pain management in palliative care

[Hockeynursing]

Hi there.

I wasn't sure whether to post this in med-surg or hospice nursing but I work on a med surg floor, so I thought I'd post it here.

I recently had a palliative patient who was very near death and was in extreme abdominal/pelvic pain due to pancreatic cancer with mets to bladder and throughout abdominal cavity. He had multi-organ failure and was voiding frank blood with clots (causing. The catheter to keep getting blocked!). He has dilaudid subQ 2-4 mg PRN q1 hour ordered but he was unable to ask for pain meds. I was giving him dilaudid every 1.5-2.5 hours on night (2 mg). This was an attempt to kept him comfortable as when I came on shift he was in agonizing pain and fell out of bed consequently and it took a while to "catch up" to pain relief. Now here is my predicament that I value your opinion on. We had an order for no vitals but in the middle of the night his breathing slowed to 10breaths per minute. He seemed to be comfortable and was in no obvious distress at that time (he was on 5 L oxygen for comfort). Near the end of my shift, he was crying out in pain and asked for "anything I had". Knowing that his resps were a little low (and his ascites was making it hard to breathe), would you continue to administer dilaudid for this patient who was palliative as the goal was comfort care?

As an aside, the MRP did assess him at 2200 and said there was nothing to be done but continue with comfort care.

The ethical side of me says that I should administer the dilaudid, but I am curious to here from people with more experience? I suppose I could have called for a non-opiate pain relief and put it through his IVAD but he was NPO and in immense pain with any injection.

thanks so much for your help!

[SnowShoeRN]

I would. The goal of comfort care is comfort. We don't typically monitor vital signs or tele because once someone has been made DNR with comfort care only, not only are those considered interruptions to patient comfort but any changes in VS or tele would be irrelevant to the plan of care. This is a very sort of cut and dry watered down version of what's going on, but yeah.

If he was sleeping comfortably with resps around 10, awesome. If he wakes up in agony with resps around 10 or even lower, give the medication.

I should add that if you're uncomfortable or the order has some kind of "hold if RR less than whatever" parameters, then see if you can go about getting the order clarified.

[nutella, MSN, RN]

It all comes down to the goals for care.

If the goal for care is comfort measures only and the patient has the appropriate code status ordered by the MD (DNR/DNI), pain needs to get relieved. This kind of cancer causes extreme pain and needs to be treated appropriately at the end of life.

The way you would go about it is to start with the lower amount of ordered pain medication IV/sc but if the pain is not relieved you need to get an additional order. The rule is that we recommend to switch to a continues infusion when the patient needs pain medication q 2 h at the end of life. If a patient is uncomfortable or screaming out in pain - that is unacceptable at end of life with CMO and DNR/DNI. In those cases we accept that the patient needs pain medication to get relief from pain and suffering and acknowledge that the medication will have side effects. I am not talking about overdosing or "killing" somebody - I am talking about giving enough medication that the pain and suffering is relieved. Pat with severe pain often require cont pain medication via pump, if possible a pumps that allows for bolus programming in addition.

As an inpatient palliative care nurse I assess patients like yours and help the primary nurse as a consult RN. A patient that is screaming out in pain needs pain medication! Of course breathing is not great, the patient was probably imminently dying, but you are not killing the patient if you give enough medication to relief pain. The illness is killing the patient.

BTW - if a patient has a VAD (port) it is a good idea to access that for iv injection of pain meds in such a patient.

[OCNRN63, RN]

I absolutely would have given him the pain medication. End stage pancreatic cancer can be very painful, so his pain medication regimen needs to be reviewed. This patient should not be on prn pain meds only. He needs to be on a continuous pain medication with breakthrough doses as required.

The goals for managing pain for hospice/end of life patients are different from patients who are admitted for surgery and expected to go home and resume their usual lifestyle.

Do you have a palliative care team at your hospital? If you do it might be beneficial to talk to someone from their team to get a better understanding of management of end of life care patients.

[Pepper The Cat, BSN, RN]

Most of our palliative pts are on CADD pumps. This means they get a constant infusion of pain meds, and can bolus if necessary. No one cares what their respiration are. These pts are dieing. Nothing is going to change that. Give them the pain meds, keep them comfortable. Give them a comfortable death.

Making someone experience pain just because their RR is 10 is wrong,

[Hockeynursing]

Thank you all for feedback. I did in fact give him the pain meds, but wanted to know what your opinion was. No palliative care team at our hospital unfortunately.

[Hockeynursing]

I really appreciate the help!

[Tenebrae, BSN, RN]

When someone is palliative and in the end stage of life, if its charted and they need it I give it.

I once had a palliative patient who died 10 minutes after I gave them 4 drops of clonazepam.

I'd like to say the next time you encounter a situation like this, dont be afraid to say to your doctors, can we have a continuous infusion for this patient. They run through a sub cut needle in the skin and usually (although will be tailored to the needs of each patient) something for pain, something for nausea and something for anxiety/agitation. It works continually over a 24 hour period and it generally helps even out the pain swings and keeps a patient much more comfortable. You may need to give boluses but the idea is that the amount in the pump is tailored depending on the PRN doses

[loriangel14, RN]

I would have given the 4 mg q1h until he was comfortable. Then give it as often as needed. Being unable to ask for meds is no excuse for not giving them. The poor man should have been on a PCA

[Jensmom7, BSN, RN]

Hospice weighing in. Comfort means you do whatever is needed to keep your patient symptom free.

Very often, our patients who are in LTC and transitioning, or imminent, don't get what they need when their symptom meds are PRN, because they can't ask for the med. So, that's when we schedule the Roxinol, or Ativan, and switch from Atropine drops to a Scop patch.

[loriangel14, RN]

The patient shouldn't have to ask. If it's apparent they are in pain you need to medicate.

[KelRN215, BSN, RN]

Why monitor vitals at all in an end of life/comfort care patient? There really is no point to it. Seems like the patient needs MORE pain meds, if anything. Why is he not on a PCA with continuous and demand doses? Every time this subject comes up on here, I think of the dying 8 year old who I took care of many years ago. At the end, he was on 100 mg of morphine PER HOUR with 10 mg boluses available q 10 min PRN. He weighed 24 kg. A typical dose of morphine for a child this size would be 2.4 mg q 2-4 hrs PRN, which if given q 2 hours ATC would be 28.8 mg per day. In one hour, the child was getting about 4 days worth of morphine. He lived for DAYS on this dose. And we stopped monitoring VS or labs or anything else that wasn't meant to comfort him.

For the OP's patient, I'd have given the full 4 mg dose q 1hr.