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Pain management and end-of-life care Perry G Fine*: Perry G Fine, MD, completed medical school
in 1981 at the Medical College of Virginia in Richmond (VA, USA). He served an internship in 1982 at the Community Hospital of Sonoma County in Santa Rosa, California, and completed his residency in 1984 at the University of Utah Health Sciences Center in Salt Lake City (UT, USA). In addition, Dr Fine completed a fellowship in 1985 at the Smythe Pain Clinic of the University of Toronto in Ontario, Canada. Dr Fine is a Professor in the Department of Anesthesiology of the School of Medicine at the University of Utah, where he serves on the faculty in the Pain Research Center, and is an attending physician in the Pain Management Center. Currently, he serves on the Board of Directors and is Immediate Past President of the American Academy of Pain Medicine, and represents the Academy on the Steering Committee of the Pain Care Coalition, Washington, DC, USA. He also serves on the Clinical Models Committee of the Coalition to Transform Advanced Care (C-TAC). Dr Fine is the External Strategic Advisor for Capital Caring, Washington, DC, developing sustainable models of advanced illness coordinated care in community settings, as an integrative component of comprehensive advanced illness care. Since 2003, he has chaired the National Initiative on Pain Control, a broad-reaching pain improvement project of the American Pain Foundation. Dr Fine is widely published in the fields of pain management and end-of-life care. He serves on several scientific advisory boards and the editorial boards of several peer-reviewed medical journals, including Pain Medicine and the Journal of Pain and Symptom Management. As a medical avocation, he worked as a team physician for the University of Utah football team for 18 years and was a medical officer for the 2002 Winter Olympics in Salt Lake City. He is the recipient of the 2007 American Academy of Hospice and Palliative Medicine Distinguished Hospice Physician Award, and the 2008 American Pain Society John and Emma Bonica Public Service Award. He is the recipient of the American Academy of Pain Management’s 2010 Head and Heart award and the 2011 Nyswander Award, presented at the annual Pain and Chemical Dependency meeting in New York City (NY, USA). In 2012, the Perry G Fine, MD Endowed Fund in Pain and Palliative Medicine was created at West Virginia University by Hospice Care Inc. to honor his contributions to the fields of pain and palliative care and ensure continuing education of health professionals in these essential domains. What aspects are involved in considering the treatment of pain in end-of-life care? QQ
Goals of care need to be established with every patient facing life-limiting illness, and since most patients and their
News & Views News Journal Watch Ask the Experts Interview
families prioritize ‘comfort’ as a highlevel priority – and pain is so prevalent in advanced medical illness – pain and associated causes of suffering require ongoing assessment and management. Certainly, pain stands out as a major part of
*Pain Research Center, School of Medicine, University of Utah, Salt Lake City, UT, USA; [email protected]
10.2217/PMT.12.30 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(4), 325–328
ISSN 1758-1869
325
NEWS & VIEWS ASK THE EXPERTS focus of palliative care consultant requests in hospital settings, and in hospice – the interd isciplinary model of care at the end of life. The emotional impact of facing death, including the inevitable existential and spiritual questions that arise, may compound pain and suffering, requiring sensitivity to this particularly unique clinical context that is often very different from the various other social circumstances of patients experiencing severe acute or persistent pain. Dignity is a central concern of both patients and their loved ones at the end of life, and the relief of severe pain is a necessity to achieve some measure of dignity as death approaches. Along these same lines, the final shared experiences that family members retain of their lovedones become almost immutably engraved in their memories. The enduring image of a loved one dying a painful death often leaves a deep emotional wound that causes irreparable suffering. This horrible legacy is to be assiduously avoided by anticipating and rapidly treating severe pain when it occurs [1–5] . Research has been carried out into evidence-based practices for the diagnosis and treatment of pain in older patients and patients in hospices. In your opinion, what have been the major outcomes of such research? QQ
I think the most telling thing to come out of pain research in end-of-life care settings, including hospice, but most especially long-term care facilities and hospitals, is that there is still considerable room for improvement in applying ‘best practices’, as recommended in clinical guidelines. As a result, too many people die with poorly assessed and managed pain. It turns out that the barriers are largely systems- and knowledge-based. Recent research demonstrates that the vast majority of patients experiencing moderate or more severe pain could gain relief from the rather routine treatment modalities we currently have, if applied in a disciplined and rigorous manner [5] . Opioids are widely used in the treatment of chronic and breakthrough pain. What factors does a clinician need QQ
326
Pain Manage. (2012) 2(4)
to take into account when prescribing such drugs in an end-of-life setting – for example, the risk of unintentionally hastening death in very ill or medically frail patients?
