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 30-90 mg/24 hr4:1 91-300 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-2 500 mcg/hr250 mcg/hr:1 mg/hr b

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