Pain Management: Palliative Care of Advanced Malignancy - Essay Example

Pain Management in Palliative Care Advanced malignancy care is a challenge to medical professionals like nurses for many reasons. Besides instituting various treatments that prevent progression of the disease, reduce development of complications and prolong life of the patient, nurses are also posed with a challenge of relieving devastating symptoms of the disease like pain which add to the miserable state of the patient. For those in terminal stages of cancer, provision of palliative care remains the only hope to relieve the patient from suffering to some extent (WHO, 2009). The corner stone of palliative care is pain management (WHO, 2009). This is because pain is very severe and distressing in cancer patients and can lead to physical disability, emotional maladjustment, social detachment, psychological depression and distress, sleep disturbances, loss of appetite, and feeling of unwell and above all make their journey to death miserable (National Health Service, 2006). In fact, pain is the only aspect of terminal illness that can be relieved. Nurses taking care of terminally ill cancer patients must be aware of this and take necessary measures to relieve pain in them (Kearney et al, 2000). This essay discusses pain relief management in a terminally ill cancer patient an exercise to gain further understanding into palliative care of advanced malignancy. The aim of palliative care is to enhance the quality of life of the patient and influence the course of the disease in the most positive sense. The care must be initiated as early as possible in the course of the disease in conjunction with other supportive therapies like chemotherapeutic, medical and surgical interventions. Palliative care adapts the philosophy of hospice care and the interdisciplinary practice. It applies to all terminally ill patients irrespective of their diagnosis, race, religion, age, gender and culture (National Cancer Control Programme, 2005). Pain relief is the corner stone of palliative care and enhances the spiritual value of care. Along with pain relief, other symptoms like nausea and vomiting, regional swelling, sleeplessness, gastritis and constipation must be addressed (Johnson et al, 2006). Quality of life of the patient may be enhanced by encouraging the patient and allowing the patient to indulge in activities which are a source of enjoyment and relaxation for him or her like watching movies and listening to music, by making the patient feel that the patient is yet a much wanted member in the family and by providing the patient time and space to spend family with her spouse, children and grand children (National Cancer Control Programme, 2005). Education and training must also be delivered to caregivers and family members to increase the psychological and social dysfunctioning of the patient (Keefe et al, 2005). One of the important aspects of providing palliative care is involvement of the family members and friends in taking decisions pertaining to the patient (National Cancer Control Programme, 2005). Even the patient must be involved and this increases the sense of dignity and self-esteem of the patient. Proper communication and provision of appropriate information to both the patient and her family members before any decision is taken like starting a new intravenous line, changing pain medication or referring to a new consultant increases trust between the patient and the nurses. As Mok and Chiu (2004) rightly put it , "Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse–patient relationships in palliative care." It is very important for nurses to develop a trustworthy relationship with the patient and the family members because they stay with the patient until death, through the journey of illness and the trustful relationship offers some comfort to the patient. Nurses will be able to deliver the best possible care to the patient only by establishing such a relationship. Also, through such a relationship, nurses will be able to prepare the patient and the family members to death. Caring actions, right attitude and trustworthiness establish connectedness to the patient and help her and her family members go through the journey of death with some solace and peace. The family members must be prepared for death and must be asked to come to terms with the fact. If necessary, they must be provided counseling and appropriate therapies. They must be allowed to see the patient as much as possible. However, the family members must not be allowed to see some distressing aspects of care like changing of dressing, securing intravenous lines, change in the color of the area, etc (National Cancer Control Programme, 2005). Part of palliative care is maintaining the dignity of the patient before and even after death. This is because, reliance of the patient on the nurses and other caregivers erodes the sense of dignity. Once day-to-day deterioration has begun in the patient and when the situation has come that death can occur any time, the patient must be provided holistic comfort, symptoms must be managed properly, he or she must be given minimal drugs, the wishes must be upheld, anxiety levels must be alleviated and her fear, religious needs and spiritual needs must be addressed by telling the patient that r family is around (National Cancer Control Programme, 2005). There are 3 main themes in maintaining dignity and they are "the unrecognizable body, fragility and dependence and inner strength and a sense of coherence" (Hall, Longhurst and Higginson, 2009). Dignity in the patient can be upheld by allowing the patient to do as many activities as possible and by treating the patient with respect. The WHOs Pain Relief Ladder is a useful guide to prescribe medications for pain (WHO, 2009) (Refer Fig.2). This ladder consists of 3 steps of pain from below to up. The lowest is the step of mild pain. Mild pain is that pain which is self-limited and may or may not require treatment. