C.A.R.E.S.: A Tool for the Care of the Dying

Bonnie Freeman, RN, DNP, ANP, ACHPN, Compassionate Person-Centered Care for the Dying

Comfort

Pain Management
You must act as an advocate for your patient to control their pain. Pain control is an essential need for all dying patients.

  • The route of the medication determines time to maximum effect:
    • IV peak effect is 15 minutes
    • PO in 60 minutes
    • Sub-q in 30 minutes
    • Transdermal 4 to 6 hours
  • Terminal pain/pain during dying is best managed by around the clock, scheduled, or a continuous infusion of opioid (such as from a PCA pump) and additional doses (boluses) given as needed for breakthrough pain.
  • There is no maximum dose of opioids for pain control.
  • Nurses are often frightened the opioid they give a patient will cause them to die prematurely.
    • There will always be a last dose when caring for a dying patient. Keep in mind the legal and ethical concepts of intent.
    • The patient is dying because of their disease process not the opioid.
  • Adjustments in dosage or type of opioid may be required in the presence of renal failure, and if the pain medication does not help to control the patient’s pain.
    • Consider fentanyl if the patient is in renal failure and if the patient is having small seizure like tremors (myoclonus).
    • Opioids stay in the system longer with renal failure. Dosage is usually smaller.
    • Consider changing the type of opiate if pain remains uncontrolled.