Palliative Pain Management: When Both Pain and Suffering Hurt

Abstract

Patients with advanced cancer frequently experience intractable pain without sufficient response to a conventional pharmacological approach. One reason for refractory pain at the end of life can be the bidirectional nature of pain and suffering. Three terminally ill patients were assessed using a multidimensional palliative pain concept, including sensory, affective, cognitive, and existential components. In these patients, resistant pain did not equal insufficient eradication of the nociceptive input, but also suffering. Unrelieved emotions, depressive or anxious symptoms, delirium, difficulties communicating, or chemical coping influenced the expression of pain, illuminating the phenomenon of somatization. Palliative pain treatment integrated analgesic treatments, psychological, rehabilitative, and existential interventions, in consideration of individual expectations and outcomes. With the disciplined assessment and alternative multidisciplinary palliative approach, the quality of life of three terminally ill cancer patients with intractable pain could be enhanced, and unnecessary interventions and escalation of medications avoided.

Dying is a Transition

“…Complex problems such as severe pain with emotional, spiritual, or existential components 8 are hardly treatable by a needs-based approach only. This approach entails the misleading interpretation that dying is manageable and thus furthers the claim for a right to die without suffering.…”

Intractable Pain: Intoxication or Undermedication?

“…6,9 Somatization was also a possibility worthy of consideration. 11 However, the patient's dramatic and sustained response suggests that somatization was not an explanation for the intractable pain syndrome. Finally, patients with delirium can overtly express their pain because of the disinhibition caused by global brain dysfunction.…”

“…Opioid rotation is still the main treatment in such a case. 11,12 Hyperalgesia can occur in two patterns: primary and secondary. 13 Primary hyperalgesia leads to an exaggerated nociceptive response at the site of the lesion; secondary hyperalgesia is observed beyond the region of the actual tissue damage.…”

State of Art of Managing Pain in Patients With Cancer

“…Unrevealed psychosocial distress may amplify pain expression and trigger a vicious cycle of increased pain expression, anxiety, escalation of opioids and benzodiazepine use, and impaired cognitive function. 36,37 A quick and widely used screening tool is the 1-item distress thermometer that can screen for distress in cancer patients. 38,39 Because psychosocial distress can vary among patients and is often difficult to comprehend in depth, assessment by an interdisciplinary team is of paramount importance.…”