Opioids are an indispensable component of pain management at the end of life. When prescribed and taken appropriately, the opioid analgesic class has been shown to be safe, without overt risks of hastening death. Most patients with nociceptive sources of pain respond well to opioids, but it should be noted that opioids are not the panacea for all pain conditions – especially neuropathic pain conditions associated with advanced illness. Approximately 20% of patients with advanced medical illness (mostly cancer) do not obtain adequate pain control using the conventional ‘three-step ladder’ approach. So clinicians need to know what else can be done to relieve pain when patients are not responding favorably to systemic opioids [6] . As a member of the Clinical Models Working Group of the Coalition to Transform Advanced Care, could you briefly explain what the aims of the group are, and where the management of pain features within these? QQ
It is an unfortunate and equally uncomfortable truth in modern American healthcare that we spend a lot and get very little value for our money as we respond mostly reactively to the recurrent crises that arise from the many and various chronic conditions that we accumulate as we grow older. We have an acute-care system that is poorly adapted to the needs of patients and their families living with chronic progressive medical conditions. The aim of the Coalition to Transform Advanced Care (C-TAC) and the Models Working Group in particular is to develop highly effective (both in terms of highquality intermediate and end outcomes, while reducing overall costs), comprehensive, advanced illness coordinated care programs that are well-integrated into mainstream healthcare systems. Pain is one of the many burdens associated with chronic progressive disease, and so pain control is an important
future science group
ASK THE EXPERTS component in crisis-averting assessment and management in the models under development [101] . In your experience, how important is effective education and community integration for pain clinicians involved in end-of-life/palliative care? QQ
This is both necessary and doable. It takes a concerted and proactive effort for all healthcare professionals to inform, educate and align themselves so that dying patients and their families receive the best care possible, in a setting preferred by the patient, which is usually their own home. I have found that the all-too-common barriers to timely and effective care are mostly knowledge- and systems-related, not callous disregard by individuals. These barriers include late referral to hospice, insufficient pain specialist–consultant relationships established in advance by hospice programs, and recognition by hospice providers of which patients might benefit from referral to a pain medicine specialist. So it is incumbent upon all of us who treat patients with chronic progressive illnesses in community practice settings, emergency departments, and hospitals to bridge those divides through self-education and asserting the needs of these patients by proactively and overtly making those connections. Personally, I wish more pain specialists took an active interest in this important area of healthcare and created liaisons with palliative care and hospice programs [7] . What further research is required in the field of pain management, specifically in end-of-life settings? QQ
I think it is fair to say that if we used the tools we have at our disposal, we could References 1
Paice J, Fine PG. Pain management at end of life. In: Oxford Textbook of Palliative Nursing (2nd Edition). Ferrell B, Coyle N (Eds). Oxford University Press, NY, USA (2005).
2
Fine PG, Casarett D. Pain management at the end of life. In: Raj’s Practical Management of Pain, 4th Edition. Benzon H, Rathmell J, Wu CL, Turk DC, Argoff CE (Eds). Mosby Elsevier, PA, USA (2008).
future science group
NEWS & VIEWS
greatly improve the quality of life of most patients at the end of life. Nonetheless, from a purely biomedical standpoint there are limits to our ‘tool kits’, especially with regard to central pain conditions (e.g., post-stroke and deafferentation pain syndromes) and widespread metastatic bone disease, among other highly refractory painful conditions. Similarly, there remains much work to be done in gleaning better understanding of mind–body interactions and the emotional–psychological–spiritual dimensions of pain experiences in people with far-advanced disease who are facing imminent death. Communication of pain is a big problem for those with severe cognitive impairment and verbal limitations, such as those with advanced dementing illness. We need better means to assess for pain in that growing population. There are unique aspects to the ethics of pain-related research in vulnerable populations, including those at the end of life that require better understanding and – ironically enough – research into improving such research. There are several recent reviews and book chapters that the journal’s readership can pursue in order to rapidly get up to speed in this arena [8–10] . Financial & competing interests disclosure PG Fine is on the advisory board for Ameritox, Archimedes, Cephalon /Teva, Purdue Pharma, Nektar and Nuvo. He also provides medical–legal consulting for Johnson & Johnson and Mylan. PG Fine has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript. 3
4
5
Fine PG. Palliative care and pain control in terminal illness. In: Neural Blockade in Pain Management (4th Edition). Cousins M et al. (Eds). Lippincott Williams & Wilkins, PA, USA (2009).
