Challenges in pain management at the end of life

Effective pain management in the terminally ill patient requires an underst anding of pain control strategies. Ongoing assessment of pain is crucial an d can be accomplished using various forms and scales. it is also important to determine if the pain is nociceptive (somatic or visceral pain) or neuro pathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Nociceptive pain can usually be controlled with nonsteroidal antiinflammat ory drugs or corticosteroids, whereas neuropathic pain responds to tricycli c antidepressants or anticonvulsants. Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a signi ficant amount of medication for breakthrough pain is already being given, t he baseline dose of sustained-release analgesic medication should be increa sed. If pain does not respond to one analgesic medication, physicians shoul d use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be contro lled on a specific regimen. The impact of unresolved psychosocial or spirit ual issues on pain management may need to be addressed.