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May 1998
Volume 62 |
Number 5
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| Anesthesia and
Palliative Care |
Maywin Liu, M.D.
Multiple opportunities exist for anesthesiologists to apply their
skills beyond the perioperative period. One potential area is
palliative medicine. Palliative medicine, the specialty that cares
for the dying, is a small and unglamorous field. However, the
number of patients who will require the services of this specialty
will increase as the Baby Boomers age and as more people reach
the oldest "old" category (>80 years).
One of the most common symptoms experienced by the dying
is pain. Patients with cancer represent one group with the greatest
number suffering from pain. Up to 67 percent of all cancer patients
suffer with pain1 with the prevalence
increasing to between 80 percent and 100 percent in advanced stages.2
However, pain is not limited to cancer patients. It is also a
prominent symptom in patients dying of AIDS and end-stage cardiac
and renal disease. Pain is listed by patients as the most distressing
of all symptoms.3
Palliative medicine is currently dominated by oncologists.
However, given the prevalence of pain, the role of the anesthesiologist
in palliative care should be obvious. Despite the care of the
oncologists, a significant portion of cancer patients report their
pain as poorly controlled.4 One
of the largest obstacles to pain control is lack of awareness
of the problem. Though patients list pain as the most troubling
symptom, it is often overlooked or underemphasized by the treating
physician.
These patients may benefit from the intensive treatment
that a pain specialist can provide. Higginson et al.5
demonstrated that a team dedicated to pain control substantially
decreased pain and improved quality of life in cancer patients.
This difference resulted solely through the application of the
World Health Organization (WHO) guidelines6
for pain medication management. However, despite the routine
application of pain guidelines in this study, a few patients continued
to report severe pain.
Anesthesiologists were not included as part of the care
team in this study, and the reasons for poor pain control were
not listed. The addition of a pain-trained anesthesiologist may
have improved pain relief through the judicious use of adjuvant
drug therapy, neurolytic blocks or implantable drug delivery devices.
Currently, the mainstay of cancer pain management is opioids.7
However, despite published guidelines, the application of the
appropriate use of opioids is not widespread. There continues
to be a pervasive fear among many physicians of prescribing these
medications. Reasons include fear of possible loss of license
and fear of patient addiction.
Another significant problem associated with opioids is
side effects. Opioids commonly cause nausea, constipation and
sedation. Though no analgesic ceiling effect exists for opioids,
doses are often limited by these side effects. As higher doses
of opioids are prescribed, rarer complications such as myoclonus
and hyperalgesia may become more prevalent. All who prescribe
opioids for pain control should be aware of the adverse effects
associated with their use. Routine administration of opioids should
mean routine administration of medications to treat or prevent
opioid-related side effects. Opioid rotation can also be effective
in treating or lessening the severity of side effects.8
Despite compliance with WHO guidelines, up to 10 percent
of patients will have pain poorly controlled with opioids alone,
7 and some will have pain poorly
controlled even with adjuvant oral or parenteral medications.
Some of these patients (e.g., pancreatic cancer patients) may
benefit from the additional pain relief that a block can provide.
In addition, if the analgesia from oral or parenteral opioids
is not sufficient or if significant side effects limit their efficacy,
intrathecal or epidural analgesic agents may be an option. Many
oncologists are not aware of these options for pain control or
consider them very late in the course of the patient's life when
they may be of little benefit. Neurolytic blocks are known to
improve quality of life and potentially increase life expectancy.9
Pain specialists have the potential to advance palliative
care research. Oncologists tend to concentrate their research
efforts on the treatment of cancer, with the pain related aspects
of cancer considered less important. Additional outcome studies
of current treatment modalities for pain still need to be done.
Pain specialists should have a prominent role in the development
of novel or improved pain therapies. Currently, there are few
effective agents for neuropathic pain. In addition, many pain
conditions unique to the cancer patients (e.g., stomatitis) are
difficult to control with current therapies.
The role of the pain specialist should be integral in
palliative medicine. Improved pain control for terminal patients
can be achieved by educating our oncology colleagues on the options
we can provide for pain control and directly participating on
teams to address the palliative care needs of the patients.
References:
- Cleeland CS, Gonin R, Hatfield AK. Pain
and its treatment in outpatients with metastatic cancer. N
Engl J Med. 1994; 330:592-596.
- Coyle N, Adelhardt J, Foley KM, Portenoy
RK. Character of terminal illness in the advanced cancer patient:
Pain and other symptoms during the last four weeks of life.
J Pain Symptom Manage. 1990; 5:83-93.
- Weitzner MA, Moody LN, McMillan SC. Symptom
management issues in hospice care. Am J Hospice & Palliative
Care. 1997:190-195.
- Serlin RC, Mendoza TR, Nakamura Y, Edwards
KR, Cleeland CS. When is cancer pain mild, moderate, or severe?
Grading pain severity by its interference with function.
Pain. 1995; 61:277-284.
- Higginson IJ, Hearn J. A multicenter
evaluation of cancer pain control by palliative control teams.
J Pain Symptom Manage. 1997; 14:29-35.
- World Health Organization Expert Committee.
Cancer pain relief and palliative care. WHO, Geneva, Switzerland,
1990.
- Portenoy RK. Pharmacologic management
of cancer pain. Seminars in Oncology. 1995; 22:112-120.
- de Stoutz ND, Bruera E, Suarez-Almazor
M. Opioid rotation for toxicity reduction in terminal cancer
patients. J Pain Symptom Manage. 1995; 10(5):378-384.
- Lillemoe KD, Cameron JL, Kaufman HS,
Yeo CJ, Pitt HA, Sauter PK. Chemical splanchnicectomy in patients
with unresectable pancreatic cancer. Ann Surgery. 1993;
217:447-457.
Maywin Liu, M.D., is Assistant Professor
in the Department of Anesthesia, Pain Management Center, Hospital
of the University of Pennsylvania, Philadelphia, Pennsylvania.
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