PAIN MANAGEMENT AT THE END OF LIFE

KELLI GERSHON, FNP-BC, ACHPN

SYMPTOM MANAGEMENT CONSULTANTS (SMC)

KELLI@PALLIATIVEMEDICINE.US

DISCLOSURES

• The presenter has no real or perceived conflicts of interest that relate to this presentation.

OBJECTIVES

1) Describe pain assessment in the patient at the end of life2) Discuss nursing interventions to relieve pain for the patient at the end of life3) Discuss pain management in the transition of a patient from inpatient to home

INTRODUCTION

•Who am I?•Who are You?

MRS. SMITH

• 32 y.o female with advance breast cancer• Admitted to acute care hospital for uncontrolled

abdominal pain• Consult Palliative care for uncontrolled pain, “NOT END OF

LIFE”

MRS. SMITH

Subjective• Pain is 10/10

• On going pain in her left chest wall, right groin area and bilateral feet

• New acute pain which brought her to the hospital in her stomach

• Has nausea with vomiting

• Pain worse at night

• Constipation

• Denies SOB

MRS. SMITH

• PMH: Breast cancer mets to brain, bone, lymph nodes, lung and liver s/p chemo and XRT

• PSH: Mastectomy, Craniotomy, Port placement, tonsillectomy• Social: Married (to renew vows in 4 days), 3 children (5 y.o. 7 y.o.

and 10 y.o.)

MRS. SMITH DIVING DEEPER INTO SUBJECTIVE

• ESAS Edmonton Symptom Assessment Scale• Mini Mental State Exam• Memorial Delirium Assessment Scale• CAGE questioner

ESAS

MRS. SMITHPAIN COMPLAINT

• Is pain what ever your patient says it is?• What factors could influence someone's expression

of pain?

MINI MENTAL STATE EXAM

MDAS MEMORIAL DELIRIUM ASSESSMENT SCALE

CAGE QUESTIONER

1) Have you ever tried to cut down on your drinking?

2) Has anyone ever annoyed you discussing your drinking?

3) Have you ever felt guilty about your drinking?

4) Have you ever had to have an eye opener?

MRS. SMITH

Objective

•Vitals BP 106/72 R 12 P110 Pulse Ox 94% Temp 98.9

•PE: PERRL; oral mucosal dry; S1S2 tachy; lungs dec right greater than left; hypoactive bs with slight distention; + 2 edema bil le; nuero MDAS 7/30

•Labs of importance: WBC 14.4, H/H 8.5/24.7, Bun 65, Creatine 1.3, Albumin 2.1, Calcium 7.2

•Diagnostic: Upper GI showed esophagitis with possible fungal component

MRS. SMITH

Medications

•Duragesic 300 mcg q 72 hours

•Hydrocodone/Acetaminophen 10/325 1 po q 4 hours prn (takes 6 per day)

•Hydromorphone 2 mg 1 po q 4 hours prn (takes about 5 per day)

•Morphine Extended Release 30 mg po BID

•Gabapentin 300 mg po tid

•Lidoderm patch daily to back

•Started at hospital hydromorphone PCA with 1.5 mg basal rate and 0.5 mg IV q 15 minutes prn pain

MRS. SMITH

• “Opioid Soup” what’s wrong with it…….• Where do we start?• What does the nurse need to know?

MRS. SMITH

• Morphine Equivalent Daily Dose (MEDD)

• Converts all opioids to the same currency

• They all have their exchange rate

• Gives the practitioner a chance to understand the total dose

EQUAL ANALGESIC CHART

Name IV PO Morphine

Morphine 10 mg 30 mg n/a

Hydrocodone 5 mg = 5 mg

Hydromophone 2 mg 4 mg IV 10 to 1 (x10 to po)PO 5 to 1 (x5 to po)

Duragesic n/a n/a 50 mcg=100 mg (x2 to po)

Oxycodone 10 mg = 15 mg (x15 to po)

METHADONE MEDD

Oral MEDD (mg/day)Oral morphine: oral methadone

< 30 2:1

30-99 4:1

100-299 8: 1

300-499 12:1

500-999 15:1

> 1000 20:1

MRS. SMITH

MEDD

•Duragesic 300 mcg = 600 mg

•Hydrocodone/Acetaminophen 10/325 1 po q 4 hours prn (takes 6 per day)= 60 mg

•Hydromorphone 2 mg 1 po q 4 hours prn (takes about 5 per day) = 50 mg

•Morphine Extended Release 30 mg po BID= 60 mg

•Hydromorphone used 60 mg IV over 24 hours= 600

•Hospital MEDD= 600+60+50+60+600= 1370

•Home MEDD= 770 about

MRS. SMITH

Pain medication orders•Methadone 15 mg po q 6 hours ATC •Stopped duragesic, take off•Decrease Basal rate by ½ in am then d/c completely next day•Hydromorphone 4 mg to 8 mg IV q 2 hours prn•Hydromorphone 8 mg po to 16 mg po q 4 hours prn

MRS. SMITH

Other orders•Treating fungal infection esophagus•Educated patient on timing of pain meds•Discussed plan, multiple plans are better than no plan•Discussed depression, anxiety and “fears”•Educated nurse on “suffering” and “chemical coping”

MRS. SMITH

Nurses Role

1) Great Subjective exam including rule out delirium

2) Develop therapeutic relationship while establishing boundaries

3) Help with “timing” of medications

4) Help to identify other coping strategies

5) Patient advocate to discuss plans and appropriate health care providers

MRS. SMITH HOMEWARD BOUND

• Need to be on long acting and short acting oral medication at least 12 hours prior to discharge

• Bowls need to be moving

• Need to try to simulate home activity at hospital to make sure pain is controlled

• Need to obtain triplicate scripts for opioids

• Establish home care program

MRS. SMITH

Home Care Options

1) Home with no services

2) Home with outpatient follow up (limited number of palliative clinics)

3) Home with home health (Palliative care if able)

4) Home hospice

MRS. SMITH

• Pain was well controlled with MEDD being around 900

• Patient was able to express concern about caring for children alone while husband at work

• Patient able to say she is “sad” but not depressed

• Family meeting with husband, mother, grandmother and oncologist to make a plan

• Discharged home on Friday night and renewed her vows on Saturday afternoon

• Followed at home on home health palliative care program

QUESTIONS

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