Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Palliative Care
Published in: BMC Palliative Care 1/2020

01-12-2020 | Opioids | Research article

“No thanks, I don’t want to see snakes again”: a qualitative study of pain management versus preservation of cognition in palliative care patients

Authors: Pete Wegier, Jaymie Varenbut, Mark Bernstein, Peter G. Lawlor, Sarina R. Isenberg

Published in: BMC Palliative Care | Issue 1/2020

Login to get access

Abstract

Background

Towards the end of life, use of opioid analgesics becomes more common in patients to control pain and improve quality of life. While pain medication may help manage pain, unwanted cognitive side effects are frequently noted. This balancing act presents a trade-off for patients between pain relief and adverse effects, where the desire to relieve pain must be evaluated against the desire to maintain cognitive clarity and may represent a difficult decision for patients receiving palliative care. Our goal was to understand how patients’ decision making about pain medications balances the pain relief from those medications against the cognitive decline often associated with them.

Methods

We conducted qualitative semi-structured interviews with patients receiving home-based palliative care from a program in Toronto, Canada. Interview recordings were transcribed and analyzed using thematic analysis.

Results

Thirty-one interviews were conducted. Some patients preferred cognitive preservation over pain management because of a sense that cognition is central to their identity, the desire to maintain lucidity, a desire to continue participating in work or hobbies, and fear of addiction. Conversely, some patients preferred pain management over cognitive preservation because of a desire to avoid suffering, an inability to sleep without medications, or an acceptance of some cognitive compromise. A few patients attempted to find balance through tapering drugs, limiting their use of breakthrough analgesic doses, or using alternative strategies.

