del dolor en pacientes terminales
1: Postgrad Med 2001
Aug;110(2):99-100, 108-9, 113-4 [Texto
Pain management for dying patients. How to assess needs and provide
Pain and Palliative Care Program, Dana Farber Cancer Institute, Brigham
and Women's Hospital, Boston, USA. firstname.lastname@example.org
Patients at the end of life need not have unrelieved pain. Thorough
assessment and multidisciplinary treatment can provide comfort with a
minimum of adverse effects. Patients and their families can be freed to
accomplish their final goals, and the bereaved families can be spared the
pain of memories of loved ones who suffered in their final days.
2: Nurs Clin North Am 2001 Dec;36(4):779-94, vii-viii
Managing pain at the end of life.
Easley MK, Elliott S.
Pain Research Group, The University of Texas M. D. Anderson Cancer Center,
Houston, Texas 77030, USA. email@example.com
There are many threats to a calm and peaceful passing, but none more
distressing than unrelenting pain. Pain exists not only in the physical
realm, but also in the psychological, social and spiritual senses.
Discussion of barriers and responsibilities are important to assure that
pain is appropriately treated. Effective pain treatment relies on
communication among patients, families, and care providers. Nurses are a
central force in this communication and must act as leaders and advocates
in planning care and relieving pain in dying patients.
3: Am Fam Physician 2001 Oct 1;64(7):1227-34 [Texto
Challenges in pain management at the end of life.
Miller KE, Miller MM, Jolley MR.
Department of Family Medicine, University of Tennessee College of
Medicine, Chattanooga 37403, USA. firstname.lastname@example.org
Effective pain management in the terminally ill patient requires an
understanding of pain control strategies. Ongoing assessment of pain is
crucial and can be accomplished using various forms and scales. It is also
important to determine if the pain is nociceptive (somatic or visceral
pain) or neuropathic (continuous dysesthesias or chronic lancinating or
paroxysmal pain). Nociceptive pain can usually be controlled with
nonsteroidal antiinflammatory drugs or corticosteroids, whereas
neuropathic pain responds to tricyclic antidepressants or anticonvulsants.
Relief of breakthrough pain requires the administration of
an immediate-release analgesic medication. If a significant amount of
medication for breakthrough pain is already being given, the baseline dose
of sustained-release analgesic medication should be increased. If pain
does not respond to one analgesic medication, physicians should use an
equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be
controlled on a specific regimen. The impact of unresolved psychosocial or
spiritual issues on pain management may
need to be addressed.
4: Am Fam Physician 2001 Oct 1;64(7):1154, 1156, 1158, 1160
Managing pain at the end of life.
5: WMJ 2001;100(5):67-8
'Modern medicine' includes pain management and sensitive end-of-life care.
Medical College of Wisconsin, USA.
6: 1526-5900 2001 Jun;2(3):171-180
Ethical dilemmas in pain management.
Ferrell BR, Novy D, Sullivan MD, Banja J, Dubois MY, Gitlin MC, Hamaty D,
Lebovits A, Lipman AG, Lippe PM, Livovich J.
American Pain Society/American Academy of Pain Medicine Ethics Task Force.
The purpose of this study was to survey the membership of the American
Pain Society and the American Academy of Pain Medicine to determine their
beliefs about ethical dilemmas in pain management practice. Respondents
rated ethical dilemmas for their importance as well as their own
competence in dealing with these ethical issues. The survey also included
an open-ended question that asked respondents to describe clinical
situations in which they had encountered ethical dilemmas. A total of
1,105 surveys were analyzed, with physicians (N =
612), nurses (N = 189), and psychologists (N = 166) representing the
professions with the greatest response. Management of pain at the end of
life, general undertreatment of pain, and undertreatment of pain in the
elderly were the most frequently encountered dilemmas. Qualitative data
were analyzed to identify ethical issues in the case examples provided by
the respondents. Major themes included inappropriate pain management,
barriers to care, interactions and conflicts with others, regulatory/legal
issues, euthanasia, assisted suicide, and research issues. We conclude
that ethical dilemmas are common in pain management practice and that
resolution of these dilemmas requires commitment by individual
professionals as well as health systems. Copyright 2001 by the American
7: Am J Hosp Palliat Care 2001 Mar-Apr;18(2):89-101
Treatment options to manage pain at the end of life.
Yakima Physicians Pain and Palliative Medicine Consultants, Yakima,
Experts believe that the time preceding death can be comfortable if people
die without pain, with dignity, and in their own way. Given current
analgesic options, psychological and spiritual interventions, and an
effective health care delivery system, all these goals are achievable.
