{"id":1033,"date":"2024-04-15T09:29:13","date_gmt":"2024-04-15T13:29:13","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/?post_type=chapter&#038;p=1033"},"modified":"2024-04-15T18:18:50","modified_gmt":"2024-04-15T22:18:50","slug":"2-7-4","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/chapter\/2-7-4\/","title":{"raw":"2.7.5 Pain and Symptom Management","rendered":"2.7.5 Pain and Symptom Management"},"content":{"raw":"At the end-of-life, the most common symptoms include:\r\n<ul>\r\n \t<li>Dyspnea<\/li>\r\n \t<li>Pain<\/li>\r\n \t<li>Agitation and delirium<\/li>\r\n \t<li>Anxiety and depression<\/li>\r\n \t<li>Airway secretions<\/li>\r\n<\/ul>\r\nThe progression of these symptoms may vary within a few hours because death time is unexpected but the pace to approaching death may be quick.\u00a0Assessment and provision of psychosocial and spiritual needs is critical throughout the LTC stay.[footnote]Kaasalainen et al., 2021[\/footnote]\r\n\r\nPain:\r\n<ul>\r\n \t<li>For severe pain, oral morphine, hydromorphone or oxycodone are first line options<\/li>\r\n \t<li>Consider both regular and breakthrough doses for dose adjustment considering safety according to each resident\u2019s situation<\/li>\r\n \t<li>Breakthrough doses are generally 10% of the total opioid dose\/day<\/li>\r\n \t<li>Optimize opioid therapy before adding adjuvants e.g., antidepressants, anticonvulsant etc.<\/li>\r\n<\/ul>\r\nDyspnea:\r\n<ul>\r\n \t<li>Identify and treat reversible causes as possible<\/li>\r\n \t<li>Provide fresh air when O2 levels are satisfactory<\/li>\r\n \t<li>utilize non-pharmacological intervention because dyspnea may not be due to hypoxia<\/li>\r\n \t<li>Opioids are first line for medication management<\/li>\r\n \t<li>Bronchodilators may be used for mild dyspnea<\/li>\r\n \t<li>Corticosteroid trial may be used<\/li>\r\n \t<li>Benzodiazepines with opioid can help with anxiety\/panic in severe distress[footnote]Mehta &amp; Chan, 2008[\/footnote][footnote]BC Centre for Palliative Care, n.d.[\/footnote][footnote]Busse et al., 2017[\/footnote]<\/li>\r\n<\/ul>\r\nRespiratory Congestion\/Oral Secretions\r\n<ul>\r\n \t<li>Noisy breathing, respiratory tract secretions or death rattle is the noise produced with breathing due to residents\u2019 inability to swallow saliva or a respiratory infection at the end-of-life<\/li>\r\n \t<li>It may cause agitation and a feeling of suffocation in an alert person and distress in care partners and health care providers<\/li>\r\n \t<li>Institute non-pharmacological interventions:<\/li>\r\n \t<li>humidity, mouth care, frequent repositioning, and avoid suction if possible (can cause agitation)<\/li>\r\n \t<li>Subcutaneous and transdermal anticholinergic therapy<\/li>\r\n \t<li>If fluid overload, consider diuretics<\/li>\r\n<\/ul>\r\nRefractory Symptoms and Palliative Sedation\r\n<ul>\r\n \t<li>Offer palliative sedation for dying patients when symptoms remain unrelieved and cause suffering for them<\/li>\r\n \t<li>It should not be utilized relieve care partners\u2019 or health care providers\u2019 discomfort<\/li>\r\n \t<li>Utilize palliative sedation only when there is limited prognosis and other interventions such as artificial nutrition, hydration, unnecessary medications and bowel interventions may have been discontinued<\/li>\r\n<\/ul>","rendered":"<p>At the end-of-life, the most common symptoms include:<\/p>\n<ul>\n<li>Dyspnea<\/li>\n<li>Pain<\/li>\n<li>Agitation and delirium<\/li>\n<li>Anxiety and depression<\/li>\n<li>Airway secretions<\/li>\n<\/ul>\n<p>The progression of these symptoms may vary within a few hours because death time is unexpected but the pace to approaching death may be quick.\u00a0Assessment and provision of psychosocial and spiritual needs is critical throughout the LTC stay.