By G. JAY WESTBROOK

I am a geriatric hospice nurse, and Jorge Gonzalez (not his real name) was my newest referral, an 86-year-old male with untreatable organ cancer that had spread to his bones and left him with less than six months to live. I was told that he was at home, nonambulatory and bedbound, bowel and bladder incontinent, at risk for falls, somewhat confused and on Tylenol #3, which contains codeine, for pain.

At the Gonzalez residence in East Los Angeles, I encountered a caring and concerned family and a patient, Señor Gonzalez, in agonizing pain. After performing a pain assessment, I contacted his physician to request orders for strong opiates to relieve and manage my patient's pain.

THE DOCTOR'S DENIAL

The physician refused to prescribe opiates and stated, "At his age and level of confusion, he's not feeling that much pain, and I'm not going to prescribe drugs that will get me in trouble with the DEA [federal Drug Enforcement Agency] and either send this patient into respiratory arrest or turn him into a drug addict." (See "Legal Influences at Life's End: Enforcing Rights or Impeding Care?" elsewhere in this "In Focus" section.)

Resisting my impulse to ask if he thought Señor Gonzalez would get out of bed and mug him, I simply requested that our hospice medical director take over this patient's pain management. He agreed, and we had the patient on strong oral opiates before the day was over.

Within three days, Señor Gonzalez was essentially pain free, lucid, ambulatory, bowel and bladder continent and no longer bed bound. Within a week, he was taking a daily morning walk, with his beloved dog, Mona--one-half mile each way to the store to purchase La Opinion, a Spanish-language newspaper, for his wife and a Los Angeles Times for himself. He also began working in his garden every afternoon. He maintained these activities for the next five months, until his cancer's progression put him back in bed for the last two weeks of his life. He died at home, surrounded by family, and pain free.

The costs of allowing a terminally ill person to remain in pain are tremendous. On a spiritual level, untreated pain can lead to an increased sense of suffering and a separation for many from the solace of their belief in God.

Psychologically, untreated pain can manifest itself in responses such as increased anxiety, fear, depression and suicidal thoughts. On a physiological and functional level, pain can lead to a range of problems, for example, fatigue, falls, disturbances in appetite or sleep, and immobility. Socially, untreated or undertreated pain can result in decreased opportunity for social interaction or leisure, reduced mental competence and significantly increased caregiver burden.

Despite these overwhelming costs of not adequately treating pain, study after study has revealed less-than-adequate pain management for elderly cancer patients. (See the "Research Today"section, "Elders in Pain--Gaps Found in Research and Practice".)

PRINCIPLES FOR MANAGING PAIN

Healthcare practitioners do not have to wait for major policy changes or new practice standards to develop before helping patients at the end of life. Here are some basic principles of pain management for older cancer patients:

• Pain is a subjective experience--it is whatever patients say they feel.
• Obtain a pain history, and use standardized and quantifiable pain assessments.
• Determine the etiology of the pain.
• Choose an appropriate analgesic class from the World Health Organization Analgesic Ladder.
• When choosing doses for elderly patients, remember to "start low, go slow."
• Terminal cancer pain should be treated with sustained-release, around-the-clock (ATC) analgesics as opposed to immediate-release dosing used as needed.
• Always have an immediate-release analgesic prescribed for pain that breaks through, and make sure its dose is proportional to the ATC medication being used.
• Adjust the dosage of both the sustained-release and immediate-release analgesics upward as needed to keep the patient comfortable.
• Anticipate side effects and incorporate a prophylactic approach to their treatment.
• Avoid using Demerol on an ongoing basis because of central-nervous-system side effects.
• Use any nonpharmacological techniques, such as meditation, guided imagery and visualization, that work for a given patient, and remember that no one technique is ideal for all patients.
• Continue to assess and reassess pain levels, causes of pain and side effects.
• Stay focused on the primary purpose of pain management--patient comfort.

Pain management can not only lead to comfort, but also can restore a degree of function which allows patients to engage in those activities which give their lives joy and a sense of value, meaning and worth.

G. Jay Westbrook, a registered nurse, is clinical director of HealthWaves Ltd. in Los Angeles.

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American Society on Aging
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