Pain management: CA pt mets to bone and '20%of kidney function left'

[coogabooga]

'm totally at a loss with a new hospice patient of mine. Hx: breast CA with mets to bone, lung, liver. She was given the wrong chemo and it messed up her kidneys and hearing. She states she has 20 percent of her kidney function and has 7-8/10 pain to her hips and legs front the CA. I'm very new to hospice and can't seem to come up with anything to manage the pain..

She takes oxycodone IR 10mg q 3 hours PRN and dilaudid 12mg q 3 hours PRN. She says it doesn't help the bone pain but either "knocks her out" or just makes her feel apathetic. I'm told that NSAIDs work best for bone pain but she is too afraid to try because of her kidney function....

When I talk to her she seems miserable. She's a highly intelligent, fairly young (57) lady.

[Double-Helix, BSN, RN]

I think someone needs to have a conversation with this patient about her goals for her treatment. She's a hospice patient, which tells me she may be focused more on comfort than on cure at this point. What are her desires? To prolong life as long as possible? To be able to attend family functions? To maximize her quality of life? To minimize pain? Discuss why specifically NSAIDs worry her. Yes, it has to do with her kidney function, but what specifically is she afraid will happen? She will have to go on dialysis? She will die sooner?

It's true the NSAIDs can be contraindicated in patients with poor kidney function, however in this case, does the benefit outweigh the risk? Does controlling her pain outweigh the fact that it could further compromise her kidney function? Perhaps someone could suggest a short trial of NSAIDs to see if they are effective. If they are, the patient can make a better informed decision about the pros vs cons.

Once her providers, and the patient herself, have a better understanding of your goals, it can help you all make better treatment decisions geared toward whatever outcome the patient desires.

[tyvin, BSN, RN]

Is her pain constant...how long has she been on hospice? What other type of meds is she on? What is the pain like...stabbing, burning, etc...?

We can't direct to prescribe but knowing these things would help us to guide you in the right direction.

[coogabooga]

She is a new patient to hospice (1 1/2 weeks) and the pain is constant and an achy pain in her hips and down her legs. Strong 7. Increases with mobility... I sincerely appreciate the advice. Going over her goals is a good idea. Small trial, maybe smaller doses to see any effect. I will try that this week, at least just talk to her about it more.

[angelajo2]

Dexamethasone and methadone have been very effective for bone pain with our pts. You need docs that are able to monitor pt closely if methadone is to be used though.

[Daisy_08, BSN, RN]

I was thinking some dex or gabapentin? There is one school of thought that believes too much pain med can increase pain? But with the the pt usually cannot locate the pain. Maybe a fentanyl patch, or dilaudid pump?

[AtlantaRN, RN]

Choline Magnesium Trisilicilate 1200mg, i can't recall 2-3 times a day can help with bone pain (its an old drug, and its cheap, but it works), also steroids are helpful. dexamethasone can be titrated up to 96mg/day but insomnia is a major side effect.

[wooh, BSN, RN]

Clonidine maybe?

[coogabooga]

Thanks everyone for the input.

[tewdles, RN]

my original post never showed up...

I also agree that gabapentine might be a good option and that a steroid may help.

Is the patient a candidate for palliative radiation for the bone mets?