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Management of Pain and Spinal Cord Compression in Patients with Advanced Cancer

Janet L. Abrahm, MD, ACP-ASIM End-of-Life Care Consensus Panel
[+] Article, Author, and Disclosure Information

This paper was written by Janet Abrahm, MD, and was developed for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel. Members of the ACP-ASIM End-of-Life Care Consensus Panel were Bernard Lo, MD (Chair); Janet Abrahm, MD; Susan Block, MD; William Breitbart, MD; Ira R. Byock, MD; Kathy Faber-Langendoen, MD; Lloyd W. Kitchens Jr., MD; Paul Lanken, MD; Joanne Lynn, MD; Diane Meier, MD; Timothy E. Quill, MD; George Thibault, MD; and James Tulsky, MD. Primary staff to the Panel were Lois Snyder, JD (Project Director); Jason Karlawish, MD; and Karine Morin, LLM. This paper was reviewed and approved by the Ethics and Human Rights Committee and the Education Committee, although it does not represent official ACP-ASIM policy. Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey, MD (Chair); Joanne Lynn, MD; Richard J. Carroll, MD; David A. Fleming, MD; Steven H. Miles, MD; Gail J. Povar, MD; James A. Tulsky, MD; Alan L. Gordon, MD; Siang Y. Tan, MD; Vincent Herrin, MD; and Lee J. Dunn Jr., LLM. Members of the Education Committee were Faroque A. Kahn, MD (Chair); Michael A. Ainsworth, MD; John B. Bass, MD; John R. Feussner, MD; Donald E. Girard, MD; John J. Hoesing, MD; Faith T. Fitzgerald, MD; Alphonso Brown, MD; Jerome H. Carter, MD; Sandra Adamson Fryhofer, MD; William J. Hall, MD; Rodney Hornbake, MD; Christine S. Hunter, MD; Mary E. Moore, MD; and Kurt Kroenke, MD.

Acknowledgments: The author thanks Dr. Daniel Haller, the members of the ACP-ASIM End-of-Life Care Consensus Panel, and the outside reviewers for critiquing the manuscript.

Grant Support: In part by the Greenwall Foundation (ACP-ASIM End-of-Life Care Consensus Panel). The Open Society Institute Project on Death in America Faculty Scholars Program provided salary support for Dr. Abrahm. The opinions expressed here are those of the author and not necessarily those of the Open Society Institute.

Requests for Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians-American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, lsnyder@mail.acponline.org.

Current Author Address: Janet L. Abrahm, MD, 514 Maloney, Hospital of the University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104.

Ann Intern Med. 1999;131(1):37-46. doi:10.7326/0003-4819-131-1-199907060-00009
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General internists often care for patients with advanced cancer. These patients have substantial morbidity caused by moderate to severe pain and by spinal cord compression. With appropriate multidisciplinary care, pain can be controlled in 90% of patients who have advanced malignant conditions, and 90% of ambulatory patients with spinal cord compression can remain ambulatory. Guidelines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for physicians who infrequently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory prostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed and activated. Practical suggestions are offered for assessment and treatment of all aspects of his pain, including its physical, psychological, social, and spiritual dimensions. The methods of pain relief used or discussed include nonpharmacologic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiating, titrating, and changing opioid routes and agents; and preventing or relieving the side effects they induce are also covered. Data on assessment and treatment of spinal cord compression are reviewed. Physicians can use the techniques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer.


Grahic Jump Location
Figure 2.
Management guidelines for severe cancer pain.4

MSO = morphine sulfate.

Grahic Jump Location
Grahic Jump Location
Figure 1.
Pain assessment scales.

The verbal numerical scale, word scale, and the two visual analogue scales shown are four validated, commonly used scales for pain assessment. On a visual analogue scale, the patient marks the point that represents the intensity of his or her pain now, on average, at its worst, and at its best. See reference 3 for more information.

Grahic Jump Location




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