The prevalence of pain varies by dx, stage of disease, and setting of care. Approximately 1/3 of patients with cancer experience pain at the time of diagnosis, while 2/3 with metastatic disease report pain. Less is known about the prevalence of pain in those with diagnoses other than cancer.
Pain is described by the World Health Organization as a “multidimensional phenomenon with sensory, physiological, cognitive, affective, behavioral and spiritual components.” Pain is a complex biopsychosocial phenomenon, an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in these terms. (Pain is whatever the patient says it is.)
Considered to be the largest organ system in the human body, our skin protects our internal organs and structures. The skin layers include the epidermis, dermis, and subcutaneous tissue. Although skin is only 1 to 2 mm thick, it contains 15% of the total weight for an adult and acts as the first line of defense against invading microorganisms.
Providing protection for the underlying tissues and organs.
Receptors in the skin sense pain, pressure, and temperature changes.
Skin also plays a role in fluid balance, temperature regulation, and the synthesis of vitamin D.
The subcutaneous fatty layer acts as a cushion and stores fat for energy.
Alteration in skin integrity:
Age – As a person ages, physiological changes inherent to the aging process occur, such as reduced elasticity, loss of skin turgor, and decreased vascularity. Changes also occur in the cells at the junction of the dermis and epidermis, which may result in skin tearing more easily in elderly. Patients with a terminal illness pose a unique risk of alternations in skin integrity, and one aspect gaining attention includes the concept that skin injuries for these patient may be unavoidable and related to dying process.
Scope and Standards of Practice – End of life Care
Structure and processes of care: the composition and qualifications of the interdisciplinary team and define how the team should collaborate with patients and families.
Physical aspects of care: management of physical symptoms such as pain, fatigue, anxiety, and others.
Psychological and psychiatric aspects of care: assessment of the psychosocial needs of patients and families. the requirement for bereavement support is included in this domain.
Social aspects of care: focus on leveraging family strengths and social support mechanisms to alleviate family stress.
Spiritual, religious, and existential aspects of care: emphasizes the roles of the members of the interdisciplinary team, especially the chaplain, in recognizing and addressing spiritual and existential distress. Specifically, the competency of all team members in understanding and supporting the religious practice preferences of patients and families is stressed.
Cultural aspects of care: describes cultural competence and defines processes for the provision of culturally sensitive care.
Care of the patient at the end of life: Highlights the importance of providing multidimensional interdisciplinary end-of-life care for patients and their families, which includes educating them and building them through the dying process.
Ethical and legal aspects of care: addresses advance care planning, ethics, and legal aspects of care. The role of the interdisciplinary team in broaching end-of-life conversations and documenting patients’ preferences is stressed. Consultation with ethics committees and legal counsel is also emphasized.
Death rattle – as patients near death, they are unable to cough to clear secretions that begin to pool in the oropharynx and bronchi, resulting in rales (“death rattles”). Because the sound is often distressing to family members, an anticholinergic (glycopyrrolate or atropine) may be given subcutaneously to relieve respiratory distress. A hyoscine hydrobromide transdermal patch is also available, but action is slower, 12 hours compared to 1 minute for injections. Risks associated with anticholinergics include xerostomia (dry mouth), increased sedation, and increased delirium. Elevating the head of the bed or turning the patient to the side may also relieve rattling. Patients normally stop taking fluids as they near death, resulting in dehydration and drying of the mucous membranes of the mouth. The death rattle also begins to lessen.
Palliative care is a form of specialized medical care which aims to optimize the quality of life and alleviate the suffering of patients through early identification and treatment of new symptoms along with management of those that prove refractory.
Excessive secretions can cause the frequently noted ” death rattle” in patients that are actively dying. This is caused by relaxation of the oropharyngeal muscles leading to a pooling of secretion in the throat. While it is typically not distressing for the patient, it does often make family members and other visitors uncomfortable. Anticholinergic agents, especially sublingual atropine drops, can be administered to assist in secretion reduction. Anticholinergic agents have multiple side effects, including decreased/ absent bowel sounds, decreased sweating, hot skin, and mydriatic pupils (dilated pupils).