Palliative, Comfort Care and Hospice

A patient’s quality of life is always important—before, during, and after cancer treatment. Many patients do not realize that most cancer pain can be treated effectively with medications. There may also come a point during the course of an advanced cancer patient’s treatment where the focus shifts to palliative, or comfort, care. At this time, pain management and emotional and spiritual support become primary concerns. Hospice care is available for patients during the last months of their lives to ensure that comfort is provided. This article discusses palliative care for cancer patients, specifically pain management and hospice care.

• Coping with Cancer Pain
• Hospice Care

Coping with Cancer Pain

More than 50% of cancer patients must cope with pain on a daily basis and of these patients, more than 30% suffer moderate to severe pain. Most cancer pain (90%) can be controlled with medications. It is important that patients communicate with their healthcare providers so that cancer pain can be treated effectively and the patient can remain as comfortable as possible.

Cancer pain can occur for several reasons. Sometimes, the pain is a result of the tumor itself. Other times, pain occurs when cancer has spread into soft tissues (such as the muscle or connective tissue) or into organs or bones. Pain can also be a result of a nerve injury or from a tumor putting physical pressure on a nerve. Cancer treatments (such as surgery, chemotherapy, or radiation) can also lead to pain.

Cancer pain can be assessed with a variety of tools in addition to physical examination and an analysis of the patient’s medical history. These assessment tools include:

• Numerical pain scale: Patients identify the extent of their pain on a scale from 0 to 10, 0 being no pain and 10 being the worst pain imaginable.
• Visual analog scale: Patients are given a scale that consists of straight line with the left end of the line representing no pain and the right end of the line representing the worst pain. They are asked to mark where their pain falls on this scale.
• Categorical pain: Patients describe their pain as none, mild, moderate, or severe.
• Pain faces scale: Patients are given a serious of faces with different expressions and asked which face best describes their pain.

After a patient’s pain is thoroughly assessed, his or her cancer team will develop a treatment plan. Medications are the most common method of treating cancer pain. Categories of medicines that may be used include:

• Non-opiods: These medicines are used for mild pain or combined with other medicines to provide greater pain relief. Examples include acetaminophen (such as Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen).
• Opiods: These medicines provide the strongest pain relief and are available by prescription only. Opiods are classified as weak (for mild or moderate pain) and strong (for severe pain). Examples include codeine, fentanyl, hydrocodone, hydromorphone, levorphanol.
• Adjuvant analgesics: These medicines have multiple purposes but can be effective for relieving pain. Examples include antidepressants, anticonvulsants, steroids, local anesthetics.

Besides drug therapies, other methods for relieving cancer pain include surgery, radiation therapy, chemotherapy, nerve blocks, or non-medical therapies (including massage, relaxation, distraction, hypnosis, physical therapy, imagery, heat and cold therapy, positioning for comfort, coping skills, emotional support, and counseling).

Recently, the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS) published new cancer patient treatment guidelines for patients to help them understand that cancer pain can be treated. The new ACS/NCCN cancer pain treatment guidelines explain what causes cancer pain, the obstacles involved in finding relief from pain, how physicians assess pain, how cancer pain is treated, and more. The guidelines are written specifically for patients and can be obtained by calling the NCCN at 1.888.909.NCCN or the American Cancer Society at 1.800.ACS.2345. Guidelines may also be viewed or downloaded from the NCCN website at http://www.nccn.org/

Hospice Care

Hospices programs provide care for terminally ill patients and support for families. Reserved for patients who have moved beyond treatments to cure their disease, the focus of hospice care centers around the patient’s quality of life. This includes attention to pain management and emotional, spiritual, and psychological support. Hospices can allow patients to spend their last days in a comfortable environment with minimal pain.

Though tailored to each patient’s needs, the hospice team often includes:

• Physicians
• Nurses
• Aides
• Social workers
• Counselors (including clergy members)
• Therapists (speech, physical, occupational, etc.)
• Volunteers

Many of these people make planned visits to the patient’s home or nursing home. Some hospice programs are designed to care for patients in freestanding facilities or hospitals. Medical equipment, supplies, medications, and other necessities can also be provided with hospice care. Grief counseling is often available to family members after the patient’s death.

While hospice care is intended for what is expected to be the final months of a patient’s life, patients and loved ones may wish to begin investigating hospice programs well before services are needed. Often, the patient’s physician or treatment team can recommend a high quality hospice program.

When hospice is needed, the patient or his or her loved ones can contact the hospice themselves or ask the patient’s physician to refer him/her to a particular hospice program. Before hospice care begins, the staff will discuss the patient’s medical situation and life expectancy with his or her primary physician. Then, the staff will meet with the patient and loved ones to discuss what services are needed. These services include pain and comfort management, emotional/spiritual support, medications, etc. Financial and insurance matters will also be discussed at this time. Based on the discussion with the patient, family members, and the patient’s physician, a "plan of care" will be created.

Hospice care is usually covered by the patient’s health insurance company, Medicare, or Medicaid (in 43 states), if the patient is eligible. However, patients and/or family members should check with their insurance provider prior to choosing hospice care to understand the nature of the coverage, whether any out-of-pocket expenses are required, whether room and board coverage is provided for patients who receive hospice care in freestanding facilities, and other essential information.

Hospice resources:

• National Hospice and Palliative Care Organization
  http://www.nhpco.org/

• Hospice Foundation of America
  http://www.hospicefoundation.org/

• American College of Physicians Home Care Guide for Advanced Cancer
  http://www.acponline.org/public/h_care/

Updated: June 24, 2007