Pain management is one of the most important aspects of end-of-life care.
Effective analgesics should be chosen carefully, in keeping with the
patient's overall condition, level and stability of pain, and specific
patient/family wishes. Ideally, analgesics should be initiated as soon as
appropriate. The variety of routes of delivery, ranging from oral to
transdermal or epidural to intrathecal, allows a selection that will
achieve comfort and yet be least troublesome for the caregiver and
patient. As the palliative care specialty continues to grow in the United
States, it is imperative that health care professionals in the field
develop basic to advanced primers to assist in equipping colleagues in all
specialties with an understanding of effective opioid use, as well as the
multidimensional aspects of helping patients achieve comfort at the end of
8: Lancet 2001 Apr 28;357(9265):1311-5
Understanding the experience of pain in terminally ill patients.
Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ.
Department of Clinical Bioethics, Warren G Magnuson Clinical Center,
National Institutes of Health, Building 10, Room 1C118, Bethesda, MD
20892, USA. email@example.com
BACKGROUND: Terminally ill patients commonly experience substantial pain.
Unresolved pain has been cited as evidence that end-of-life care is of
poor quality. However, the data on which that conclusion is based are
limited. We aimed to provide additional data on the experience of pain in
such patients. METHODS: We interviewed 988 terminally ill patients from
six randomly selected US sites. We asked them who had treated their pain
in the previous 4 weeks (primary-care physician, pain specialist, or
both), and whether they wanted more pain medication than they were
receiving, or why they did not want more. FINDINGS: 496 (50%) terminally
ill patients reported moderate or severe pain. 514 (52%) individuals had
seen a primary-care physician for treatment of pain in the previous 4
weeks and 198 (20%) saw a pain specialist. Of those who had been treated
by their primary-care physician, 287 (29%) wanted more therapy, 613 (62%)
wanted their pain therapy to remain the same, and 89 (9%) wanted to reduce
or stop their pain therapy. Several reasons for not wanting additional
therapy were offered-fear of addiction, dislike of mental or physical
side-effects, and not wanting to take more pills or injections. We saw no
association between disease and amount of pain between disease and the
desire for more treatment. Black patients were more likely to seek
additional pain therapy, see a pain specialist, and refuse additional
medication because of fear of addiction than other populations.
INTERPRETATION: Although half of terminally ill patients experienced
moderate to severe pain, only 30% of them wanted additional pain treatment
from their primary-care physician. The number of patients experiencing
pain remains too high. However, the number is not as large as perceived.
Additionally, most are willing to tolerate pain. Furthermore, the
experience of pain is constant across major terminal diseases.
9: Clin Geriatr Med 2000 Nov;16(4):853-74
Division of Geriatric Medicine, Department of Medicine, University of
California at Los Angeles School of Medicine, Los Angeles, California
90095-1687, USA. firstname.lastname@example.org
Pain is a common problem encountered among elderly people in subacute and
long-term care facilities. Pain often is underestimated and undertreated
in these settings. Most pain problems can be improved by careful
assessment and careful use of analgesic drugs and nondrug strategies.
Subacute care and other long-term care facilities often present unique
challenges to pain management. Clinicians who care for patients in these
settings must help to establish a plan of care that is reasonable for the
given resources and skills often available in
these settings. Clinicians have an obligation to improve comfort and
dignity for these patients, especially those near the end of life.
10: CA Cancer J Clin 2000 Mar-Apr;50(2):70-116; quiz 117-20
The management of cancer pain.
Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem,
Any therapeutic strategy developed for patients experiencing cancer pain
depends on the goals of care, which can be broadly categorized as
prolonging survival, optimizing comfort, and optimizing function. The
relative priority of these goals for any individual should direct
therapeutic decision-making. By combining primary treatments, systemic
analgesic agents, and other techniques, most cancer patients can achieve
satisfactory relief of pain. In cases where pain appears refractory to
these interventions, invasive anesthetic or neurosurgical maneuvers may be
necessary, and sedation may be offered to those with unrelieved pain at
the end of life. The principles of analgesic therapy are presented, as
well as the practical issues involved in drug administration, ranging from
calculating dosage to adverse effects, and, when necessary, how to switch
and/or combine therapies. Adjuvant analgesics, which are drugs indicated
for purposes other than relief of pain but which may have analgesic
effects, are also listed and discussed in some detail. Surgical and
neurodestructive techniques, such as rhizotomy or cordotomy, although not
frequently required or performed, represent yet other options for patients
with unremitting pain and diminished hope of relief. Although cancer pain
can be a complex medical problem arising from multiple sources, patients
should be assured that suffering is not inevitable and that relief is
11: Am Fam Physician 2000 Feb 1;61(3):755-64 [Texto
Managing pain in the dying patient.