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The uppermost step is that of severe pain. This pain interferes with most of the daily living activities. The individual may need treatment for many weeks, months or even years. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen. Then if necessary, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. Generally, chronic pain is associated with anxiety and fears, adjuvants like anti-anxiety drugs may be given. Drugs given to relieve pain must be given every 3-6 hours, round the clock. According to the WHO, the ladder approach treatment allows a patient to get the right drug with the right dose at the right time in the most effective manner and at the least possible cost (WHO, 2009). These drugs can be given as a combination with drugs of the other steps. These drugs too have side effects similar to mild opiods. One of the methods to prevent or decrease side effects would be to change the type of drug once in every few days. These medications are seldom useful in bone pains which occur due to metastases. For bone pains, patients should be treated with oral biphosphonates like clodronate, pamidronate and zoledronic acid. oral biphosphonates have been studied widely and clinically proven in breast cancer metastases (Poznak, 2002). Nurses have an important role in the assessment and monitoring of management of patients pain and other symptoms. Nurses can be the first persons to evaluate pain and then can advise the treating physician whether the pain remedy advocated was appropriate. Nurses can also evaluate the effects of the medications prescribed after the patient uses the medicines. Nurses must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When the patients report side effects, the nurse must record, manage and monitor the symptoms, guide physician about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as coordinators of different specialities by educating the patient about the dosage of the drugs and the need for good pain control (Delphi Study, 2007). Other than pharmacological approach to cancer pain management, non-pharmacological methods are also available which have been proved to be quite effective in bring down pain in a patient with advanced malignancy. Research has shown that these approaches are not only effective, but also acceptable by patients. There are many non-pharmacological approaches to pain management, the most widely studied of which is transcutaneous electrical nerve stimulation or TENS. According to cochrane database, there is no effective evidence to recommend TENS as an useful modality of pain relief in cancer patients and that more research is warranted in this perspective. TENS is a non invasive safe method of applying electrical current through the skin for the purpose of gaining neuropathic pain control in cancer patients. The battery-operated TENS unit is connected to the surface of the skin using 2-3 electrodes. TENS can be modulated and mechanized to deliver either high intensity or low intensity electrical waves. While high intensity TENS activates delta-opioid receptors in the spinal cord and in the supraspinal region, low intensity TENS activates the mu-opioid receptors (Menefee and Monti, 2005). Thus, pain relief is very critical for management of a patient under palliative care. Both pharmacological and non-pharmacological pain relief strategies are available. Pain relief enhances quality of life and is further enhanced by upholding the spiritual wishes of the patient and dignity of the patient. References Delphi Study. (2007). WHO Normative Guidelines on Pain Management. Retrieved from http://72.14.235.132/search?q=cache:XaoHa1yWUgkJ:www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf+Delphi+Study.+(2007).+WHO+Normative+Guidelines+on+Pain+Management&cd=1&hl=en&ct=clnk&gl=in Kearney, N., Richardson, A., & Giulio, P. (2000). Cancer nursing practice a textbook for the specialist nurse. London: Churchill Livingstone. Keefe, F.J, Abernethy, A.P., Campbell, L.C. (2005). Psych.ological approaches to understanding and treating disease-related pain. Ann Rev Psychol., 56, 601 –630 Hall, S., Longhurst, S., and Higginson, I. (2009). Living and Dying with Dignity: A Qualitative Study of the Views of Older People in Nursing Homes. Medscape Today. Retrieved from http://www.medscape.com/viewarticle/710065 Johnson, A., Harrison, K., Corrow, D., Taylor, M., and Johnson, R. (2006). Chapter 17: Palliative care and health breakdown. In E.Chang, J. daily and D. Elliott (Eds.). Pathophysiology applied to nurisng practice (pp 448- 471). Sydney: Elsevier. Menefee, L.A., and Monti, D.A. (2005). Nonpharmacologic and Complementary Approaches to Cancer Pain Management. Journal of American Osteopathic Association, 105(5), 15-20. Mok, E. and Chiu, P.C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing 48(5), 475–483. National Cancer Control Programme. (2005). Manual for Palliative Care. Retrieved from http://www.whoindia.org/LinkFiles/Cancer_resource_Manual_5_Palliative_Care.pdf NHS Best Practice Statement. (2006). Management of chronic pain in adults. Retrieved from www.nhshealthquality.org Poznak, C.H.V. (2002). The Use of Bisphosphonates in Patients With Breast Cancer: Palliative Bone Pain Therapy. Medscape Today. Retrieved from http://www.medscape.com/viewarticle/447549_7 Shaw, S.M., (2006). Nursing & Supporting patients with chronic pain. Nursing Standard, 20(19), 60-65. WHO. (2009). WHO Definition of Palliative Care. Retrieved on from http://www.who.int/cancer/palliative/definition/en/ Read More