Conclusions

Decision making around pain and pain management is a highly preference-sensitive process—with no clear right or wrong decisions, only the preferences of each patient. The findings from this study may influence the design of future patient-facing decision aids around pain management. Future studies should pilot interventions to better assist patients with this decision.
Appendix
Available only for authorised users
Literature
1.
Imhof S, Kaskie B. How can we make the pain go away? Public policies to manage pain at the end of life. Gerontologist. 2008;48(4):423–31.PubMedCrossRef
2.
Joshi M, Chambers WA. Pain relief in palliative care: a focus on interventional pain management. Expert Rev Neurother. 2014;10(5):747–56.CrossRef
3.
Krashin D, Murinova N, Jumelle P, Ballantyne J. Opioid risk assessment in palliative medicine. Expert Opin Drug Saf. 2015;14(7):1023–33.PubMedCrossRef
4.
Sholjakova M, Durnev V, Kartalov A, Kuzmanovska B. Pain relief as an integral part of the palliative care. Open Access Maced J Med Sci. 2018;6(4):739–41.PubMedPubMedCentralCrossRef
5.
Jackson N, Doherty J, Coulter S. Neuropsychiatric complications of commonly used palliative care drugs. Postgrad Med J. 2008;84(989):121–6.PubMedCrossRef
6.
7.
World Health Organization. Cancer pain relief; 1986.
8.
Dalal S, Bruera E. Access to opioid analgesics and pain relief for patients with cancer. Nat Rev Clin Oncol. 2013;10(2):1–9.CrossRef
9.
Canadian Institute for Health Information. Opioid prescribing in Canada: How are practices changing? Ottawa, ON; 2019.
10.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. J Am Med Assoc. 2016;315(15):1624–2.CrossRef
11.
Flemming K. The use of morphine to treat cancer-related pain: a synthesis of quantitative and qualitative research. J Pain Symptom Manag. 2010;39(1):139–54.CrossRef
12.
Coyle N. In their own words: seven advanced cancer patients describe their experience with pain and the use of opioid drugs. J Pain Symptom Manag. 2004;27(4):300–9.CrossRef
13.
Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol. 2007;19(1):44–8.PubMedCrossRef
14.
Schumacher KL, West C, Dodd M, et al. Pain management autobiographies and reluctance to use opioids for cancer pain management. Cancer Nurs. 2002;25(2):125–33.PubMedCrossRef
15.
Kurita GP, Sjøgren P, Ekholm O, et al. Prevalence and predictors of cognitive dysfunction in opioid-treated patients with cancer: a multinational study. J Clin Oncol. 2011;29(10):1297–303.PubMedCrossRef
16.
Reyna VF. A theory of medical decision making and health: fuzzy trace theory. Med Decis Mak. 2008;28(6):850–65.CrossRef
17.
Holmberg C, Waters EA, Whitehouse K, Daly M, McCaskill-Stevens W. My lived experiences are more important than your probabilities: the role of individualized risk estimates for decision making about participation in the study of Tamoxifen and Raloxifene (STAR). Med Decis Mak. 2015;1:1–13.
18.
Fraenkel L, Peters E, Tyra S, Oelberg D. Shared medical decision making in lung cancer screening: experienced versus descriptive risk formats. Med Decis Mak. 2016;36(4):518–25.CrossRef
19.
Scherer LD, Kullgren JT, Caverly T, et al. Medical maximizing-minimizing preferences predict responses to information about prostate-specific antigen screening. Med Decis Mak. 2018;360(13):0272989X1878219–0272911.
20.
Wegier P, Armstrong BA, Shaffer VA. Aiding risk information learning through simulated experience (ARISE): a comparison of the communication of screening test information in explicit and simulated experience formats. Med Decis Mak. 2019;39(3):196–207.CrossRef
21.
Samuel CA, Mbah O, Schaal J, et al. The role of patient-physician relationship on health-related quality of life and pain in cancer patients. Support Care Cancer. 2020;28(6):2615–26.PubMedCrossRef
22.
23.
24.
Meghani SH, Knafl GJ. Salient concerns in using analgesia for cancer pain among outpatients: a cluster analysis study. World J Clin Oncol. 2017;8(1):75–85.PubMedPubMedCentralCrossRef
25.
Meghani SH, Wool J, Davis J, Yeager KA, Mao JJ, Barg FK. When patients take charge of opioids: self-management concerns and practices among cancer outpatients in the context of opioid crisis. J Pain Symptom Manag. 2020;59(3):618–25.CrossRef
26.
Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S. Patient-related barriers to pain management: the barriers questionnaire II (BQ-II). Pain. 2002;99:385–96.PubMedCrossRef
27.
Gunnarsdottir S, Sigurdardottir V, Kloke M, et al. A multicenter study of attitudinal barriers to cancer pain management. Support Care Cancer. 2017;25(11):3595–602.PubMedCrossRef
28.
Lewin K. A dynamic theory of personality. New York: McGraw-Hill; 1935.
29.
30.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.CrossRef
31.
Creswell JW, Poth CN. Qualitative Inquiry & Research Design: choosing among five approaches. 4th ed. Thousand Oaks, CA: Sage Publications; 2018.
