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


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.