Whitecar PS, Jonas AP, Clasen ME.
Wright State University School of Medicine, Dayton, Ohio, USA.
End-of-life care can be a challenge requiring the full range of a family
physician's skills. Significant pain is common but is often undertreated
despite available medications and technology. Starting with an appropriate
assessment and following recommended guidelines on the use of analgesics,
family physicians can achieve successful pain relief in nearly 90 percent
of dying patients. Physicians must overcome their own fears about using
narcotics and allay similar fears in patients, families and communities.
Drugs such as corticosteroids, antidepressants and anticonvulsants can
also help to alleviate pain. Anticonvulsants can be especially useful in
relieving neuropathic pain. Side effects of pain medications should be
anticipated and treated promptly, but good pain control should be
maintained. The physical, psychologic, social and spiritual needs of dying
patients are best managed with a team approach. Home visits can provide
comfort and facilitate the doctor-patient relationship at the end of life.
12: JAMA 2000 Jan 12;283(2):255-8
The Pain Relief Promotion Act of 1999: a serious threat to palliative
Orentlicher D, Caplan A.
Center for Law and Health, Indiana University School of Law-Indianapolis
46202-5194, USA. email@example.com
Recent educational efforts in the US medical community have begun to
address the critical issue of palliative care for terminally ill patients.
However, a newly introduced bill in Congress, the Pain Relief Promotion
Act of 1999 (PRPA), could dramatically hinder these efforts if enacted.
The act criminally punishes the use of controlled substances to cause-or
assist in causing-a patient's death. The primary purposes of PRPA are to
override the physician-assisted suicide law currently in effect in Oregon
and prohibit other states from enacting similar laws. The act also
includes valuable provisions for better research and education in
palliative care, but the benefits of those provisions are outweighed by
the punitive sections of the act. Under PRPA, the quality of palliative
care in the United States could be compromised when physicians, fearing
criminal prosecution, err on the side of caution rather than risk their
patients' deaths by using highly aggressive pain treatments. Furthermore,
PRPA would put Drug Enforcement Administration officials, who have no
medical expertise, in the position of regulating medical decisions. The
act also would interfere with individual states' long-standing authority
over medical practice. Finally, PRPA would discourage physicians from
engaging in experimentation and innovation in palliative care, again out
of concern for crossing the line between relief of suffering and
physician-assisted suicide. Other bills have been introduced that go much
further than PRPA to encourage palliative care, without its problematic
provisions. Regardless of the controversy surrounding physician-assisted
suicide in the United States, the need for quality end-of-life care will
be far better served if Congress enacts one of these bills rather than
13: Ann Intern Med 1999 Jul 6;131(1):37-46
Management of pain and spinal cord compression in patients with advanced
cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of
Physicians-American Society of Internal Medicine.
Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
General internists often care for patients with advanced cancer. These
patients have substantial morbidity caused by moderate to severe pain and
by spinal cord compression. With appropriate multidisciplinary care, pain
can be controlled in 90% of patients who have advanced malignant
conditions, and 90% of ambulatory patients with spinal cord compression
can remain ambulatory. Guidelines have been developed for assessing and
managing patients with these problems, but implementing the guidelines can
be problematic for physicians who infrequently need to use them. This
paper traces the last year of life of Mr. Simmons, a hypothetical patient
who is dying of refractory prostate cancer. Mr. Simmons and his family
interact with professionals from various disciplines during this year.
Advance care planning is completed and activated. Practical suggestions
are offered for assessment and treatment of all aspects of his pain,
including its physical, psychological, social, and spiritual dimensions.
The methods of pain relief used or discussed include nonpharmacologic
techniques, nonopioid analgesics, opioids, adjuvant medications, radiation
therapy, and radiopharmaceutical agents. Overcoming resistance to taking
titrating, and changing opioid routes and agents; and preventing or
relieving the side effects they induce are also covered. Data on
assessment and treatment of spinal cord compression are reviewed.
Physicians can use the techniques described to more readily implement
existing guidelines and provide comfort and optimize quality of life for
patients with advanced cancer.