Symptom Management at the End of Life
Am Fam Physician. 2009 Jun 15;79(12):1050-1051.
The focus of most of modern Western medicine is to heal patients when they are sick. Recently, however, there has been a greater emphasis on improving the quality of life of patients when that is all that can be accomplished. The American Medical Association and the Robert Wood Johnson Foundation funded an entire program for physicians, the Education in Palliative and End-of-Life Care Project, to emphasize care of patients near the end of life.1
The article by Drs. Clary and Lawson in this issue of American Family Physician is a useful and concise source of information on symptom management in patients at the end of life.2 Consistent emphasis on pain relief is crucial. There are a variety of studies showing that pain can severely impair patients' quality of life, as well as put them at risk of depression and suicide.3 For constant pain, it is most effective to use both a continuous long-acting pain medication to prevent pain and a short-acting pain medication to treat breakthrough pain. The dose for breakthrough pain needs to be large enough to get the patient out of pain. Doses that are too low can lead to pseudoaddiction (drug-seeking behavior in patients who are receiving inadequate treatment for their pain that can be mistaken for addiction).4 It is also important to avoid combination pain medications that contain an opioid and another medication such as acetaminophen or ibuprofen. The danger is that the patient will accidentally overdose on the nonopioid, causing organ damage (with acetaminophen) or increased adverse effects without increased pain relief (with ibuprofen).
Drs. Clary and Lawson emphasize some important aspects of pain and symptom management that can often be overlooked by physicians.2 One key point is the physician's role as a guide for patients and their families at the end of life. Their anxiety and fears can often be relieved by descriptions of various events as they happen, or better yet, before they happen (for example, explaining to the family that the “death rattle” is not uncomfortable for the patient, so that the family can be more relaxed about the symptom, if or when it occurs).5
The idea that it is more comfortable to prevent constipation than to treat it is a major part of symptom management. The advent of a new medication, methylnaltrexone (Relistor), as the first targeted medication useful for the relief of existing opioid-induced constipation is a great step forward. Another drug, methylphenidate (Ritalin), is useful to treat somnolence and lack of energy, which are other common opioid-related adverse effects.6 At very low doses, haloperidol (formerly Haldol) can treat nausea and vomiting.7,8 Other useful medications for nausea and vomiting caused by various etiologies, including an obstructed bowel, are corticosteroids and octreotide (Sandostatin).9
It is important to realize that all persons will one day die, and that it is likely that most physicians will be involved at some point in the care of patients at the end of life. Physicians in that situation will need to know how to prevent as much pain as possible.
1. The EPEC Project. http://www.epec.net/EPEC/webpages/index.cfm. Accessed April 13, 2009.
2. Clary PL, Lawson P. Pharmacologic pearls for end-of-life care. Am Fam Physician. 2009;79(12):1059–1065.
3. Foley KM. Acute and chronic cancer pain syndromes. Doyle D. Oxford Textbook of Palliative Medicine. 3rd ed. New York, NY: :Oxford University Press; 2005:298–316.
4. Kirsh KL, Whitcomb LA, Donaghy K, Passik SD. Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study. Clin J Pain. 2002;18(4 suppl):S52–S60.
5. Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, Grambow S, Parker J, Tulsky JA. Preparing for the end of life: preferences of patients, families, physicians, and other care providers. J Pain Symp Manage. 2001;22(3):727–737.
6. Rozans M, Dreisbach A, Lertora JJ, Kahn MJ. Palliative uses of methylphenidate in patients with cancer: a review. J Clin Oncol. 2002;20(1):335–339.
7. Critchley P, Plach N, Grantham M, et al. Efficacy of haloperidol in the treatment of nausea and vomiting in the palliative patient: a systematic review. J Pain Symp Manage. 2001;22(2):631–634.
8. Lohr L. Chemotherapy-induced nausea and vomiting. Cancer J. 2008;14(2):85–93.
9. Mannix K. Palliation of nausea and vomiting in malignancy. Clin Med. 2006;6(2):144–147.
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