Another Christmas has come and gone, and in its wake are those usual thoughts of the future and the past: Thoughts of loved ones no longer here. Thoughts of the pain some of them endured before they were able to leave the living. Thoughts of what painful ailment might be lurking in the shadows of days hence, and the coping methods that might be used to minimize the damage to self and loved ones from poor health.
Pain has a profound effect on the quality of life of seriously ill patients, bereaved family members, and providers of health care. The pain of chronic illness can negatively impact sleep, immune function, cognition and mobility. Daily pain has an effect greater than that of advancing age or the number of chronic medical conditions; and the lack of relief of that pain can lead to suicide in later life. Unfortunately, there has been little research on pain in the final years of life. An analysis of data resulted in a recent publication in "Annals of Internal Medicine", focusing on pain in the last 2 years of life.
This article was interesting in that the authors measured not only the frequency of pain, but also the degree to which patients were burdened by their pain. In fact, almost half of the participants were troubled by their pain during the final month of life; one-third reported clinically significant pain during the final 2 years of life. Interestingly, pain prevalence was independent of the terminal diagnosis: There were equivalent rates of pain for cancer, heart disease and frailty.
Caregivers need to appreciate that close monitoring and titration of pain-relieving modalities must occur regularly as a patient approaches death. Unfortunately, it can be difficult to predict death, and thus refine the timing of appropriate pain treatment. However, a solution to this problem may be in realizing that clinically significant pain was reported by at least one quarter of study subjects in each of the last 24 months of life: Caregivers need to confront the reality of pain in patients with chronic illness whose death is not necessarily imminent. This should capture a significant number of sufferers of pain who might otherwise fall through the cracks of adequate treatment.
Despite the recognition that pain in later life is indeed a major and looming public health issue, there are relatively few older patients in pain clinics. And those suffering from arthritis have much more pain compared to those without arthritis. Perhaps due to mobility impairments patients are unable to attend recommended appointments; these patients also suffer more depression and social isolation. Even in elderly individuals with a major life-threatening illness, the successful management of pain often will require the consideration of other chronic problems (such as arthritis), which ironically may have a more profoundly and daily effect on quality of life than the diagnosis which will eventually be the cause of death.
It is incumbent upon clinicians to focus on the pain of patients with chronic illness, and not just on the pain of patients with a clearly terminal disease. When all is said and done, we are all terminal. And it might be the pain that is slowly killing us.