Am. J. Hosp. Palliat. Care 27, 369–376 (2010). 6
Fine PG. The Hospice Companion (2nd Edition). Oxford University Press, NY, USA (2012).
Portenoy RK, Sibirceva U, Smout R et al. Opioid use and survival at the end of life: a survey of a hospice population. J. Pain Symptom Manage. 32(6), 532–540 (2006).
7
Sanders S, Mackin ML, Reyes J et al. Implementing evidence-based practices: considerations for the hospice setting.
Fine PG. The evolving and important role of anesthesiology in palliative care. Anesth. Analg. 100, 183–188 (2005).
8
Fine PG (Section Editor). Pain due to cancer. In: Bonica’s Management of Pain, 4th Edition.
www.futuremedicine.com
327
NEWS & VIEWS ASK THE EXPERTS Ballantyne J, Rathmell J, Fishman SM (Eds). Lippincott, Williams and Wilkins, Philadelphia, PA, USA (2009). 9
328
Chapman CR, Lipshischitz DL, Angst MS et al. Opioid pharmacotherapy for chronic non-cancer pain in the United States:
a research guideline for developing an evidence-base. J. Pain 11(9), 807–829 (2010). 10
Fine PG. Recognition and resolution of ethical barriers to palliative care research. In: Handbook of Pain and Palliative Care: Biobehavioral Approaches for the Life Course.
Pain Manage. (2012) 2(4)
Moore RJ (Ed.). Springer Science + Business Media, NY, USA, 825–838 (2012). Website 101 Coalition to Transform Advanced Care.
http://advancedcarecoalition.org
future science group
Pain management and end-of-life care Perry G Fine*: Perry G Fine, MD, completed medical school
in 1981 at the Medical College of Virginia in Richmond (VA, USA). He served an internship in 1982 at the Community Hospital of Sonoma County in Santa Rosa, California, and completed his residency in 1984 at the University of Utah Health Sciences Center in Salt Lake City (UT, USA). In addition, Dr Fine completed a fellowship in 1985 at the Smythe Pain Clinic of the University of Toronto in Ontario, Canada. Dr Fine is a Professor in the Department of Anesthesiology of the School of Medicine at the University of Utah, where he serves on the faculty in the Pain Research Center, and is an attending physician in the Pain Management Center. Currently, he serves on the Board of Directors and is Immediate Past President of the American Academy of Pain Medicine, and represents the Academy on the Steering Committee of the Pain Care Coalition, Washington, DC, USA. He also serves on the Clinical Models Committee of the Coalition to Transform Advanced Care (C-TAC). Dr Fine is the External Strategic Advisor for Capital Caring, Washington, DC, developing sustainable models of advanced illness coordinated care in community settings, as an integrative component of comprehensive advanced illness care. Since 2003, he has chaired the National Initiative on Pain Control, a broad-reaching pain improvement project of the American Pain Foundation. Dr Fine is widely published in the fields of pain management and end-of-life care. He serves on several scientific advisory boards and the editorial boards of several peer-reviewed medical journals, including Pain Medicine and the Journal of Pain and Symptom Management. As a medical avocation, he worked as a team physician for the University of Utah football team for 18 years and was a medical officer for the 2002 Winter Olympics in Salt Lake City. He is the recipient of the 2007 American Academy of Hospice and Palliative Medicine Distinguished Hospice Physician Award, and the 2008 American Pain Society John and Emma Bonica Public Service Award. He is the recipient of the American Academy of Pain Management’s 2010 Head and Heart award and the 2011 Nyswander Award, presented at the annual Pain and Chemical Dependency meeting in New York City (NY, USA). In 2012, the Perry G Fine, MD Endowed Fund in Pain and Palliative Medicine was created at West Virginia University by Hospice Care Inc. to honor his contributions to the fields of pain and palliative care and ensure continuing education of health professionals in these essential domains. What aspects are involved in considering the treatment of pain in end-of-life care? QQ
Goals of care need to be established with every patient facing life-limiting illness, and since most patients and their
News & Views News Journal Watch Ask the Experts Interview
families prioritize ‘comfort’ as a highlevel priority – and pain is so prevalent in advanced medical illness – pain and associated causes of suffering require ongoing assessment and management. Certainly, pain stands out as a major part of
*Pain Research Center, School of Medicine, University of Utah, Salt Lake City, UT, USA; [email protected]
10.2217/PMT.12.30 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(4), 325–328
ISSN 1758-1869
325
NEWS & VIEWS ASK THE EXPERTS focus of palliative care consultant requests in hospital settings, and in hospice – the interd isciplinary model of care at the end of life. The emotional impact of facing death, including the inevitable existential and spiritual questions that arise, may compound pain and suffering, requiring sensitivity to this particularly unique clinical context that is often very different from the various other social circumstances of patients experiencing severe acute or persistent pain. Dignity is a central concern of both patients and their loved ones at the end of life, and the relief of severe pain is a necessity to achieve some measure of dignity as death approaches. Along these same lines, the final shared experiences that family members retain of their lovedones become almost immutably engraved in their memories. The enduring image of a loved one dying a painful death often leaves a deep emotional wound that causes irreparable suffering. This horrible legacy is to be assiduously avoided by anticipating and rapidly treating severe pain when it occurs [1–5] . Research has been carried out into evidence-based practices for the diagnosis and treatment of pain in older patients and patients in hospices. In your opinion, what have been the major outcomes of such research? QQ
