Interventions
Physical Pain
Once it is determined that what appears to be refractory pain is related to the physical experience of disease, and psychosocial, spiritual, and existential concerns have been identified and a plan is in place to address them, nonopioid and opioid medications should be gradually increased until pain is relieved at a level acceptable to the patient. Detailed discussion of pain management, including medication choices and dose escalation, is outside the scope of this article. Consulting the WHO pain guidelines and practice guidelines relevant to the patient and his/her age and diagnosis is recommended. Readers are referred to the WHO Web site (http://www.who.int/cancer/palliative/painladder/en/) and the 2009 American Geriatrics Society Clinical Practice Guidelines (http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2009/).
If dose escalation results in intolerable adverse effects or sedation lasting more than a few days, then opioid rotation—switching to another agent—may improve pain control. Opioid rotation is also helpful for patients who experience hyperalgesia, or over(hyper)sensitivity to pain. Hyperalgesia occurs when a patient experiences increasing levels of pain despite consistent increases in the dose of an opioid. A clinician should suspect hyperalgesia when pain is not responding to higher doses of opioids or when a patient is experiencing pain from what is usually not painful (allodynia). Unless experienced in opioid rotation, consultation with palliative care specialists is recommended, including interpretation and application of equianalgesic tables. In addition, careful attention to underlying medical, renal, and hepatic disease should be taken into account to avoid adverse effects related to contraindications and/or impairment in medication metabolism and excretion. If uncertain, it is always advisable to consult a palliative care team or an experienced clinical pharmacist.
Treating Psychosocial, Spiritual, and Existential Suffering
While addressing physical pain to improve a patient's comfort level, palliative care specialists should also initiate a plan of care for other important domains of palliative treatment—the psychological, social, and spiritual aspects of care. Recognizing that patients suffer with not only physical pain, but also grief and depression (psychological), changes in role and relationships (social), and possibly question personal value (spiritual or existential), interventions should be individualized to specific needs. Often, patients report that when care is holistic and encompasses the "whole person," physical symptoms appear more manageable.
One approach to treating distress in people with life-limiting illness is dignity therapy, a psychotherapeutic approach to relieve suffering that encompasses multiple domains of the illness (physical, psychological, spiritual, and social). Dignity therapy provides a way to improve the sense of meaning and purpose in patients approaching the end of life. Through life narratives, patients discuss past events, memories, or accomplishments that brought them great pleasure and a feeling of pride. Participants also express current and future intentions for those they will leave when they die. Participants in dignity therapy must be able to speak, as the question-and-answer sessions are audio recorded. Nine questions are posed in the protocol. The recordings are transcribed and returned to the participant for their own use. In a randomized controlled clinical trial, dignity therapy is reported to have shown significant benefit to quality of life. Family members report that the intervention not only reduces patient suffering, but also positively impacts their own bereavement. This type of meaning-centered treatment is administered by a specialist who has undergone training (https://dignityincare.ca/en).
All staff, regardless of discipline, must work to maintain patient dignity by offering choices and supporting patient autonomy. Strategies clinicians can implement to support a patient with psychosocial, spiritual, or existential suffering include active listening, being present, and being open. Patients may prefer to engage in spiritual practices during procedures, while receiving treatments, or during medication therapies—clinicians at the bedside should be supportive of these practices. Clinicians need to remember to remain neutral in opinions and nonjudgmental when patients are sharing thoughts, feelings, past events, and possibly regrets.
Some patients find life review through sharing memories and storytelling beneficial while experiencing suffering in life-limiting illness. Spending time with close friends and family or viewing and creating photo albums may be helpful. Through these activities, a patient can "reconnect with simple aspects of life that have brought depth and significance."