• Secondary liver cancer pain alleviation. Any tips from pros with experience?

    Asked by FreeBird on Saturday, March 23, 2013

    Secondary liver cancer pain alleviation. Any tips from pros with experience?

    I am a caregiver for my dad with pancreatic cancer, and secondary tumor in the liver. So, now he is experiencing some of the symptoms of liver disease-- mainly a visible mass in the upper right abdomen, and pain in the same place that has increased in recent days. Does anyone with experience in alleviating the pain and discomfort of this type of cancer have any tips that I can bring up with the Hospice team? He is already using morphine for pain management. Looking for any tricks of the trade, besides the medications.

    11 Answers from the Community

    11 answers
    • GregP_WN's Avatar
      GregP_WN

      I hope your Dad isn't in too much pain Freebird. My Hospice nursers usually done a great job adjusting Mom and Dad's meds to keep them medicated when it was needed. They were lung and prostate/bladder/bone, so I can't help your question on liver. Carm probably can.

      Hope he gets compfortable.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      Thank you Greg. He has ups and downs. The past few days, though he has had more pain than usual-- a sort of stabbing pain right in that upper right abdomen, and around the back side. They just boosted the morphine up on Friday. They think some of the pain might be from retaining fluid, with the added pressure. So he started on diuretics. The breakthrough morphine takes a while to kick in. This is the first time he looks visibly distressed. After a while, the meds do kick in. He is having to use it more often. He's eating well though. Still aware, and doing okay. Moving around.

      almost 4 years ago
    • carm's Avatar
      carm

      Freebird,
      I am so sorry to hear of this latest event. I can imagine that it must be terrible for you. When you are addressing pain management, one of the harder issues is when the liver is involved. The liver is what metabolizes most drugs and if it is not functioning properly, the pain meds accumulate in the liver to toxic levels and the doses have to be adjusted to reflect that. If he is with hospice as you state and on morphine, is it still by pill or is it in intensol form? Is he on both long and short acting morphine? The answers to my questions are key in determining the next course to take. Sometimes pain is exaserbated by anxiety, and therefore pain meds should be taken with anti-anxiety meds like Haloperidol. Sometimes it is the route, and if Morphine does not touch his pain, perhaps you might ask hospice for B (Belladonna) & O (Opioid) suppositories. In end of life care, I know the drugs used in the pain management of intractable pain. And when you speak with the hospice nurse, make sure you describe his pain as "Intractable" so that he or she will know the next course to take. Address the anxiety as well. Some hospice organizations will use lorazepam (Ativan) for the anxiety. It is not my favorite go to drug in end of life care because either it will work for the patient or it will work against the patient; so it can be unstable and then as a result increase the anxiety. End of Life care is generally 2 weeks or less, and we tend to use Haldol for anxiety with an Ativan back-up; A very good and tried and true drug. A hospice nurse will only gage their response by your words, so if the pain is intractable that should set off an alarm bell that the pain threshold has decreased and titration to comfort is a necessity. If you need anything, you know where to find me. You are one of my favorite posters here on this site and if I can be of any service to you, please do not hesitate. You are both in my thoughts, Carm RN.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      Thank you Carm. They are in pill form, morphine ER 75mg, 3 times a day, and morphine IR 15mg for breakthrough pain. They offered a patch if he'd rather have it.

      They do have Ativan in his little emergency kit that we're not supposed to open unless they order it.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      Here's the list of medications in his comfort kit that has to stay sealed until they order it, if you're interested in what they're using here, Carm:

      morphine sulfate powder
      sterile water irrig.
      lorazepam tablets (Ativan)
      lorazepam powder
      diphenhydramine hcl powder
      haloperidol usp powder
      haloperidol lac 2mg/ml
      polybase ointment
      metoclopramide hcl powder
      acetaminophen powder (Tylenol)
      prochlorperazine 10 mg
      prochlorperazine powder
      anaspaz 0.125 mg tablet

      almost 4 years ago
    • carm's Avatar
      carm

      Freebird,
      Did he just join hospice because it sounds like you are describing a rescue pack? I really don't see the rationale of his morphine in pill form but the patch is probably a duragesic/fentanyl patch that is usually prescribed as worn for 3 days and changed every 72 hours. So he needs the anti anxiety meds and if I were you I would go with the haldol first. I don't see anything for excess salivary secretions which is weird for a rescue pack. But anyway, anxiety heightens pain and for the meds to be effective he needs to be less tense. Heightened pain will elevate the pulse and blood pressure and will quicken his respiratory exchange. Did he sign a DNR? If you need help off line let me know but if they can't or won't get that pain under control, threaten to revoke the DNR and take him to the ER for intractable pain. That always gets the correct response. They know that by law you cannot force anyone to get a DNR and if he does not have one they will have to supply cardiac rescue meds so when patients threaten that revocation, it is a big motivator, good luck my friend, Carm RN.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      He has been with Hospice for about two months. They're nice. The nurse comes twice a week, the doctor every couple of weeks, and the social worker every few weeks. They have been good about giving him whatever medication he needs. Sometimes I think too much. Every time something comes up, there's another pill. At the moment, he swallows almost 30 pills a day including his laxative and stool softener. This is a new experience with the additional pain and discomfort. So maybe there is something going on in there that represents a new stage in this process. I'm learning as I go. He does have a DNR order by his choice. He is on a rollercoaster with the pain right now. He goes through periods where he is at a 2 on the 1-10 scale, then he'll get that stabbing breakthrough pain and report an 8 out of 10. Hopefully they will sort out the medicines. It's a new experience for me, so I'm not sure what to expect. He has a little nervous twitch as well, in his arms and legs. The symptoms he is experiencing now are very similar to when he filled up with fluid last year. He has swelling and petechiae in his lower legs. So they have him elevating his legs, and using the diuretic. That swelling has been going on ever since he used the new nebulizer drug, which he stopped about 2 weeks ago.