I think the most telling thing to come out of pain research in end-of-life care settings, including hospice, but most especially long-term care facilities and hospitals, is that there is still considerable room for improvement in applying ‘best practices’, as recommended in clinical guidelines. As a result, too many people die with poorly assessed and managed pain. It turns out that the barriers are largely systems- and knowledge-based. Recent research demonstrates that the vast majority of patients experiencing moderate or more severe pain could gain relief from the rather routine treatment modalities we currently have, if applied in a disciplined and rigorous manner [5] . Opioids are widely used in the treatment of chronic and breakthrough pain. What factors does a clinician need QQ
326
Pain Manage. (2012) 2(4)
to take into account when prescribing such drugs in an end-of-life setting – for example, the risk of unintentionally hastening death in very ill or medically frail patients?
Opioids are an indispensable component of pain management at the end of life. When prescribed and taken appropriately, the opioid analgesic class has been shown to be safe, without overt risks of hastening death. Most patients with nociceptive sources of pain respond well to opioids, but it should be noted that opioids are not the panacea for all pain conditions – especially neuropathic pain conditions associated with advanced illness. Approximately 20% of patients with advanced medical illness (mostly cancer) do not obtain adequate pain control using the conventional ‘three-step ladder’ approach. So clinicians need to know what else can be done to relieve pain when patients are not responding favorably to systemic opioids [6] . As a member of the Clinical Models Working Group of the Coalition to Transform Advanced Care, could you briefly explain what the aims of the group are, and where the management of pain features within these? QQ
It is an unfortunate and equally uncomfortable truth in modern American healthcare that we spend a lot and get very little value for our money as we respond mostly reactively to the recurrent crises that arise from the many and various chronic conditions that we accumulate as we grow older. We have an acute-care system that is poorly adapted to the needs of patients and their families living with chronic progressive medical conditions. The aim of the Coalition to Transform Advanced Care (C-TAC) and the Models Working Group in particular is to develop highly effective (both in terms of highquality intermediate and end outcomes, while reducing overall costs), comprehensive, advanced illness coordinated care programs that are well-integrated into mainstream healthcare systems. Pain is one of the many burdens associated with chronic progressive disease, and so pain control is an important
future science group
ASK THE EXPERTS component in crisis-averting assessment and management in the models under development [101] . In your experience, how important is effective education and community integration for pain clinicians involved in end-of-life/palliative care? QQ
This is both necessary and doable. It takes a concerted and proactive effort for all healthcare professionals to inform, educate and align themselves so that dying patients and their families receive the best care possible, in a setting preferred by the patient, which is usually their own home. I have found that the all-too-common barriers to timely and effective care are mostly knowledge- and systems-related, not callous disregard by individuals. These barriers include late referral to hospice, insufficient pain specialist–consultant relationships established in advance by hospice programs, and recognition by hospice providers of which patients might benefit from referral to a pain medicine specialist. So it is incumbent upon all of us who treat patients with chronic progressive illnesses in community practice settings, emergency departments, and hospitals to bridge those divides through self-education and asserting the needs of these patients by proactively and overtly making those connections. Personally, I wish more pain specialists took an active interest in this important area of healthcare and created liaisons with palliative care and hospice programs [7] . What further research is required in the field of pain management, specifically in end-of-life settings? QQ
I think it is fair to say that if we used the tools we have at our disposal, we could References 1
Paice J, Fine PG. Pain management at end of life. In: Oxford Textbook of Palliative Nursing (2nd Edition). Ferrell B, Coyle N (Eds). Oxford University Press, NY, USA (2005).
