Medical Aspects of Pain Control [1]
What is Pain?
Pain is an unpleasant sensory and emotional experience.
The sensation of pain is a useful warning signal that actual or potential damage is occurring or will occur to the body’s tissues. The frequency and intensity of pain varies depending on which particular disease the patient has, how advanced the disease is and what other health problems they are experiencing.
The pain experience is unique to an individual.
It can be magnified by psychosocial stressors, and modified through psychological and emotional support. It is what the person describes and not what others think it ought to be.
In the mid-1960s, Cicely Saunders recognized that there was much more to pain than the medical/physical aspects. She developed the concept of ‘total pain’ – encompassing physical, psychological, social, cultural and spiritual aspects.
Signs of pain
- Facial signs: furrowed brow, grimace, eyes closed tight, clenched teeth, taut lips.
- Body posture signs: very still, stiff, can only get comfortable in one position.
- Tense, unhappy when they move, or you move them.
- Appear irritable and withdrawn rather than content.
- No appetite or excessive appetite.
Helping relieve pain
Find out what helps or makes it worse – movement, massage, support on a pillow, distraction (music, company, television/radio). Find their most comfortable position.
Medicines given to relieve pain increase in strength in the order:
- Paracetamol (Non-Opioid)
- Panadeine (Mild opioid)
- Morphine (Strong Opioid)
Non-Opioids include aspirin, paracetamol, anti-inflammatories. Mild Opioids include codeine. If there is inadequate relief from regular administration of these then the patient is given Strong Opioids (morphine, oxycodone, hydromorphone, fentanyl, methadone).
In recent years many more people, when first diagnosed, are in an advanced state of pain. More and more patients are prescribed opioids straight away. Morphine is not addictive providing you are in pain. The pain receptors metabolize the morphine. If you are not in pain, the drug goes to the brain and gives you a ‘high’. Pethidene is very addictive and lasts only three hours. Fentanyl can be used as patches on the skin. It is widely used in hospices, lasts three days and is useful for neuropathic pain.
Adjuvants are medications where the primary role is not pain relief but they supplement the benefit of analgesics and improve pain control. eg. Ketamine; Anti-epileptics (sodium valproate; gabapentin; pregabalin); Anti-depressants (amitryptaline)
Despite the advances in pain control, there is much unrelieved pain, due to three factors: economic, family dysfunction, self-expression (fear, culture, support, haste).
Old Age, Palliative Care, Signs of Death
Ageing is often treated like a protracted illness during which the whole emphasis is on keeping the person alive; old people are often not allowed to die. As a result, the person and the carers go through much trauma, many ups and downs.
If a person with dementia develops an acute problem such as a urinary tract infection, it is often not wise to take them out of their home-ground as they get too confused.
The ageing process can lead to slow failure of the liver and kidneys over several years. This is different from the end-of-life stage which is irreversible, and generally starts 24-48 hours before death.
Physical indicators of approaching death include: profoundly weak, essentially bed-bound, kidneys and liver deteriorate, toxins start to accumulate, no excretion, drowsy for extended periods, disoriented with time, short attention span, disinterested in food and drink, can’t swallow.
There are many similarities between issues at birth and at death e.g. dependence, loving care, incontinence, dehydration, lack of nutrition, senses not operating properly, except hearing. However, at death, spiritual awareness increases.
End-of-Life Behaviour
We all know when we are dying, but some can’t accept it and hang on. Sometimes if a carer gives the person permission to die, they will. People sometimes choose to die when their loved ones walk out of the room – maybe they don’t want to hurt them. At the other extreme, there are people who die soon after diagnosis. It may be that they have actually known for some time, but didn’t admit it or go to a doctor.
Even for those who are struggling with their death benefit from a loving family and a good environment. Human support and care helps ease the death.
The majority of people do not accept their death. They are anxious about what is going to happen to them. Because they are fearful, they want you just to be present with them, not to judge them, not to give them answers. The closer you are to someone, the more you may want the dying person to stay. A stranger can walk in and bring such peace, an emotional detachment that is not possible for a family member.
Communication with a dying person is a process of sharing – talking, listening, understanding. If someone stops listening to you, you lose your trust in that person. Non-verbals are 55-85% of the communication. Silence can be effective. ‘Soul-to-soul’ communication is possible with a dying person.
Validate the other person’s feelings even if it is anger at the losses they face in dying, but don’t let them make you angry.
Medical Terms Used at the End of Life
The ‘Death Rattle’ comes from an accumulation of fluids, when the person can’t swallow or excrete. Often the consciousness is aware but the senses have shut down to the extent that the death rattle is not painful. When the person can no longer swallow, don’t give fluids anymore, just moisten the mouth. The valves have stopped working so the body won’t let us swallow.
‘Peripheral Shutdown’ is where the extremities become cold. This is not felt by the dying person. It is just part of the mechanism of dying; blood is needed at the heart.
‘Terminal Dehydration’ gives us an euphoria that can send us spiritually to another place. The body is preparing us for death. This is quite marvellous really.
‘Terminal Restlessness’ may be due to a full bladder, the effects of morphine or a spiritual struggle.
In the last 12-24 hours, the body pushes out the last trapped air. When the diaphragm pushes the air out it causes a particular sound called the ‘Cheyne-Stoke Effect’, an involuntary mechanism.
[1] Contents of this page prepared by Len Warren of Pure Land of the Indestructible Buddha, Hayagriva Buddhist Centre, 64 Banksia Terrace, Kensington 6151 Western Australia, November 2018. Selected extracts from talks given by Teresa Prior (2006) and Suzie Vojkovic (2013).
