Symptom Management of the Dying Oncology Patient
The symptoms and suffering of the dying patient can be distressful to both the patient and the patient’s caregivers. Every effort is needed to assist the patient in comfortable and dignified death. Common symptoms at the end of life include pain, nausea,
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Lawrence Berk
12.1
Introduction
Dar’st thou die? The sense of death is most in apprehension; And the poor beetle that we tread upon, In corporal sufferance feels a pang as great As when a giant dies. William Shakespeare, Measure for Measure Act III, scene 1.
The goal for everyone, the patient, the family, and the medical staff, is for a death without suffering, a peaceful death. But, often the process of dying is complicated by unwanted symptoms. The appropriate treatment of these problems will improve the quality of the death. The most common problems include pain, nausea, dyspnea, delirium, and death rattle. This chapter reviews various approaches to these problems. This is not intended to be a systematic review, but rather to give insights into the problems and to offer potential treatments. There are many other approaches available in the literature than the ones discussed here, and these treatments are based on the present evidence from clinical trials and common usage.
12.2
Pain
Pain is a multidimensional problem, combining both the physical stimulation of nociceptors and the cognitive reaction to the stimulus that becomes the unpleasant emotional response of pain. Pain can therefore be treated by eliminating the
L. Berk, MD, PhD Morsani School of Medicine, University of South Florida, Tampa, FL, USA e-mail: [email protected]
© Springer International Publishing Switzerland 2017 L. Berk (ed.), Dying and Death in Oncology, DOI 10.1007/978-3-319-41861-2_12
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stimulus, preventing the transmission of the pain to the brain or inhibiting the cerebral sensation of pain. Treatments for cancer patients which eliminate the stimulus include surgery, radiation therapy, and chemotherapy. These treatments are often too aggressive for the dying patient during the last days. Therefore, treatment focuses on pharmacological management of the pain rather than physical relief of the pain. The primary pharmacological treatment for moderate to severe pain in dying patients is opioids. As a brief aside, opium is a mixture of alkaloids from the poppy seeds; opiates are medications which are derived from the naturally occurring alkaloids of opium; and opioids are any medications that react with the opiate receptors in the brain, including opiates (Trescot et al. 2008). The primary target for pain relief is the activation of the opiate receptors in the brain and spinal cord. There are three opiate receptors associated with pain relief, the mu receptor, the delta receptor, and the kappa receptor. The International Union of Basic and Clinical Pharmacology (IUPHAR) recommends these be called MOR, DOR, and KOR, respectively (Toll). The three most commonly used opiates are morphine, oxycodone, and hydromorphone. The two most commonly used synthetic opioids are fentanyl and methadone. In 1996, the World Health Organization published the “pain ladder: for analgesia.” In this scheme, mild pain should be treated with a nonopioid, such as a nonsteroidal anti-inflammatory drug (NSAID), with or without an adjuvan
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