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Objective 6: Understand how to approach pain management during the active dying process.

"In the patient whose dying process is irreversible, the balance between minimizing pain and suffering and potentially hastening death should be struck clearly in favor of pain relief." (Wanzer SH et al 1989)

The patient’s level of consciousness usually declines during the final hours or days. Inability to continue to swallow medication is a common development, and alternative routes of administration are often  needed. At this point, shifting to rectal, sublingual/buccal or subcutaneous administration will maintain pain control.

When patients are no longer able to communicate pain, it is wise to assume that it still exists and continue treatment as before. However, when urine output is minimal, accumulation of opioid metabolites may be problematic. At this point, some experts prefer to stop routine dosing and use only prn dosing. PRN dosing would respond to any signs of pain, such as restlessness, agitation, moaning, etc., placing an especially high importance on family perception of pain.

Agitation in the actively dying patient should be fully assessed but most often represents pain. Opioids are a more appropriate treatment than benzodiazepines.

Signs of impending death (hypotension, respiratory changes, etc.) should not be confused with opioid excess. Many physicians are afraid of “causing death” by giving opioids adequate to relieve pain.  This fear is often heightened in the active dying phase, and it is important to educate one’s self to avoid this concern.

Several studies have clearly shown that death is not hastened with opioid use.  No relationship between opioid dose and survival has been found.   In addition, the principle of “double effect” has been widely accepted.  If one’s purpose in giving higher doses of opioids is to relieve pain, then any potential “side effect” of hastening death is ethically acceptable.   

The Double Effect of Pain Medication: Separating Myth from Reality
National Cancer Institute: Pain during the final hours of life 


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