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10 Articles in Volume 15, Issue #10
2015 Has Been a Good Year for Clinical Progress
Addison’s Original 1855 Cases Reveal Stories of Chronic Pain
Can We Prevent Chronic Pain?
Letters to the Editor: Nerve Fiber Testing, Fibromyalgia
Medication Guide for Pain—A Short Primer for Primary Care
Odd Pet Behavior During SCS Trial—Case Report
Opioid-Induced Constipation: New and Emerging Therapies—Update 2015
Palliative Care: Dying With Dignity
PPM Editorial Board: Year in Pain Management 2015
QT Intervals and Antidepressants

Palliative Care: Dying With Dignity

Palliative care helps patients and families cope with the spiritual, emotional, and physical pain and suffering of terminal illness and end of life issues.
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“The best thing that you can do is to educate the patient. Let’s get back to the point of, ‘What are the goals of care?’ What does the patient want at this point?’ If the patient wants comfort measures, and they realize a cure is not really possible, then maybe we need to rethink, for example, whether an aggressive, potentially toxic prescribed medicine is really needed,” she noted.

For some practitioners, it could be an understandably unpopular decision to take a patient off a drug that has been shown in some cases to be potentially curative. However, patients with advanced illnesses can end up with an unnecessary burden of polypharmacy, where a high number of their medications are treating non-life-threatening comorbidities and causing avoidable adverse effects in the process.2

Major studies have shown that when EOL patients have access to effective palliative care throughout their course of treatment, “more effective decisions can be made about when to stop aggressive therapies when the burden exceeds the benefit,” Dr. McPherson said. “Patients actually live longer [and] feel better, because sometimes the interventions we use in these settings are so toxic that they may in fact prematurely end someone’s life.”

It is important to define and understand the nature of the tensions that exist, agreed Dr. Portenoy. “Usually, the tension is about disease modifying therapies, which hold some hope for prolonging life and sometimes improving the quality of life, but also sometimes carry a high associated burden of side effects and risks,” he noted. Dr. Portenoy agrees with Dr. McPherson, a core precept of palliative care is repeated goal setting that considers the medical realities (ie, benefit versus toxicity or other burden) and are informed by the patient’s values and preferences. “If patients and their families are given the opportunity to have discussions with a trusted professional that consider all these factors, then this challenge can be met in a way that supports the patient and family through a difficult time,” he added.

One contentious issue surrounding this topic is the use of HMG-CoA reductase inhibitors, typically referred to as ‘statins,’ for the prevention of stroke and other cardiovascular events in EOL patients. Current guidelines recommend that patients manifesting ischemia or who are at high risk for the disease should be taking statins because studies have shown that the drugs reduce all-cause mortality.3,4

However, a recent large randomised control study found that the actual survival gains of taking statins could be “surprisingly small.” The researchers found the highest postponement of all-cause mortality peaked at 27 days, and this was specifically for patients who had an average of 5.8 years on simvastatin therapy for their unstable angina or myocardial infarction.5

If a patient is nearing the final weeks of his or her life, the researchers strongly suggested that statins should be stopped. Taking a statin to prevent heart attack may not be the best route, they noted, especially if the statin is causing unpleasant side effects, like muscular problems. In such a case, removing the statin from the patient’s drug regimen could improve the patient’s quality of life (QOL) and perhaps make their medical care more cost-effective.6

“Every medication has to have a therapeutic goal. So you have to ask the question, ‘Are we achieving that goal with this drug?’” Dr. McPherson said. Another example can be found in female hospice patients taking alendronic acid (Fosamax) for their comorbid osteoporosis, she noted. Known to irritate the upper gastro-intestinal mucosa and even cause stomach ulcers,7 the medication can come with significant burdens for someone who is dying or in a compromised state. Having to take the drug, remain upright, drink water, and then fast for hours before breakfast in order to avoid gastroesophageal reflux as recommended in the Package Insert may be a routine the patient wants to avoid, altogether. Or, it may be a routine they simply can’t manage at a certain stage in their illness, realistically.

The drug also is known to cause generalized muscle, joint, and bone pain and possibly increase the risk for gastrointestinal toxicity when combined with non-steroidal anti-inflammatory drugs (NSAID).7 A patient with cancer or who is receiving chemotherapy can experience painful bone, or osteonecrosis.8 Getting a patient the best palliative care, including the best pain management, may mean reevaluating the necessity of such a drug, something that requires clear, honest communication between the patient and his or her health care provider.

“I provide the facts and I say, ‘May I share my opinion with you?’ And people are smart, they get it…I despise it when people ‘should’ on me. No one likes it when people say, ‘You should do this, you should do that.’ But I’m also a believer in free will. I’m going to give you the facts, I’m going to share with you my opinion, and then you’re going to make up your mind.”

Setting Up an End-of-Life Plan for Interventions

Those one-on-one conversations between the palliative care professional and the patient can be difficult. For example, hospice patients with dementia may not be able to communicate clearly and speak for themselves, in which case palliative care professionals do often have to turn to the family of the patient to determine the next step.

“Somebody has to make some tough decisions,” said Dr. McPherson, “so if you have dementia and you’re on all those drugs for dementia, but they’re not helping you, it’s hard to have that conversation with the patient, or more likely the family, because that drug’s the only thing there is, so the family might say, ‘What do you mean you’re going to stop this drug?’”

Advance care planning is one of the most important conversations to be had when a patient is approaching EOL, noted Dr. McPherson. “Honoring a patient’s personal beliefs or religious values and establishing what treatment options he or she prefers in EOL scenarios is an integral aspect of mapping a patient’s goals of care and providing the best possible palliative approach.”

These discussions are different with every patient—or if the patient is unable to communicate, the patient’s medical decision maker—which is usually a family member or designated surrogate. It is what makes Physician Orders for Life-Sustaining Treatments (POLST) (aka Medical Orders for Life-Sustaining Treatments [MOLST]), significant tools for establishing the patient’s treatment preferences, so they can pass away with dignity.9 While not every state requires these forms, practitioners typically support their usage because they provide an actionable plan for emergency care and help prevent unwanted, extraordinary treatment.

Last updated on: February 9, 2016
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Pain Management in a Palliative Care Setting

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