Introduction
Andrew Zimmer is dying. A 48-year-old with metastatic prostate cancer, he lives at home with his wife, a 10-year-old son, and a 14-year-old daughter. His condition has deteriorated significantly in the last month, and he and his family are aware that he probably has only weeks or days to live. Ms. Zimmer reports that for the past several weeks her husband has had no appetite and has been sleeping more during the day. She also says that for the past few days he has been moaning and seems to be in greater pain when she tries to move him. Mr. Zimmer is lethargic but rousable. When questioned, he says, 'The pain is worse,' rating it at 8 on a 0-to-10 scale, and describes the pain as aching, constant in his lower back, and worse with movement. Although he takes two tablets of hydrocodone with acetaminophen every four hours (each containing 5 mg of hydrocodone and 325 mg of acetaminophen), he says that 'the medicines just don't seem to be working any more.'
The interdisciplinary team, which includes the physician, the nurse, the social worker, the home health aide, and the family's chaplain, meets with the couple. Various approaches are tried to address the somatic and neuropathic components of his pain, including aggressive titration of pain medications, opioid rotation, the use of corticosteroids and other adjuvant drugs, and a change from the oral to a parenteral route of administration. But the pain continues to escalate. He is evaluated and found not to be a candidate for anesthetic procedures such as epidural infusion and nerve block. After lengthy discussion at a subsequent meeting, Mr. Zimmer asserts that, although he'd like to remain capable of interacting with his family, he would accept sedation if the pain cannot be controlled.
Mr. Zimmer need not die in agony. For most terminally ill patients, pain relief is possible. Yet pain remains a primary concern of these patients and their families. Despite decades of efforts to improve pain management, researchers continue to document inadequate assessment of pain and unrelieved pain in patients with a number of life-limiting diseases. Terminal illness also affects family members, especially caregivers. Witnessing a loved one's pain can cause severe emotional distress.
Nurses can help to manage patients' pain through regular assessment, intervention planning, and the administration of pharmacologic and nonpharmacologic treatments. They can also improve pain outcomes by educating and counseling patients and families, monitoring for adverse effects of treatments, and participating in the development of institutional policies related to the treatment of pain. This article offers a brief overview of some principles of the use of analgesics and focuses on three areas: difficulties in assessing pain in patients who are either nonverbal or cognitively impaired, the need to distinguish pain from other symptoms of distress among the dying, and the use of sedation for intractable pain and other symptoms.