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The care of the dying: pain management. นายแพทย์รัฐพล แสงรุ้ง คลินิกระงับปวด ภาควิชาวิสัญญีวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร. A Good Death is the culmination of A Good Life. WHO’ s definition of palliative care.

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the care of the dying pain management

The care of the dying:pain management

นายแพทย์รัฐพล แสงรุ้ง

คลินิกระงับปวด ภาควิชาวิสัญญีวิทยา

คณะแพทยศาสตร์ มหาวิทยาลัยนเรศวร

who s definition of palliative care
WHO’ s definition of palliative care

“An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual”


Pain and other symptoms management

a common goal of palliative care

the peace tool
The PEACE Tool
  • assessment
  • pain and other symptoms
  • emotive burden
  • shared, informed decision making
  • care planning and communication
  • domestic and economic needs of patients and care-givers
  • spirituality
  • Physical symptoms
  • Emotive (and cognitive) symptoms
  • Autonomy related issues
  • Communication, and Completion of life affairs related issues
  • Economic burden and other practical issues
  • Transcendent and spiritual issues
physical symptoms
Physical symptoms


  • Pain
  • Anorexia and other appetite or oral intake related issues
  • Incontinence and other genitourinary symptoms
  • Nausea and other gastrointestinal symptoms (constipation, vomiting, diarrhea)

Respiratory symptoms (dyspnea, cough)

  • Ulcerations and other skin complaints
  • Level of functioning
  • Energy and other related issues such as fatigue or asthenia
  • Sedation, sleep and other side effects of treatment (including opioids and chemotherapy)
diagnosing dying
Diagnosing dying
  • Signs
  • The patient becomes bed-bound
  • The patient is semi-comatosed
  • The patient is only able to take sips of fluid
  • The patient is no longer able to take oral drugs

“ Multi-professional team agree ”

symptoms at the end of life
Symptoms at the end of life
  • Breathlessness
  • Cough/noisy respirations
  • Terminal restlessness
  • Myoclonic jerking
goals of care for patients in the dying phase
Goals of care for patients in the dying phase
  • Comfort measures
  • Current medication assessed and non-essentials discontinued
  • As required subcutaneous medication written up as per protocol (pain, agitation, respiratory tract secretions, nausea and vomiting)
  • Discontinue inappropriate interventions (blood test, antibiotics, intravenous fluid/medications)


  • Ability to communicate
  • Insight into condition assessed
  • Religious/spiritual support
  • Religious/spiritual needs assessed with patient/family

Communication with family/other

  • Identify how family/other are to be informed of patient’ s impending death
  • Family/other given relevant hospital information
  • Communication with primary healthcare team
  • General practitioner is aware of patient’ s condition


  • Plan of care explained and discussed with patient/family
  • Family/other express understanding of plan care

The overriding goal of palliative care is to reduce suffering and maintain an acceptable quality of life throughout the course of a progressive illness, including the periods of advanced illness and active dying

most common symptoms
Most common symptoms
  • Pain
  • Nausea and vomiting
  • Agitation
  • Respiratory tract secretions
drugs administration
Drugs administration
  • Analgesic: morphine, oxycodone, hydromorphone
  • Antiemetic: metoclopramide, dimenhydrinate, haloperidol
  • Sedative: midazolam, haloperidol
  • Antimuscarinic: glycopyrronium

Many patients and families suffer from untreated pain at the end of life

  • Failure to treat pain effectively can result from
  • a lack of clinician training in palliative care
  • the fear of violating ethical, moral, and legal tenets in the administration of pain medication to the dying patient
prevalence of pain
  • at least one-fifth of the million patients who die in hospitals each year experienced pain
  • 50 percent had daily pain
  • 85 percent had moderate or worse pain
  • common feature at the end of life
  • 93 percent of patients dying from HIV/AIDS

had pain at the end of life

  • 75 percent of patients with heart failure had pain during the last six months of life
  • 70 percent of patients with advanced cancer had moderate to severe chronic pain
  • 40 percent of cancer pain had undertreatment
total pain
Total Pain
  • Suffering pain of clear physical origin
  • More severe pain or exacerbation of pain that relate to
  • Psychological pain
  • Social pain
  • Spiritual pain
  • Pain “ all over ” and “ unable to localize ”
incident pain
Incident Pain
  • Subtype of episodic pain
  • Transient
  • Typical occur on movement
  • Rapid onset
  • Severe intensity
  • Administration of a “ rescue dose ” (fast action and short duration)
neuropathic pain
Neuropathic Pain
  • Adjuvant analgesia (malignancy association)
  • Anticonvulsants
  • Tricyclic antidepressants
  • Benzodiazepine
  • NMDA antagonists
  • steroid
  • Opioid (partially effective)
bone pain
Bone Pain
  • Opioids
  • NSAIDs (rectal, parenteral)
  • Dexamethasone
other symptoms management
Other symptoms management
  • Breathlessness
  • Opioids: diamorphone, morphine
  • Benzodiazepines: lorazepam, midazolam
  • Oxygen therapy
  • Cough/noisy respirations
  • Appropriate position
  • Anticholinergics: hyoscinehydrobromide, glycopyrronium

Terminal restlessness

  • Exclude: urinary retention, discontinue steroid
  • Benzodiazepines: midazolam, haloperidol
  • Myoclonus jerking
  • Due to rapid escalation of opioid dose
  • Benzodiazepine: midazolam
  • Pain and symptom control together with the wider consideration of the patient and family
  • The treatment of pain at the end of life is the right of the patient and a moral duty, as well as legal obligation, of the clinician caring for the suffering