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Key Clinical Questions Pain

  • image How do I choose an appropriate opioid dose for my patient?

  • image What adjuvant medications can I use for neuropathic pain?

  • image How do I treat a patient who is experiencing a pain crisis?

  • image When should I consult a palliative care or pain specialist?

  • image How do I select an appropriate antiemetic for my patient?

  • image How do I treat nausea in a patient with malignant bowel obstruction?

  • image What nonpharmacologic strategies can I use to relieve my patient’s dyspnea?

  • image What is an appropriate dose of opioid for treating dyspnea?

  • image What do I say to family members who are concerned that opioids may hasten the patient’s death?

  • image How do I manage loud secretions (“death rattle”) in a dying patient?

  • image What do I say to family members who are distressed by the noisy secretions?

Terminal Delirium
  • image How do I evaluate an agitated dying patient?

  • image How do I identify terminal delirium and distinguish it from other kinds of delirium?

  • image What medications are useful for treating terminal delirium?

Nutrition and Hydration
  • image How do I counsel family members who are upset that the patient is no longer eating?

  • image Are there any clinical situations in which artificial nutrition and hydration may be helpful for patients with advanced disease?

Complementary Medicine
  • image Is there data to support the use of complementary therapy to relieve common symptoms such as pain and nausea?

  • image How do I advise a patient who asks me about a therapy with which I am unfamiliar?


Studies of patient perspectives on end-of-life care consistently report pain control as a major priority. Nonetheless, the literature shows that many patients experience poor pain control. In one well-known study (SUPPORT trial: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments), approximately 40% of hospitalized patients experienced severe pain in the last 3 days before death.

When the focus of care is quality of life and comfort, any poorly controlled symptom should be treated urgently. Many patients already fear that pain will be an inevitable part of their disease process and that “nothing can be done.” Hospitalists play a vital role in correcting this misconception and ensuring that patients with advanced illnesses receive adequate pain control.


Pain can be described as nociceptive or neuropathic in origin. In nociceptive pain, peripheral nociceptors in the skin, musculoskeletal system, or viscera detect noxious stimuli and send impulses via afferent A-delta or C fibers to the dorsal horn of the spine. These signals are transmitted through ascending spinothalamic tracts to the thalamus and then to the cortex. Neuropathic pain occurs when the peripheral or central nervous system itself suffers damage or develops pathologic changes in sensitization. Neuropathic pain is generally more difficult to control than nociceptive pain. In reality, however, any type of chronic pain can significantly alter the sensory pathways and cause pathologic activation of the nervous system even after the ...

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