32.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health C. 2007;19(6):349–57.CrossRef
33.
Bill C-45: An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts In. 42nd Parliment, 1st Session.
34.
Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). In. 42nd Parliment, 1st Session: C-14.
35.
Piamjariyakul U, Myers S, Werkowitch M, Smith CE. End-of-life preferences and presence of advance directives among ethnic populations with severe chronic cardiovascular illnesses. Eur J Cardiovasc Nurs. 2014;13(2):185–9.PubMedCrossRef
36.
García-Toyos N, Escudero-Carretero MJ, Sanz-Amores R, Guerra-De Hoyos J-A, Melchor-Rodríguez J-M, Tamayo-Velázquez M-I. Preferences of caregivers and patients regarding opioid analgesic use in terminal care. Pain Med. 2014;15(4):577–87.PubMedCrossRef
37.
Dzierżanowski T. Prospects for the use of cannabinoids in oncology and palliative care practice: a review of the evidence. Cancers. 2019;11(2):129–17.PubMedCentralCrossRef
38.
Boland EG, Bennett MI, Allgar V, Boland JW. Cannabinoids for adult cancer-related pain: systematic review and meta-analysis. BMJ Support Palliat Care. 2020;10(1):14–24.PubMedCrossRef
39.
Ballantyne JC, Sullivan MD. Intensity of chronic pain—the wrong metric? N Engl J Med. 2015;373(22):2098–9.PubMedCrossRef
40.
McCracken LM, Hoskins J, Eccleston C. Concerns about medication and medication use in chronic pain. J Pain. 2006;7(10):726–34.PubMedCrossRef
41.
Markotic F, Obrdalj EC, Zalihic A, et al. Adherence to pharmacological treatment of chronic nonmalignant pain in individuals aged 65 and older. Pain Med. 2013;14:247–56.PubMedCrossRef
42.
Timmerman L, Stronks DL, Groeneweg JG, Huygen FJ. Prevalence and determinants of medication non-adherence in chronic pain patients: a systematic review. Acta Anaesthesiol Scand. 2016;60(4):416–31.PubMedCrossRef
43.
Timmerman L, Stronks DL, Huygen FJ. The relation between patients’ beliefs about pain medication, medication adherence, and treatment outcome in chronic pain patients: a prospective study. Clin J Pain. 2019;35(12):941–7.PubMedCrossRef
44.
Lewis ET, Combs A, Trafton JA. Reasons for under-use of prescribed opioid medications by patients in pain. Pain Med. 2010;11:861–71.PubMedCrossRef
45.
Pask S, Dell’Olio M, Murtagh FEM, Boland JW. The effects of opioids on cognition in older adults with cancer and chronic noncancer pain: a systematic review. J Pain Symptom Manag. 2020;59(4):871–93 e871.CrossRef
46.
Watt CL, Momoli F, Ansari MT, et al. The incidence and prevalence of delirium across palliative care settings: a systematic review. Palliat Med. 2019;33(8):865–77.PubMedPubMedCentralCrossRef
47.
Rainsford S, Rosenberg JP, Bullen T. Delirium in advanced cancer: screening for the incidence on admission to an inpatient hospice unit. J Palliat Med. 2014;17(9):1045–8.PubMedCrossRef
48.
Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000;160:786–94.PubMedCrossRef
49.
Oldenmenger WH, Geerling JI, Mostovaya I, et al. A systematic review of the effectiveness of patient-based educational interventions to improve cancer-related pain. Cancer Treat Rev. 2018;63:96–103.PubMedCrossRef
50.
te Boveldt N, Vernooij-Dassen M, Leppink I, Samwel H, Vissers K, Engels Y. Patient empowerment in cancer pain management: an integrative literature review. Psychooncology. 2014;23(11):1203–11.CrossRef
Metadata
Title
“No thanks, I don’t want to see snakes again”: a qualitative study of pain management versus preservation of cognition in palliative care patients
Authors
Pete Wegier
Jaymie Varenbut
Mark Bernstein
Peter G. Lawlor
Sarina R. Isenberg
Publication date
01-12-2020
Publisher
BioMed Central
Published in
BMC Palliative Care / Issue 1/2020
Electronic ISSN: 1472-684X
DOI
https://doi.org/10.1186/s12904-020-00683-1

Other articles of this Issue 1/2020

BMC Palliative Care 1/2020 Go to the issue

Research article

Views of advanced cancer patients, families, and oncologists on initiating and engaging in advance care planning: a qualitative study

Research article

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial

Research article

Health and intention to leave the profession of nursing - which individual, social and organisational resources buffer the impact of quantitative demands? A cross-sectional study

Research article

Nothing to lose: a grounded theory study of patients’ and healthcare professionals’ perspectives of being involved in the consent process for oncology trials with non-curative intent

Research article

Limited knowledge and access to palliative care among women with cervical cancer: an opportunity for integrating oncology and palliative care in Zimbabwe

Research article

Peer support to maintain psychological wellbeing in people with advanced cancer: findings from a feasibility study for a randomised controlled trial