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.