Pain Management in Terminally Ill Patients

Uncontrolled pain is a large issue for patients with end of life illnesses. Studies reveal that the majority of pain problems is as high as 50% among older folks at the end of life. It is estimated that one out of four elderly cancer patients in nursing homes receive no treatment at all for daily pain. Acute or chronic pain is reported among 30% of newly diagnosed cancer patients and increases from 60% to 80% among patients with advanced disease.

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Although cancer is the illness that is usually associated with pain at end of life, patients with non-cancerous terminal illness, including AIDS, end-state cardiac, pulmonary, and cerebrovascular diseases, such as Alzheimer’s.

Patients are sometimes reluctant to report pain to physicians because of the fear of being regarded as complainers. Older patients may worry about being involuntarily being hospitalized or having additional tests or procedures. Denial may be a defense mechanism to avoid confronting the prognosis implication of increasing pain.

Concerns about addiction should be of minimal worries to the majority of terminally ill patients. However, may doctors continue to confuse physical dependence with addiction. Physical dependence is the largely, unavoidable physiological adaptation to opioid use that requires continued use of the medication to avoid withdrawal. It usually happens within day to weeks of starting opioids. For those patients in which the source of pain is taken away, opioids may be quickly and safely tapered down without continued need for the medication.

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Addiction, in contrast, represents a state of psychological dependence in which the patient shows a behavioral pattern of drug craving and great amount of involvement in obtaining and using the drug for reasons other than pain. Addicted patients tend want to acquire the drug despite financial, legal and psychosocial difficulties.

Many doctors still have a poor understanding of opioid pharmacology and are fearful of causing addiction, significant respiratory depression, or premature patient death. The fear of the development of analgesic tolerance usually prompts doctors to withhold opioids from patients with severe pain until they are near death.

In the end of life care, it is important that we achieve relief of pain, preventing pain recurrence, optimizing the patient’s sense of well-being and restoring a sense of hope and belief in the value of life. The goal is to provide the least obtrusive, least sedating and most effective analgesic treatment.

This article was brought to you by Dr. Senegal, pain management MD with Sutter Health and Jennifer Lin, RN with Vitas Hospice Healthcare.

Why I Chose to Take a Luxury Sedan to the Airport

Trips to the airport should not be a stressful ordeal. I have had the experience of using taxi cabs in the past for a 45 minute trip to the airport. One of my colleagues mentioned to me that he has been utilizing the services of San Francisco Limousine. My initial thought was, “But why would you want to take a limo to the airport”? He explained, to my surprise, that limo companies are one of the best kept secrets in the transportation industry. Many of their businesses come from corporate and airport services. Almost every limo company carries, not only limos, but sedans like Lincoln Town Cars and SUVs. In fact, the majority of their business comes from corporate and airport services.

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My next thought was that it must cost more to hire a limo company for an airport transfer. The fact is, it costs just about the same as a taxi fare. The difference between riding a cab versus a limo hire sedan, well there are many. First, there is a level of class and professionalism that comes with a limo hire car. Second, the vehicles have more comfortable seating and the companies usually provide complimentary bottled water for your refreshment. You also get a professional chauffeur who personally opens your door and assists you with your luggage. Limo companies also have the option of “meet and greet” which is having the chauffeur wait for you inside the airport with a sign upon arrival to airport.

After hearing such good reviews about this I decided to call San Francisco Limousine and booked a pick up from Oakland to SFO international airport. My driver, Dan, arrived 10 minutes early and helped with my luggage. He was very polite and well-mannered. We arrived at the airport with ample time to check in and get through security check point. All-in-all, the experience with this company was great and I tipped the driver at the end. There is certainly a noticeable business etiquette with using a limo company.

These sedans are best to be booked in advance. That is the one disadvantage to using a limo company over a cab. Taxi cabs sit and wait and if you need transportation at the last minute, they may be the best option. If you were to call a limo company, they would have to determine how far the driver is to the airport and how soon he could get there, which could be in 30 minutes.

