End of life: hospice & palliative care (Proceedings)

Our moral imperative is to advocate on behalf of a being that cannot advocate for itself, and that means preventing and treating pain. Our patients at the end of their lives can (and often do) encounter both acute and chronic pain. We must keep our eyes, ears, and mind open to "see" pain in these patients, and leverage the many tools we have available, both drug and non-drug.

When employing pharmacologic agents, one useful strategy is to keep in mind the World Health Organization "pain ladder". When we find pain in these patients, we can take the following steps in the following order:

Begin with NSAIDs, then add on other nonopioids; next as necessary, mild opioids; then strong opioids such as morphine, until the patient is free of pain. To manage anxiety, additional drugs may be used. To maintain comfort, medications should be given "by the clock", that is every 3-6 hours, rather than only when the client perceives the patient is in pain. The idea is to administer the right drug in the right dose at the right time. In humans this approach has proven itself 80-90% effective.

NSAIDs remain the cornerstone of managing chronic pain. If the patient can tolerate them, NSAIDs make sense for hospice/palliative care patients who suffer from inflammatory conditions. The following NSAIDs are labeled for use in the dog: meloxicam, carprofen, Deracoxib, etodolac, tapoxalin, and firecoxib. Meloxicam is labeled for chronic use in the cat in the EU. NSAIDs are great for decreasing inflammation and providing. They are appropriate as a sole analgesic for minor pain, and serve as a useful adjuvant when treating moderate to severe pain. NSAIDs are readily available, not controlled, oral (easy to administer), have a relatively long duration of action, are relatively inexpensive with No CNS side-effects. They tend to work well in patients with chronic musculoskeletal disorders.

For patients who cannot tolerate NSAIDs, consider microlactin to assist with decreasing inflammation.

In building a pain management pyramid for the hospice/palliative care patient, we would next begin to add adjunctive medications that complement the activity of the NSAIDs. In patients who cannot tolerate NSAIDs, these adjuncts can be used instead — use them in addition to NSAIDs when possible.

Gabapentin works at the α-2-δ subunit/ligand of the calcium channel in the membranes of neurons in the dorsal horn. It is a cornerstone of chronic and neuropathic pain in humans, and works exceptionally well for chronic pain in dogs and cats. We generally start at a dose of 2 – 20 mg/kg PO BID – TID and escalate the dose as needed. Sedation is the dose-limiting side effect and can be remedied by simply lowering the dose and escalating the dose slowly.

Amantadine is an anti-flu agent that is also an NMDA receptor antagonist. It has proven itself useful for chronic/neuropathic pain in canine patients, and can be compounded for small patients and cats. We use a dose of 3 – 5 mg/kg PO q24hr.

As pain escalates, we can next reach for tramadol, a synthetic analgesic with weak mu opioid activity, as well as norepinephrine and serotonin activity. It is not controlled, augments other therapies, and can be used in both dogs and cats. We start with a dose of 2 – 5 mg/kg — BID in cats and TID in dogs (use with the appropriate dosing interval!) — and we escalate the dose as needed. Tramadol is extremely bitter, so beware!

TCAs, SSRIs, and SNRIs may emerge as useful adjunctive agents as they are becoming more and more important in the hands of human pain management experts.

Opioids remain an essential tool in the management of pain, both acute and chronic. There are many routes of administration, including oral, SQ, IM, IV (including CRI), transdermal (NOT in animals!), intra-articular, and epidural. Please remember that oral morphine is only 20% bioavailable in dogs and cats, so adjust dosing accordingly. With regular oral morphine, plan to dose 4x/day, and with sustained release oral morphine, plan to dose 2-3x/day. Starting doses are 1 mg/kg for dogs and 0.5 mg/kg for cats. Because of the risks associated with the potential for diversion of narcotics, be sure to familiarize yourself with and adhere to all state and federal regulation.

Oral buprenorphine provides an exceptional way to address end-of-life pain in cats. It can be used long-term in the cat, and can be delivered transmucosally under the tongue or into the cheek pouch. The starting dose for cats is 0.01 to 0.02 mg/kg given every 6-12 hours depending upon the pet's need. We dispense buprenorphine in an injection vial with an adaptor at the top, and then the doses are drawn up into TB syringes.

Physical medicine techniques provide very effective strategies to augment our pharmaceutical pain management options. These activities improve quality of life for the pet and enhance the family-pet relationship. This category of treatment includes general nursing care, environmental modification, physical rehabilitation techniques, chiropractic techniques, acupuncture, and medical massage. Benefits include increased mobility (for ambulatory patients), decreased pain, relaxation of muscle spasms, resorption of edema, increases in blood and lymph circulation, and enhanced well-being.

Keep in mind the following very simple general nursing strategies:

Attend to bowel and bladder function, keep the patient clean from stool and urine soiling, support skin integrity, turn non-ambulatory patients every 2 to 4 hours, keep bandages clean and dry, lubricate eyes if needed.

Physical medicine/rehabilitation techniques that can assist with comfort care for hospice/palliative patients include:

Cryotherapy, moist heat, massage, passive/active-assisted range of motion, chiropractic adjustment, acupuncture, myofascial trigger point release (needle and non-needle), therapeutic ultrasound, gentle therapeutic exercise (for ambulatory patients), stretching, and whirlpool/hydro-therapy.

Environmental modification ranges from the very simple to the very complex, and is limited only by the imaginations (yours and the client's…). Cover slick surfaces (carpet, mats, throw rugs, cushioned flooring), raise food and water dishes, and prevent access to stairs. Slings, vests, harnesses, and wheelchairs all provide opportunity for ongoing ambulation.

Finally, while eating "something" is better than eating "nothing", it is important to pay attention to what constitutes the best nutrient profile for the patient. Think about therapeutic nutrition to manage any specific metabolic issues. In addition, remember that omega-3 fatty acids have been demonstrated to reduce inflammation and pain.

The keys to success are fairly straightforward and yet provide dramatic results. Be sure you have an accurate and complete diagnosis (don't overlook simple things like hypothyroidism, chronic renal failure, or structural instabilities). Develop your plan and then write everything down. Schedule regular rechecks, either at the clinic or at home, depending upon the patient's ability to ambulate. Remember the "3 R's" — recheck, reassess, revise. Chronic pain is "the gift that keeps on giving" so be aggressive in both ongoing care as well as creating appropriate expectations for your clients. Keep these patients on the RADAR screen and do your best to meet their changing needs.

Additional resources include:

International Veterinary Academy of Pain Management — www.ivapm.org.

Learn how to "ask" your patients if they hurt, and then know what to do when they say "yes".