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Addressing pain at the end of life
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
ACS joins campaign to encourage use of surgical crisis checklists
To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.
When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.
To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena.
The value of checklists
The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.
Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.
The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.
The CSPS campaign
The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.
The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.
The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.
The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.
Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.
Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.
Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.
To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.
When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.
To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena.
The value of checklists
The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.
Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.
The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.
The CSPS campaign
The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.
The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.
The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.
The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.
Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.
Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.
Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.
To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.
When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.
To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena.
The value of checklists
The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.
Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.
The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.
The CSPS campaign
The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.
The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.
The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.
The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.
Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.
Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.
Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.