Pain

Pain control is achievable in 80% of patients by following the WHO guidelines for use of analgesic drugs, as outlined in chapter 2. A patient’s history and examination are used to assess all likely causes of pain, both benign and malignant. Treatment (usually with an opioid) is individually tailored, the effect reviewed, and doses titrated accordingly. Acute episodes of pain are dealt with urgently in the same analytical fashion but require more frequent review and provision of appropriate “breakthrough” analgesia. If a patient is already receiving analgesia then this is continued through the final stages; pain may disturb an unconscious patient as the original cause of the pain still exists.

If oral administration is no longer possible the subcutaneous route provides a simple and effective alternative. Diamorphine is the strong opioid of choice because of its solubility and is delivered through an infusion device to avoid repeated injections every four hours. It can be mixed with other “essential” drugs in the syringe driver. Oxycodone and alfentanil can be infused subcutaneously in cases of genuine morphine intolerance. Rectal administration is another alternative, but the need for suppositories every four hours in the case of morphine limits its usefulness. Oxycodone suppositories (repeated every eight hours) may be more practicable.

Longer acting opioid preparations (transdermal fentanyl and sustained release opioids) should not be started in a patient close to death; there is a variable delay in reaching effective levels, and, as speedy dose titration is difficult, they are unsuitable for situations where a rapid effect is required, such as uncontrolled pain. If a patient is already prescribed fentanyl patches these should be continued as baseline analgesia; if pain escalates additional quick acting analgesia (immediate release morphine or diamorphine) should be titrated against the pain with appropriate breakthrough doses.

Not all pains are best dealt with by opioids. For example, a non-steroidal anti-inflammatory drug may help in bone pain, while muscle spasm may be eased by diazepam. It is also important to remember all the non-cancer pains, new and old, that may be present.

Breathlessness

The scope for correcting “reversible” causes of breathlessness becomes limited. A notable exception is cardiac failure, for which diuresis may be effective. In most cases the priority is to address the symptom of breathlessness and the fear and anxiety that may accompany it.

General supportive measures should be considered in all cases. Face masks may be uncomfortable or intrusive at this time, but oxygen therapy may help some patients (even in the absence of hypoxia) who are breathless at rest. Nebulised 0.9% saline is useful if a patient has a dry cough or sticky secretions but should be avoided if bronchospasm is present.

Opioids and benzodiazepines can be helpful and should be initiated at low doses. Immediate release morphine can be titrated to effect in the same way as for pain. If a patient is using morphine for pain control then a dose slightly higher than the appropriate breakthrough dose (oral or parenteral) is usually required for treating acute breathlessness. The choice of anxiolytic is often determined by what is the most suitable route of administration, but the speed and duration of action are also important.