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Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

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Presentation on theme: "Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc."— Presentation transcript:

1 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Managing an Acute Pain Crisis in a Patient With Advanced Cancer Natalie Moryl, MD Memorial Sloan-Kettering Cancer Center Steven Z. Pantilat, MD Education Guides Editor

2 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. This is as much of a crisis as a code Acute Pain Crisis

3 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Mr Xs Story 33-year-old man with a 4-year history of metastatic mucinous adenocarcinoma of the appendix Completed several cycles of chemotherapy Many episodes of small bowel obstruction due to peritoneal carcinomatosis with several percutaneous draining ostomies Multiple admissions for nausea, vomiting, and abdominal pain

4 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Definition of a Pain Crisis A pain crisis –Is an event in which the patient reports severe, uncontrolled pain that is causing the patient, the family, or both severe distress –May be acute in onset or worsening gradually to an intolerable level –Requires immediate intervention

5 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Pain Assessment During a Pain Crisis Dr S (palliative care consultant): The first thing was to understand what happened. Why was he saying that his pain was worse than it had ever been before?...I explained to them [patient and family] that something potentially catastrophic had happened since the celiac plexus block, and it might be a perforation. He very well might be dying of that, and then there was the severe pain we had to deal with.

6 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Memorial Pain Assessment Card

7 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Opioid Dose Ratios There is variability in dose ratios when switching oral morphine, oral hydromorphone, and transdermal fentanyl to oral methadone, depending on the prior opioid dose a Morphine doseMorphinemethadone ratio mg/24 hr4: mg/24 hr9:1 > 300 mg/24 hr12:1 Hydromorphone doseHydromorphonemethadone ratio < 330 mg hydromorphone/24 hr0.95:1 > 330 mg hydromorphone/24 hr1.6:1 Fentanyl doseFentanylmethadone ratio 50 mcg/hr mcg/hr250 mcg/hr:1 mg/hr b

8 Care at the Close of Life: Evidence and Experience Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Terms of Use Care at the Close of Life Education Guides PowerPoint Usage Guidelines JAMAevidence users may display, download, or print out PowerPoint slides and images associated with the site for personal and educational use only. Educational use refers to classroom teaching, lectures, presentations, rounds, and other instructional activities, such as displaying, linking to, downloading, printing and making and distributing multiple copies of said isolated materials in both print and electronic format. Users will only display, distribute, or otherwise make such PowerPoint slides and images from the applicable JAMAevidence materials available to students or other persons attending in-person presentations, lectures, rounds or other similar instructional activities presented or given by User. Commercial use of the PowerPoint slides and images are not permitted under this agreement. Users may modify the content of downloaded PowerPoint slides only for educational (non-commercial) use, however the source and attribution may not be modified. Users may not otherwise copy, print, transmit, rent, lend, sell or modify any images from JAMAevidence or modify or remove any proprietary notices contained therein, or create derivative works based on materials therefrom. They also many not disseminate any portion of the applicable JAMAevidence site subscribed to hereunder through electronic means except as outlined above, including mail lists or electronic bulletin boards.


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