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Are you undertreating pain of cancer patients?
You may need to step outside your comfort zone
A cancer patient with a pericardial effusion was upset about something other than her condition when she arrived at the ED at Eastern Maine Medical Center in Bangor: not being able to see her regular oncologist.
"I explained that the cancer clinic always tries very hard to see their own patients, but they must have been booked up," says Traci Craig, RN, ADN, BSN, CEN, CCRN, FNE, the ED charge nurse who cared for the patient.
The first thing Craig did was to contact the clinic to urge the patient’s regular doctor to come to the ED. While waiting to hear back, she took the patient’s vital signs and oxygen saturation, applied oxygen by nasal cannula, and performed an electrocardiogram.
"The cardiologist and the oncologist came to see her, and she was admitted to the hospital without incident," recalls Craig. "The plan was to drain the pericardial effusion and place a pericardial window."
Cancer patients in the ED may need you to go the extra mile to meet their unique needs, urges Craig. "The medications used to treat this horrible disease cause many side effects, and often patients need to seek help in the ED," she underscores. "The patient most likely will be very nervous about coming to the ED to treat an acute problem. In addition, we often fall short when treating cancer pain in the ED."
To dramatically improve care of cancer patients, take the following steps:
• Protect patients from infection.
Chemotherapy patients are at high risk of infection, warns Craig. "Be aware that most blood counts hit their nadir seven to 14 days after treatment," she says. To reduce risk of infection, she recommends the following:
• Don’t take a rectal temperature.
Using a rectal thermometer can cause a tear in the inner bowel and increase the chance of infection due to low white cells, advises Craig. "Also, low platelets can cause bleeding. Since the bowel is so vascular, poking a hole in the bowel can increase the risk of bleeding," she adds.
• Be ready to manage "breakthrough" pain.
Breakthrough medications are given for periods in which pain escalates, or breaks through, the long-acting opioid, explains Judith A. Paice, PhD, RN, FAAN, director of the cancer pain program at Northwestern University in Chicago.
"Patients may come to the ED with pain crises or for other emergencies associated with pain," she says. "Aggressive titration, usually with an intravenous opioid, is indicated."
Opioids can be delivered safely every 15 minutes intravenously (IV), or every hour when given orally, and increased by 50% if ineffective, advises Paice.
"For the oncology patient already on opioids, the risk of adverse effects such as respiratory depression is minimal," she says.
Determine the patient’s current breakthrough dose, if he or she has used it to treat this painful event; and if so, when he/she administered the last dose, says Paice. "They may have run out of the drug or are afraid to use the medication," she notes.
Since management at home usually is oral, an equivalent parenteral dose usually is one-third or one-fourth of that dose, says Paice. For example, 30 mg of oral morphine is approximately equal to 10 mg of IV or subcutaneous morphine, she notes, adding that intramuscular administration of most drugs is not recommended.
Often, patients may not be taking a breakthrough dose, says Paice. To determine a breakthrough dose for someone on long-acting opioids, use 10%-20% of the 24-hour opioid dose, she says. So if a patient is receiving 200 mg of long-acting oral morphine each day (100 mg every 12 hours), his or her breakthrough dose would start at 20-40 mg oral immediate release morphine every hour as needed, explains Paice.
During a pain crisis, a parenteral dose likely would be used to gain more rapid control of the pain, she adds. "Thus, the appropriate dose would start at approximately 8-12 mg IV every 15 minutes and titrated upward until the patient feels relief," Paice says.
Remember to use a stool softener when starting pain medication, as many of these medications cause constipation, she advises.
Oncology patients may need large doses of pain medications that might be outside your comfort zone, says Paice. "Giving lower doses that might be appropriate for opioid-naive patients will place the cancer patient at risk for unrelieved pain, and if this goes on for a longer period of time, even withdrawal from the opioid," she warns.
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