As a patient nears the end of life, treatment goals change from measures aimed at prolonging life via cure or remission of disease to the provision of palliative care. Palliative care focuses on maximizing the quality of the patient's remaining life by relieving suffering through the control of pain and other symptoms. The provision of palliative care during this challenging period has recently become a major theme of medicine in the United States.
An extensive body of literature on the assessment and management of pain is now available. Medical schools are revamping their curricula to include this important area, and several major initiatives, including the American Medical Association's landmark Education for Physicians on End-of-Life Care Project (EPEC),1 are helping practicing physicians improve their skills. The Joint Commission on the Accreditation of Health Care Organizations has made the assessment of pain management in hospitalized patients a major priority in 2001.2
Such efforts may reverse earlier trends, which showed that patients were receiving inadequate pain relief. In one study,3 67 percent of patients with metastatic cancer reported significant daily pain, and 42 percent were not provided with adequate analgesia.3 In the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT),4 40 percent of patients reported having serious pain during the last three days of life.
Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of that damage.”5 Pain, which can be acute or chronic, or a mixture of the two, profoundly affects quality of life. While physiologically triggered, pain is mediated by a patient's subjective perceptions and is therefore uniquely perceived by each individual.
In this issue of American Family Physician, Miller and associates6 provide information on the pharmacologic management of pain syndromes. This information will be useful to anyone who provides care for patients who experience pain. Of particular value is the emphasis on nonopioid adjuvant therapies for neuropathic and somatic pain. Use of these frequently neglected medications often results in improved pain control, with fewer and less severe side effects than occur with high-dose opioids.
Nonetheless, opioids remain the mainstay of pain control in the terminally ill. As the authors of the article6 mention in their introduction, the World Health Organization (WHO) step model7 is the standard approach to pain management in patients who are approaching the end of life. When properly implemented, this program has been proved to relieve pain in more than 90 percent of patients.8
In the WHO model,7 nonopioids are used first, followed by combination products containing weak opioids and, finally, strong opioids such as morphine. Adjuvant therapies are considered at every level. A common error that physicians make in using the step model is not moving to the strong opioids of step 3 soon enough. An earlier shift avoids the distressingly common problem of excessive intake of potentially toxic co-analgesics such as acetaminophen, particularly in frail, elderly patients with impaired hepatic function. An earlier shift also facilitates appropriate use of breakthrough dosing with pure opioids, as described later in the article.6
When physicians are wrestling with challenging pain management problems, it is easy to become focused on the technicalities of drug dosing and to miss seeing some of the larger issues that are affecting patients and their quality of life. The following approaches may help avoid some of the more common pitfalls:
1. Develop a systematic, comprehensive approach to pain assessment in each patient at every encounter. The most important rule is to listen to patients—and believe them! The history and physical examination should focus on assessing the frequently multiple causes of the patient's pain. Disease status, quality of life and prognosis must always be considered. After a plan has been developed, it must be reassessed frequently, as the patient's situation often changes rapidly.
2. Constantly remind yourself that pain does not usually emanate from a single source, and that all pain is not physical in origin. The concept of “total pain” recognizes that terminally ill patients also suffer pain from emotional sources such as depression or anxiety, family stresses, social problems and spiritual fears.9 A health care system that seldom works as well or as smoothly as anyone would like can be a constant stressor for all patients. Good pain control will seldom be achieved unless all areas are systematically addressed.
3. Remember that it is unrealistic to expect a single person to provide complete, optimal care at the end of life. High-quality care is usually best delivered through an interdisciplinary team in which the skills and perspectives of the various members are complementary. The modern hospice movement provides a valuable model for the delivery of carefully integrated, coordinated care.
Although pain management at the end of life is seldom perfect, a systematic, thorough and comprehensive approach to care can result in reasonable pain control and substantially improved quality of life in most patients. Key physician skills include effective pain assessment strategies, appropriate use of opioids and adjuvant pain therapies, attention to nonphysiologic sources of pain, coordination with a strong interdisciplinary care team, appropriate follow-up and, above all, careful listening. In the words of an anonymous 16th century physician, “Cure sometimes, relieve often, but comfort always.”