A Script from a Novel…

I’ve been doing a lot of reading over the past few weeks and thought I’d share a few scripts from a few.

“I am going to prove that I’m not an idiot. I am going to bring my A game and do well on my next exam. They didn’t want to treat me differently from everyone at school because then everyone would want to be treated differently. When I get a degree in math or physics, I will be able to get a job and earn lots of money and be able to pay someone who can look after me and cook my meals and wash my clothes.”



“And I remember that night I just cried and cried and cried and your father was really nice about it at risk and he made you dinner and put you to bed. But I said I couldn’t take it anymore and then he got really mad and told me I was being stupid and said I should pull myself together and then I hit him. We had a lot of arguments like that. Your father is really patient but I’m not. And by the end, we stopped talking because we knew it would always end up in a argument and go nowhere. That was when I started spending a lot of time with Peter.”

“When you look at the sky you know you are looking at stars which hundred and thousands of light years away. Some of the stars don’t exist because their light has taken so long to get to us that they are already dead, or have exploded and collapsed.”

“Where do old cars go? Do they head to the junkyard and disappear into pieces of metal scraps or are they repurposed and converted into old fancy limousines? I knew a lady in San Jose. They called her Lolita. She’s always dreamt of being swept away in a long, sleek, black shiny limousine with a license plate that read San Jose Limo. She saw the name many times in her dreams. One day it was to become reality.”

“I listened to the sounds in the garden and then I could hear a bird singing and the traffic noise which was like the tidal wave on a beach and I could hear someone playing music and children shouting and laughing. I looked at the sky a lot. I like looking up at the sky in the garden at night.”

Grieving and Loss

An old friend of mine lost his wife a few months ago and is still grieving considerably over his loss. During that difficult time, as I’ve watched and offered support, I’ve learned quite a great deal about the grieving process.

First, the grieving process takes time and is a very personal and individual experience. I have learned that it is important to acknowledge the grief and allow it to happen. Why? Because it helps ¬†with the healing process. Healing takes time and can’t be forced or rushed. And there is no normal timeframe for grieving. Some people improve within weeks, others months. There are some, whom, after a year experience grief, especially at special occasions such as a birthdays or holidays.


We normally associate grief with the death of a loved one, but any type of loss can cause grief, such as divorce, loss of job, decline in health, a miscarriage, loss of financial stability, etc. Anyone can experience grief and loss. How a person grieves depends on life experience, coping style, nature of the loss, their faith and level of attachment to the loss.

Feelings that one can experience when they are grieving include shock and disbelief, sadness, guilt, anger and fear. Typically after a loss it can be hard to accept what has happened. They may feel numb and have a difficult time believing that the loss really happened.

With sadness, extreme sadness is a typical symptom of grief. People may feel loneliness, despair, or yearning. They may also cry a lot. Some feel guilt or regret a out things they did not did not do or say. They may also feel guilty about feeling relieved when the person dies after a long difficult illness.

Anger can be experienced and they may be angry at God, the doctors or the person who died for abandoning them. A loss can also bring on fears and worries. Some tend to feel helpless, anxious and experience panic attacks. Sometimes the death of a loved one can trigger fears about ones own mortality.

Grief is not only an emotional process, but can cause physical problems as well. For example, insomnia, weight loss or weight gain, fatigue, nausea, etc.

It is important to facilitate the acceptance of the loss and encourage the family to use their support system. It is important to listen, validate that they need time to grieve and honor specific requests of the family and support cultural and religious preferences.

Bereavement is the time after a loss during which grief is experienced and mourning occurs. When the person grieving is able to talk about the loss without having the same intensity of emotion in the beginning, then they have probably reached some level of healing.

My friend continues to heal while burying himself in his self run business, Party Bus SF, where he operates limo style buses. I pray that with time, he will heal but remember and celebrate the memories of her life as they were a wonderful couple.