Key Clinical Questions Pain
How do I choose an appropriate opioid dose for my patient?
What adjuvant medications can I use for neuropathic pain?
How do I treat a patient who is experiencing a pain crisis?
When should I consult a palliative care or pain specialist?
Secretions Terminal Delirium
What nonpharmacologic strategies can I use to relieve my patient’s dyspnea?
What is an appropriate dose of opioid for treating dyspnea?
What do I say to family members who are concerned that opioids may hasten the patient’s death?
Nutrition and Hydration
How do I evaluate an agitated dying patient?
How do I identify terminal delirium and distinguish it from other kinds of delirium?
What medications are useful for treating terminal delirium?
How do I counsel family members who are upset that the patient is no longer eating?
Are there any clinical situations in which artificial nutrition and hydration may be helpful for patients with advanced disease?
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 initial pain stimulus ...