Myths of Pain
There can be three very misunderstood elements in regards to end-of-life care. Controlling pain and other symptoms are essential to a death with dignity and quality of life to the end. There are many myths surrounding pain and symptom control, and there are issues of controversy about the need for continued hydration and nutrition to the very end.
Dying is not necessarily painful, and not all terminal diseases produce pain. But pain can be controlled and in many instances reduced to a level of tolerance that allows for normal activity without sedating effects.
Palliative care involves keeping the patient's pain and other levels of discomfort under control, allowing him to have as much quality of life as possible. The term palliative comes from the Latin word palliare, meaning “to cloak.” When there is no hope of cure, the goal is to reduce suffering. It does not mean sedating the patient for the duration.
One of the most common myths about pain medication is that it has to be sedating to work. When people experience severe or chronic pain, it often interferes with sleep. It may take some strong medications to control this pain, such as opiod analgesics like morphine. Initially theses medications will indeed induce sedation that can last about twenty-four hours. This sedation allows the person to catch up on lost sleep.
Once this has happened, the sedative effects wear off. The patient can then function with mental clarity. Any continuing sedation is usually due to other medications that may have been prescribed for anxiety or depression.
Many fear that once morphine is prescribed the end is near. Effective pain management for severe and chronic pain involves quickly controlling the symptoms, and this often requires using “the big guns.” Once pain control is achieved, the dose can actually be reduced without the pain returning. Pain that is only partially controlled or controlled on a part-time basis usually increases in severity; therefore, getting the pain under control quickly involves using stronger medications and routine administration. Experimenting with milder medications can actually induce more severe pain and prolong suffering.
The Truth about Addiction
Another common issue is addiction. With an end-of-life situation, addiction is probably the least of anyone's concerns, but physicians, patients, friends, and family alike can make a huge issue out of this. In fact, there is no empirically based evidence of addiction from morphine if it is prescribed in an appropriate dose to control the pain.
Additionally, when used for severe pain or chronic pain, the withdrawal is mild once there is no longer a need for an opiod analgesic such as morphine. In fact, the dose is usually titrated down as the pain becomes controlled, which produces no withdrawal effect.
One of the most important aspects of pain management is to take the pain medication routinely until the pain is controlled at a tolerable level. That means taking the medication as directed, such as every four or six hours around the clock. Waiting until the pain returns or becomes intense again before taking the medication does not help gain control over the pain. It can take forty-five minutes to an hour before the medication takes hold, and if the pain is intense, this suffering can be unnecessary. This can slow or prevent pain control.
Achieving Pain Management
Taking the medication routinely for several doses allows the body to relax and better cope with the pain. This is especially true for severe or chronic pain that interferes with activities of daily living such as sleep habits, appetite, activity, and mental status. Morphine, for instance, can provide a sense of comfort along with pain relief. It makes it easier to breathe, relax, sleep, eat, or move with greater ease.
Another myth about pain is that it builds character, and taking pain medication shows a weakness. Before pain-management techniques were discovered, sucking it up and being strong and stoic may have had some merit. Without the ability to control pain, fooling oneself into thinking suffering was noble may have made it less powerful and more tolerable, but today there is no need for anyone to suffer needlessly from pain and there is never a need to die a horrible, painful death.
The Pain Scale
Pain is typically measured on a comfort scale of zero to ten, with zero being no pain and ten being the worst pain imaginable. Using this scale, practitioners can prescribe pain medication and titrate it up or down according to the effectiveness. Achieving zero pain is not always the goal, especially if dealing with an underlying disease process that causes severe pain. In some instances, achieving a comfort level between zero to three is realistic. Controlling the pain to allow for ease of movement and improved sleep and eating habits provides an improved quality of life and a death with dignity.
In addition to analgesics, other modalities such as radiation, chemotherapy, antidepressants, and antianxiety medications can help achieve symptom control as well as pain control.
