Many dying patients experience pain for long periods even before reaching EOL. When pharmacologic analgesia is an option, healthcare providers must choose a medication regimen that will control pain adequately-yet they don’t have the luxury of time to change, titrate, or combine analgesics as needed. Reassess pain level after the intervention to ensure that the drug or other modality has relieved pain to the expected degree. If the patient is unable to self-report pain, use a behavioral pain scale such scales are based on behaviors determined to indicate pain. An important use of the NPI is to determine intervention efficacy a 2-point decrease in pain is deemed clinically significant. Significant pain calls for aggressive pain management, including both pharmacologic and nonpharmacologic options as needed.Īssess the patient for pain by self-report using the numeric pain intensity (NPI) rating scale, with 0 being no pain and 10 the worst possible pain. No matter what the cause, pain relief is a top priority because it can improve quality of life and relieve stress. Approximately 75% of patients with advanced cancer experience pain. Pain can stem from many causes, including chronic conditions, such treatments as chemotherapy-related neuropathies, and disease progression. Pain is the most common EOL symptom-and the most feared. Recognizing a symptom cluster and providing appropriate interventions can improve control of all symptoms. For example, providing antiemetics around the clock for nausea may increase sedation, which necessitates adjustment of other sedating drugs, such as analgesics, sedatives, and sleep medications. Once an intervention is chosen, its effect on other symptoms must be monitored. When a patient starts to report multiple symptoms, the plan of care needs to be evaluated carefully. Other symptoms that can cluster together include insomnia, pain, difficulty breathing, nausea, weakness, vomiting, appetite changes, and altered taste. Fatigue is the most common symptom that occurs in clusters it’s especially prominent in cancer patients. Such a cluster magnifies the patient’s distress and can be more difficult to treat, because symptoms can have a synergistic effect on each other and increase the overall symptom burden. In many EOL patients, symptoms occur together in a cluster, posing a greater challenge to manage. Healthcare professionals don’t have the time to try out lengthy opioid titration schedules or experiment with techniques that may or may not bring relief. These symptoms call for more advanced techniques, such as palliative sedation or implanted analgesia pumps.ĮOL symptoms require an aggressive management approach. Some EOL symptoms may become refractory examples include fluid retention in cardiac patients, which can worsen respiratory distress, as well as pain and anorexia in cancer patients. Comorbid diseases and metastatic cancer can have multifaceted presentations these need to be simplified and each item addressed. Many patients have multiple comorbidities. Managing EOL symptoms can be highly complex. Palliative-care practitioners also can help families make difficult decisions on such issues as the patient’s code status or whether to use a feeding tube. When a patient nears death, the goal of care changes from cure to comfort, and relieving symptoms is one of the most valuable contributions healthcare professionals can offer. (See How much time does the patient have left? by clicking the PDF above) From cure to comfort Although palliative care was recognized as a specialty in 2006, specially trained practitioners are still relatively few. What’s more, not all patients can access palliative-care specialists in early stages of chronic illness. Many patients and healthcare providers aren’t aware palliative care can ease symptoms they mistakenly assume it’s the same thing as terminal or hospice care. Yet all too often, palliative care isn’t used until the patient reaches the brink of death. In a study of 151 lung cancer patients randomized to receive either standard or palliative care, palliative care enhanced quality of life and extended survival even though patients received less aggressive care. Early intervention with palliative care can lead to a better quality of life, improved sleep, less fatigue, and decreased pain-in turn, enhancing the patient’s sense of well-being. With patients who are at the end of life, palliative care, as with hospice care, means that curative options are discontinued except those that relieve symptoms (such as palliative chemotherapy). Other common end-of-life (EOL) symptoms include agitation and delirium, anxiety, fatigue, weakness, constipation, nausea, and vomiting. For cancer patients, pain may predominate. For those in heart failure, for instance, dyspnea from fluid retention may cause agony. As death approaches, many patients with chronic illnesses experience uncomfortable signs and symptoms.
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