of despair, loneliness. The nurse has a central role as a member of the interdisciplinary care team in giving comfort to the patient and to his or her family Spiritual concerns about the meaning of life and death  Communication at the End of Life At any stage of the cancer journey, and especially at the end of life, patients and their close others require emotional support and reassurance. Often patients and their families have to hear bad news over a series of days or weeks. How this news is given is crucially important to patients and families. Formal communication skills training is necessary to improve patient outcomes at end of life Interdisciplinary discussion on death and dying should be a predictable process, and should include discussions on limiting the use of invasive interventions, such as CPR, which burdens a dying person's suffering.  Communication at the End of Life Ultimately, people at the end of life need to be able to spend their remaining time meaningfully and to plan for loved ones before their death. Patients and caregivers mostly prefer honest and accurate information, provided with empathy and understanding. Healthcare professionals may be able to help patients cope with their terminal prognosis by exploring and fostering realistic forms of hope that are meaningful for each patient and his or her family.  Pain and Symptom Management in Advanced Cancer and at End of Life Morphine is the gold standard and pharmacological treatments are administered according to the World Health Organization's Analgesic Ladder for Pain Relief. Immediate-release morphine is the opioid of choice for moderate to severe pain (10 mg/5 ml orally), otherwise immediate-release (10–60 mg tablets) or sustained-release (10 or 30 mg tablets). The components of an opioid essential prescription package (OEPP) to be used when initiating prescription for the control of moderate to severe chronic pain. The OEPP consists of: – Opioid: Morphine, oral, 5 mg every 4 hours – Laxative: – Antiemetic: Metoclopramide  Interventions for Dyspnea Pharmacological interventions for dyspnea are directed at the cause. Morphine sulphate is the most effective medication for relieving dyspnea. – Morphine alters the patient's perception of his or her breathing experience by reducing respiratory drive and oxygen consumption. – Morphine increases blood plasma levels of carbon dioxide and decreases arterial pH.  Interventions for Dyspnea Pharmacological interventions Short-acting benzodiazepine anxiolytics (Lorazepam) Anticholinergics (hyoscine hydrobromide) are given subcutaneously to reduce respiratory secretions. Anticholinergics are effective for reducing secretion in the mouth and respiratory tract, which creates disturbing respiratory sounds known as the ‘death rattle Bronchodilators (salbutamol) to reduce bronchospasm. Corticosteroids (dexamethasone) may reduce bronchospasm, inflammation, and dyspnea associated with advanced complex lung non-malignant diseases and cancers. Antibiotics can reduce signs and symptoms in case of upper respiratory tract infection.  Interventions for Dyspnea Nonpharmacological Nursing Management reassuring the presence of the nurse with the patient can help to alleviate dyspnea. Helping the patient to find his or her most comfortable position. Distraction and relaxation exercises may reduce the patient's anxiety and distress. The nurse's aim is to reduce the patient's anxiety, distress and suffering.  Interventions for Cough Pharmacological interventions for cough: – Morphine 5 mg PO every four hours may relieve and suppress an intractable cough. – Sedatives Haloperidol 2.5 mg given subcutaneously may be especially useful at night, drying respiratory secretions through an anticholinergic effect and helping to calm the restless, confused patient.  Interventions for Cough Nonpharmacological Nursing Management of Cough – Calming reassuring presence by the nurse with the patient nursed in the position of most comfort for him or her.  Interventions for Nausea and Vomiting Nausea and vomiting occur frequently in patients receiving palliative care and at end of life. There are multiple causes for nausea and vomiting. Irritation in the upper gastrointestinal tract and obstruction of the gastrointestinal tract may result in vomiting, when any part of the upper digestive tract is irritated or over- distended, particularly the duodenum.  Interventions for Nausea and Vomiting The selection of antiemetic depends on the cause of the patient's symptoms. Situations which might precipitate the patient's nausea should be avoided. Tolerance to opioid medication-induced nausea usually develops within a few days. There are many drugs which may help to reduce nausea and vomiting through various mechanisms. Ondansetron prevent vagal stimulation. – Side-effects include constipation, headache and hiccups. – Therefore, drug selection has to be carefully matched with patient age, diagnosis, current health and palliative care status and medication requirement. A patient experiencing nausea and vomiting on a daily or very regular basis should be prescribed antiemetics ‘at the clock’. For nausea and vomiting associated with increased intracranial pressure secondary to brain metastases, corticosteroids (for example, dexamethasone) are very effective.