<a class=\"footnote\" title=\"Kaasalainen et al., 2021\" id=\"return-footnote-1033-1\" href=\"#footnote-1033-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/p>\n<p>Pain:<\/p>\n<ul>\n<li>For severe pain, oral morphine, hydromorphone or oxycodone are first line options<\/li>\n<li>Consider both regular and breakthrough doses for dose adjustment considering safety according to each resident\u2019s situation<\/li>\n<li>Breakthrough doses are generally 10% of the total opioid dose\/day<\/li>\n<li>Optimize opioid therapy before adding adjuvants e.g., antidepressants, anticonvulsant etc.<\/li>\n<\/ul>\n<p>Dyspnea:<\/p>\n<ul>\n<li>Identify and treat reversible causes as possible<\/li>\n<li>Provide fresh air when O2 levels are satisfactory<\/li>\n<li>utilize non-pharmacological intervention because dyspnea may not be due to hypoxia<\/li>\n<li>Opioids are first line for medication management<\/li>\n<li>Bronchodilators may be used for mild dyspnea<\/li>\n<li>Corticosteroid trial may be used<\/li>\n<li>Benzodiazepines with opioid can help with anxiety\/panic in severe distress<a class=\"footnote\" title=\"Mehta &amp; Chan, 2008\" id=\"return-footnote-1033-2\" href=\"#footnote-1033-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><a class=\"footnote\" title=\"BC Centre for Palliative Care, n.d.\" id=\"return-footnote-1033-3\" href=\"#footnote-1033-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><a class=\"footnote\" title=\"Busse et al., 2017\" id=\"return-footnote-1033-4\" href=\"#footnote-1033-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/li>\n<\/ul>\n<p>Respiratory Congestion\/Oral Secretions<\/p>\n<ul>\n<li>Noisy breathing, respiratory tract secretions or death rattle is the noise produced with breathing due to residents\u2019 inability to swallow saliva or a respiratory infection at the end-of-life<\/li>\n<li>It may cause agitation and a feeling of suffocation in an alert person and distress in care partners and health care providers<\/li>\n<li>Institute non-pharmacological interventions:<\/li>\n<li>humidity, mouth care, frequent repositioning, and avoid suction if possible (can cause agitation)<\/li>\n<li>Subcutaneous and transdermal anticholinergic therapy<\/li>\n<li>If fluid overload, consider diuretics<\/li>\n<\/ul>\n<p>Refractory Symptoms and Palliative Sedation<\/p>\n<ul>\n<li>Offer palliative sedation for dying patients when symptoms remain unrelieved and cause suffering for them<\/li>\n<li>It should not be utilized relieve care partners\u2019 or health care providers\u2019 discomfort<\/li>\n<li>Utilize palliative sedation only when there is limited prognosis and other interventions such as artificial nutrition, hydration, unnecessary medications and bowel interventions may have been discontinued<\/li>\n<\/ul>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-1033-1\">Kaasalainen et al., 2021 <a href=\"#return-footnote-1033-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-1033-2\">Mehta &amp; Chan, 2008 <a href=\"#return-footnote-1033-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-1033-3\">BC Centre for Palliative Care, n.d. <a href=\"#return-footnote-1033-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-1033-4\">Busse et al., 2017 <a href=\"#return-footnote-1033-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":517,"menu_order":59,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-1033","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1033","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/users\/517"}],"version-history":[{"count":2,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1033\/revisions"}],"predecessor-version":[{"id":1051,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1033\/revisions\/1051"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1033\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/media?parent=1033"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapter-type?post=1033"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/contributor?post=1033"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/license?post=1033"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}