      almost 4 years ago
    • carm's Avatar
      carm

      Freebird,
      Well, the petechae and lower extremity swelling is common at this stage with pancreatic/liver disease. We are all a DNR by choice, personally it is one of the best decisions I ever made for myself. I think his anxiety needs to be addressed and haldol will really mellow him. I also think that his pain meds should be altered and increased. A patch would be beneficial but they don't work right away. They have to build up to a therapeutic level so if he goes to a patch, it really won't work until the 5th or 6th day. Until then, he should stay with some of the ER morphine. Some people do suffer side effects from patches at first, wild dreams, extreme stupor or behavior changes for a few days but it is just their body reacting to the introduction of fentanyl. It will level out. The twitching you are seeing are myoclonic jerks. They are common with any opioid when you increase them. If his pain is escalating then I assume he is taking more for the breakthrough pain. When ever you increase pain meds, your body has to adjust, so you see the jerks for a few days until he levels out. I don't understand the rescue pack. Most patients who join Hospice come with pain and anti-anxiety meds anyway with oncology. So it is assumed they are used to the regimen already. We usually explain the pack and let them use whatever is needed out of it. I assume he has no jaundice or ascites yet because you didn't mention it. Jeez, 30 pills is way too much, thats polypharmacy! That is a lot of work for the liver. If meds can be given by other routes it might ease that workload. Topical, rectal, sub lingual might be more effective. He must have a lot of co-morbidities. Does he have a history of cardiac problems? Hospice is a bit different than my work in end of life care. We use HAM (haldol, ativan, morphine) sandwiches and maybe a few other rescue meds like scopolamine or atropine for excess secretions but unless they have a brain tumor with seizure activity or need terminal sedation with thiopenthal, that's about it. We don't treat any co-morbidities. They don't matter at that point. We are doing more training and preparation for that final day. We have to get them prepared for the experience of the actual death with so little time remaining. It goes without saying that I am here if you need anything and they hopefully gave you a "Gone From My Sight" pamphlet so that you can gauge his progression. If not, ask for one. Best of luck to you. Address that nervousness and I think he will level out and it will become easier to conquer the pain. You are in my thoughts, Carm RN.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      Thanks for your input, Carm. I'm learning a lot reading your posts. I know many people on whatnext appreciate your experience. The cardiovascular issues he has are high blood pressure, and since his first lung surgery three years ago, he developed atrial fibrillation for which he takes meds. The good news is that today he went without a breakthrough morphine between the scheduled extended release. So maybe the increase is starting to work.

      I think the DNR was a good choice also. I brought it up last year, with our living will or advance directives, with the goal that I want to make sure his wishes are carried out, and not anyone else's if there is disagreement. We all went and got living wills several years ago when Terry Schiavo was in the news.

      The only part of Hospice I don't like is that we're curious what's going on in there and how far along he is with liver disease. They said most people don't want to know anyway because it can add to the stress. There's no jaundice yet, and it doesn't appear that there's any ascites. The doctor pressed on his belly and said it doesn't feel like there's much fluid in there.

      I will keep those drugs you mentioned in mind as we go along. Thanks.

      almost 4 years ago
    • carm's Avatar
      carm

      Freebird,
      That is why I suggested the "Gone From My Sight" book, so that you can guage the time remaining. If they do not get one out to you, let me know and I will make sure you get the information inside the pamphlet that gives you the outline. I am glad to hear that he is feeling better today. I also filled out a "Five Wishes Book" which is like an advance directive and recognized in over 40 states as a legal will. I keep my Five wishes Book and DNR in a ziploc bag in my freezer, so I always know where it is in an emergency. So if you need anything, shoot me a line and I am glad I can help out. Best of luck to you all, Carm.

      almost 4 years ago
    • FreeBird's Avatar
      FreeBird

      I think this is the book Carm was talking about http://www.charterhealthcaregroup.org/wp-content/uploads/2012/11/Gone-from-my-sight.pdf if anyone wants to have a look

      almost 4 years ago

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