CHRONIC PAIN: CAREGIVING: PAIN CONTROL FOR TERMINAL ILLNESS

Pain is a common problem with terminal illness. Pain control is the responsibility of the person's doctor and caregivers. Pain control enhances the quality of a person's life during the terminal phase of an illness. In the past, some doctors and families expressed concern that a dying person would become addicted to pain medication, an attitude that too often resulted in inadequate pain relief and needless suffering. Today, however, most people realize that drug addiction is not a realistic concern at this time and they stress that keeping a terminally ill person as pain free as possible is the major goal.

Doctors often prescribe long-acting morphine to control the pain of a terminal illness, such as cancer. If pain recurs between doses, the doctor may also prescribe a shorter-acting form of the drug or another painkiller to use between doses of the longer-acting medication. In any case, it is important to give pain medication on a regular basis to ensure continuous pain relief; once pain begins to worsen, it is more difficult to control. To keep pain under control, experts usually recommend giving pain medication "around the clock," not just when a person asks for it. If pain medication has been prescribed on an "as needed" basis, the medication should be given as soon as the person begins to feel uncomfortable. Never wait until the person is experiencing pain before giving pain medication; doing so can cause him or her unnecessary suffering and distress. If the person is taking pain medication and is still in pain, talk to the doctor or the visiting nurse; it may be necessary to adjust the dosage.

Other pain-relief methods can be used along with medication to help control pain and improve the person's sense of well-being. These methods include relaxation techniques such as deep breathing, meditation, guided imagery and massage. In general, the earlier a person begins to use relaxation techniques and massage for pain relief, the more likely these methods are to be effective.

Relaxation Techniques

Relaxation techniques help not only to relieve pain, but they can also help reduce the feelings of anxiety, anger and depression that often accompany terminal illness. However, remember that relaxation techniques are to be used as a complement to and never as a substitute for pain medication. A dying person should never be allowed or encouraged to endure pain for any reason.

A combination of deep breathing, meditation, and guided imagery exercises is often an effective way to produce a state of complete relaxation. Give your loved one the following step-by-step instructions to slowly guide him or her through this exercise:

1. Sit or lie in a comfortable position with your eyes closed.

2. Relax all of your muscles.

3. Inhale slowly and deeply.

4. Exhale slowly and completely.

5. Listen to each breath and try to concentrate on the rhythm of your breathing.

6. Concentrate on a different part of your body for a few minutes as you breathe and relax. For example, tell the person to relax his or her face, neck, shoulders, right arm, left arm, right wrist, left wrist, right leg, left leg, right foot and left foot.

7. If your mind starts to wander, go back and focus on another part of your body.

8. Finish up with a slow, deep breath as your entire body relaxes.

9. Stay quiet for several minutes and slowly open your eyes

You can help the person reach a state of total relaxation by speaking in a calm, soothing voice and providing reassurance and encouragement throughout the exercise. As a substitute for picturing various parts of his or her body, you might tell the person to picture a quiet place or a place that holds some special meaning, and ask him or her to picture that place in great detail. The person can also focus on a single word (such as "love" or "peace"), repeating it over and over again in his or her mind as he or she breathes in and out. For best results, encourage the person to perform this exercise for at least 10 minutes every day. Doing the exercise twice a day is even more beneficial.

Listening to relaxing music or watching a favorite movie on video can be enjoyable distractions that help reduce a person's awareness of pain. Reading to the person or simply sitting down and talking with him or her can also help the person focus his or her mind on something other than the pain. Some terminally ill people find that praying brings them comfort and helps them cope with pain.

Touch

As a caregiver, you should be aware of the power of touch. Most people, including those who are terminally ill, want and need to be touched. Touching is instinctive for humans, a basic element of everyday interaction. A person who does not experience touch can quickly begin to feel isolated. A caregiver can use touch to provide comfort, to reduce pain, and to communicate. Some common forms of touching are holding hands, hugging and massage.

Do not be surprised or offended, however, if your loved one objects to being touched at certain times, in certain ways, or by certain people. If he or she does not want to be hugged or does not want a massage, do not take it personally. Everyone has the right not to be touched (beyond routine touching that occurs during caregiving) and no one should have to submit to unnecessary, unwanted touching. If your loved one appears to be uncomfortable or objects to being touched, discuss it with him or her. Ask how he or she feels about being touched. Find out what he or she likes and dislikes, and make sure that all other caregivers are aware of his or her preferences.

