Manejo del dolor en pacientes terminales




1: Postgrad Med  2001 Aug;110(2):99-100, 108-9, 113-4 [Texto completo]
Pain management for dying patients. How to assess needs and provide pharmacologic relief.
Abrahm J.
Pain and Palliative Care Program, Dana Farber Cancer Institute, Brigham and Women's Hospital, Boston, USA.
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.
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.
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3: Am Fam Physician  2001 Oct 1;64(7):1227-34 [Texto completo]
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.
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.
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4: Am Fam Physician  2001 Oct 1;64(7):1154, 1156, 1158, 1160
Managing pain at the end of life.
Douglass AB.
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5: WMJ  2001;100(5):67-8
'Modern medicine' includes pain management and sensitive end-of-life care.
Dunn MJ.
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 Pain Society

7: Am J Hosp Palliat Care  2001 Mar-Apr;18(2):89-101
Treatment options to manage pain at the end of life.
Wrede-Seaman LD.
Yakima Physicians Pain and Palliative Medicine Consultants, Yakima, Washington, USA.
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 life.
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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.
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
Pain management.
Ferrell BA.
Division of Geriatric Medicine, Department of Medicine, University of California at Los Angeles School of Medicine, Los Angeles, California 90095-1687, USA.
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.
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10: CA Cancer J Clin  2000 Mar-Apr;50(2):70-116; quiz 117-20
The management of cancer pain.
Cherny NI.
Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel.
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 attainable.
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11: Am Fam Physician  2000 Feb 1;61(3):755-64 [Texto completo]
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.
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12: JAMA  2000 Jan 12;283(2):255-8
The Pain Relief Promotion Act of 1999: a serious threat to palliative care.
Orentlicher D, Caplan A.
Center for Law and Health, Indiana University School of Law-Indianapolis 46202-5194, USA.
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 PRPA.

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.
Abrahm JL.
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 opioids; initiating, 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.
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