2
Fine PG, Casarett D. Pain management at the end of life. In: Raj’s Practical Management of Pain, 4th Edition. Benzon H, Rathmell J, Wu CL, Turk DC, Argoff CE (Eds). Mosby Elsevier, PA, USA (2008).
future science group
NEWS & VIEWS
greatly improve the quality of life of most patients at the end of life. Nonetheless, from a purely biomedical standpoint there are limits to our ‘tool kits’, especially with regard to central pain conditions (e.g., post-stroke and deafferentation pain syndromes) and widespread metastatic bone disease, among other highly refractory painful conditions. Similarly, there remains much work to be done in gleaning better understanding of mind–body interactions and the emotional–psychological–spiritual dimensions of pain experiences in people with far-advanced disease who are facing imminent death. Communication of pain is a big problem for those with severe cognitive impairment and verbal limitations, such as those with advanced dementing illness. We need better means to assess for pain in that growing population. There are unique aspects to the ethics of pain-related research in vulnerable populations, including those at the end of life that require better understanding and – ironically enough – research into improving such research. There are several recent reviews and book chapters that the journal’s readership can pursue in order to rapidly get up to speed in this arena [8–10] . Financial & competing interests disclosure PG Fine is on the advisory board for Ameritox, Archimedes, Cephalon /Teva, Purdue Pharma, Nektar and Nuvo. He also provides medical–legal consulting for Johnson & Johnson and Mylan. PG Fine has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript. 3
4
5
Fine PG. Palliative care and pain control in terminal illness. In: Neural Blockade in Pain Management (4th Edition). Cousins M et al. (Eds). Lippincott Williams & Wilkins, PA, USA (2009).
Am. J. Hosp. Palliat. Care 27, 369–376 (2010). 6
Fine PG. The Hospice Companion (2nd Edition). Oxford University Press, NY, USA (2012).
Portenoy RK, Sibirceva U, Smout R et al. Opioid use and survival at the end of life: a survey of a hospice population. J. Pain Symptom Manage. 32(6), 532–540 (2006).
7
Sanders S, Mackin ML, Reyes J et al. Implementing evidence-based practices: considerations for the hospice setting.
Fine PG. The evolving and important role of anesthesiology in palliative care. Anesth. Analg. 100, 183–188 (2005).
8
Fine PG (Section Editor). Pain due to cancer. In: Bonica’s Management of Pain, 4th Edition.
www.futuremedicine.com
327
NEWS & VIEWS ASK THE EXPERTS Ballantyne J, Rathmell J, Fishman SM (Eds). Lippincott, Williams and Wilkins, Philadelphia, PA, USA (2009). 9
328
Chapman CR, Lipshischitz DL, Angst MS et al. Opioid pharmacotherapy for chronic non-cancer pain in the United States:
a research guideline for developing an evidence-base. J. Pain 11(9), 807–829 (2010). 10
Fine PG. Recognition and resolution of ethical barriers to palliative care research. In: Handbook of Pain and Palliative Care: Biobehavioral Approaches for the Life Course.
Pain Manage. (2012) 2(4)
Moore RJ (Ed.). Springer Science + Business Media, NY, USA, 825–838 (2012). Website 101 Coalition to Transform Advanced Care.
http://advancedcarecoalition.org
future science group