Massage is a good way to improve circulation, relieve pain, release tension, relax muscles and improve mobility. A trained healthcare professional, such as a nurse or a physical therapist, can teach you the basics of massage while you watch him or her give your loved one a massage. Observe closely and ask questions. Ask the instructor to watch as you practice the techniques that you have just learned. At the very least, you will be able to give your loved one a good back rub from time to time.

For a relaxing back rub, have your loved one lie facedown on the bed. Remove any clothing from his or her back and slowly and gently stroke, rub, and knead the back. Rubbing a small amount of baby oil or lotion on the back can help make the massage more soothing. When you're finished, be sure to gently dab off any excess oil or lotion with a soft towel. Replace the person's clothing and help him or her return to a comfortable position.

Foot washing is another good way to use touch to help improve your loved one's sense of well-being. Him him or her sit in a comfortable chair while soaking his or her feet in a dishpan or other suitable container filled with warm water. Before the water cools, gently wash his or her feet with mild soap and a soft washcloth. Rinse the feet thoroughly and gently pat them dry with a clean, soft towel. Massage the feet with a small amount of petroleum jelly, baby oil, or an alcohol-free cream or lotion. Be sure to blot off any excess oil or lotion. A clean pair of soft cotton socks will keep the person's feet warm and help hold in moisture. Sheepskin heel protectors will help prevent pressure sores.

Warning: Never massage the legs, especially the calves, of a person who is confined to bed, because massage can easily dislodge a clot that has developed in the leg. The clot could then travel through the bloodstream to the lungs, resulting in a pulmonary embolism (blockage of an artery that supplies blood to the lungs). Symptoms of a pulmonary embolism include sudden difficulty breathing, chest pain, rapid pulse, sweating, slight fever, productive cough (a cough that produces sputum), and possible blood in the sputum. This condition is a medical emergency. If you notice these symptoms, call 911 or your local emergency number or take the person to the nearest hospital emergency department immediately.

Measuring the Effectiveness of Pain Control

To control your loved one's pain adequately, it is important for you to know how well the pain medication is working. A simple way to determine the effectiveness of pain control is to ask a person to describe the severity of the pain on a scale of 0 to 10, with 0 representing no pain and 10 representing the worst pain he or she has ever experienced. Ask your loved one to describe the pain before you give him or her pain medication. Then, about an hour after he or she has taken the medication, ask him or her to describe the pain again. If your loved one does not feel significant improvement, contact his or her physician or visiting nurse as soon as possible. The doctor can adjust the dosage or prescribe supplemental medication to improve pain control.

It is important to note that pain control must continue without regard to a person's level of consciousness. A person who is in a coma cannot communicate, but he or she can still experience pain. If the person is no longer able to take pain medication orally, these drugs can be administered in other ways. For example, some pain medications can be administered intravenously through a special pump that can be programmed by the doctor or nurse to release the medication at intervals. In some cases, pain medications can be given through a skin patch.

Pain medication in suppository form is also available for people who are unable to take medications orally. To insert a suppository into the rectum, put on a disposable glove, turn the person on his or her side with the upper leg bent, and push the suppository deep into the rectum with the middle finger of the gloved hand. Most suppositories are self-lubricating. Sometimes, a doctor will recommend using an oral pain medication temporarily as a suppository. These drugs can be inserted into the rectum with a gloved finger that has been lubricated with petroleum jelly for easier insertion.

Side Effects of Pain Medications

Be extremely cautious with opioid pain medications, such as codeine and morphine, because they can cause sedation (drowsiness) when first administered or when the dosage is increased. Sedation that occurs when the dosage is increased should last only a day or two. If drug-induced sedation is persistent, the physician may recommend withholding the next several doses of the medication and decreasing the overall dosage. Notify the nurse or doctor promptly if the person becomes sedated. Urinary retention is another initial side effect of opioid pain medications, especially in men. Notify the nurse or doctor promptly if the person does not pass urine in more than eight hours.

Constipation often accompanies the administration of opioid pain medications and can be treated with a high-fiber diet, increased fluid intake, stool softeners and laxatives. Occasionally, constipation may require an enema. Nausea and vomiting, another side effect of pain medications, can be treated with antiemetic drugs.

These initial side effects of opioids can be followed by increasing lethargy and labored breathing; the person's breathing gets slower and slower, and could stop. This is a medical emergency. If the person's breathing becomes labored, call 911 or your local emergency number, or take him or her to the nearest hospital emergency department immediately. If your loved one is in hospice, however, emergency procedures are not implemented.