Pain at the end of life

Management

General approach

• Assess the symptom
• Reverse what you can
• Treat what remains
• Monitor frequently

Opioids

• Codeine: ~10% lack enzyme to convert to morphine
• Morphine: has toxic products that cause delirium that are renally cleared
• See opioids for more information, including an equianalgesia chart

Starting Dose

• If naive (<7-10 days), low is best
  • Morphine 2.5-5.0mg po q4h
  • Hydromorphone 0.5-1.0mg po q4h

Breakthrough

• 10% of TDD (i.e. 1/2 of the q4h dose) q1h prn
• Peak effectiveness reached around 1h after oral dose

Titration

• When stable, add breakthrough doses to standing
• Don't add it if used for incident pain (e.g. associated with specific activities)

Rotation

• Opioid rotation may decrease some side effects, including hyperanalgesia and delirium
• Use the equianalgesia chart to convert to and from oral morphine equivalents
• In general, decrease the total daily dose by about 20% when rotating to a new opioid

Management of side effects

• Constipation
• Drowsiness:
  • Decrease dose if can't keep eyes open or can't complete a conversation
• Nausea
  • Add dimenhydrinate unless already on an antiemetic
  • Should settle within a week
• Delirium
  • Opioid rotation
  • Haloperidol (standing, if necessary)