Pain managing question

Melinurse · Feb 21, 2009

I do not believe the Roxinol will send them any faster than the disease process. However, it will make it far more comfortable, dignified and compassionate. I firmly believe if it's their time to go then it's their time to go with or without the medication. However, I am also a new grad and new to hospice. Don't be afraid to medicate aggressively for pain when they are terminal and going thru the dying process. Hope this helps.

marachne · Feb 21, 2009

It is pretty well documented that aggressive pain management does not hasten death. You also need to keep in mind that tolerance does build up, so the amount that may seem excessive to you may not be for that person at that time. Titrations should always be 25-50% of former dose, which is rarely how increases are done. Also, a lot of people, particularly in LTC do not their pain well controlled, so having more regular pain medication on board may give them the first comfort they have had. While it may seem like "once we start regular medication, they die," it may be that as their disease progresses, and the pain becomes worse, they are closer to death -- proximity does not equal causation.

Not everyone who is dying is in pain, but if they have a condition that does tend to be painful (like the pancreatic cancer you mentioned). It can also be helpful for breathing issues such as people with heart failure and COPD experience.

If a person cannot tell you their needs, you can use non-verbal signs: increased respiration rate, restlessness, grimacing, guarding/holding oneself unnaturally still, moaning, furrowed brow...

If someone is on a lot of an opiate, it is also vitally important that you keep up a bowel regimen. Even if they are not eating, the gut still creates waste, and with the slowed motility from the opiates, impaction can occur, causing even more pain/discomfort.

Finally, I do wonder about giving someone Roxinol every hour -- if this is the need, an attempt to come up with a long-acting solution will both ensure better coverage and reduce the burden on both pt & caregivers. If they can still swallow, a long-acting morphine, if not, the possiblity of fentanyl...

Good luck and thanks for bringing your concerns here.

Sharry RN · Feb 22, 2009

I have struggled with this issue as well. When I first started as a hospice case manager in SNF & Alz units 4 yrs ago the majority of med issue was on both ends of the extreme. Either the residents weren't getting anything or Roxanol 1ml every time a med was given.

So I either had lots of behavior problems to deal with or gorked pts. It has taken a lot of education with the med giving staff of the facilities (ongoing), very specific (narrow) orders & lots of patience.

If I have a patient that is ES ALZ or Dementia with behaviors, pain assessment is the 1st thing I do. Are they on any pain meds now? Non-opiates to narcotics.

If the patient is able to swallow & isn't on a narcotic I will try a non-opiate scheduled 1st. This often is enough to start with. If staff have a problem getting the patient to take meds, even crushed in food, I'll try scheduling the smallest amount of Roxanol a couple of times a day, especially before hands on care. 1st thing in the morning & just before going to bed at night. As I evaluate the effects I'll either increase the dose or the times or both.

I use Fent Patchs only if getting any kind of oral med into the patient is difficult. There is a low dose 12mcg patch now that really works for the general ache of old age.

Even with all that I still question at times whether or not I'm giving the patient enough or to much.

I love what I do & I love the caregivers because they really care about their residents & they want what is best for them.

MistiroseRN · Feb 22, 2009

Thank you all for your replies. I do understand about the non verbal signs when assessing for pain. It just seems that when someone is close to dying in our facility here comes the Roxanol. Marachne that is when we are giving it every hour. I have oftened questioned if it is necessary.

I don't want my residents to be in pain. I feel I still have alot to learn about pain management. That is why I felt this was the best place for this question.

marachne · Feb 22, 2009

Thank you all for your replies. I do understand about the non verbal signs when assessing for pain. It just seems that when someone is close to dying in our facility here comes the Roxanol. Marachne that is when we are giving it every hour. I have oftened questioned if it is necessary.
I don't want my residents to be in pain. I feel I still have alot to learn about pain management. That is why I felt this was the best place for this question.

Questioning what is "always done" is generally a good idea. Policies or informal habits need to be reviewed. With pain medication, as with any other kind of care, there is no "one size fits all," but you have to look at the patient as a whole: Do they have conditions that would suggest they probably have pain? (anything from an old back injury to arthritis to the dx process they are dying from), what is their history of medication? How do they respond to the medication? Is this the best thing for them to be using? Something else to keep in mind is that if you are using morphine (as opposed to some of the synthetic opiates), you will have a build up of metabolites which can cause their own problems, especially if you have reduced renal function.

I'm usually better about this, but a great resource is "Fast Facts" which provide all kinds of direct, short, information about all kinds of EOL issues. http://www.eperc.mcw.edu/ff_index.htm

You can even go right to categories such as opioid pain medications. Read #008 Morphine and Hastened Death http://www.eperc.mcw.edu/fastFact/ff_008.htm as well as #018 and #020, #070, and #074...there will probably be more that you find useful as well as others that are not related to opioids that may be useful.

There are people who do not experience pain or breathlessness at the end of life, there are those who do not react well to Roxinol or who do better with another medication for a range of reasons, there are people who have other symptoms that need other responses. Routinely giving Roxinol w/o assessing the individual and their needs is irresponsible. Good for you for questioning the practice.

leslie :-D · Feb 22, 2009

w/o seeing/knowing your pt, my initial reaction is givng hourly doses is a bit aggressive.

it is commonly done, but is reserved for those pt experiencing acute pain.

it all depends on what the dosage is, however.

2mg/hr, isn't going to have the same effect as 10mg/hr.

it is really hard to say though, w/o knowing any past and current history.

and yes!

please, manage his bowel regimen.

constipation can exacerbate pain like you wouldn't believe.

leslie

MistiroseRN · Feb 23, 2009

Marachne thank you so very much for the links. Again thank you all for replying.

Sharry RN · Feb 23, 2009

Marachne I also thank you for those links. I agree with Leslie, it does depend on the amounts given. Also I would think it would be difficult on the staff to be giving the Roxanol every hr. If the doses were small I would probably try to change the scheduled times to every 2hrs or 4hrs & see how the patient tolerates it.

In the 4 yrs I've been doing hospice in facilities with just ES Alz or dementia as a DX, I've never had to schedule the Roxanol every hr at the EOL.

Misterose do you have any say in the scheduling or are these standard orders from the physicians?