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Perioperative Analgesia for a Patient Going for Spine Surgery 285
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Perioperative Considerations
for Palliative and Terminally Ill Patients
Lara India
Abstract Pain related to s erious illness, especially cancer, is a common complaint
amongst patients with terminal illness or receiving palliative care. Anesthesiolo-
gists must carefully consider how to control these patients’ intra- and postoperative
pain due to their complex pre-existing pain management regimens and potential
contraindications to certain adjuvant pain medications. Understanding the patient’s
baseline opioid use and how to convert it to appropriate intravenous formulations is
crucial. Additionally, anesthesiologists should recognize that terminally ill patients
are susceptible to non-physical types of pain, which may emerge or worsen during
the perioperative period. It is essential for anesthesiologists to be familiar with non-
pharmacological interventions to address these different facets of a patient’s total
pain.
Keywords Palliative care
· Cancer pain · Total pain · Opioid conversions · Goals
of care
1 Introduction
Palliative care is a clinical approach that aims to improve quality of life metrics
for patients facing serious illnesses, regardless of whether the illness is terminal or
life-prolonging treatments are offered concurrently [1]. While the development of
palliative care in the United States historically focused on symptom management
and end-of-life care specifically for cancer patients, a patient with any serious illness
may benefit from palliative care.
This chapter will largely focus on perioperative considerations for palliative care
patients with cancer-related pain, given its prevalence and the high number of cancer
patients encountered by anesthesiologists in the perioperative setting. According to
the National Cancer Institute, there were 1.8 million new cancer diagnoses in 2020
L. India (
B
)
Anesthesiology and Hospice and Palliative Medicine, Medical College of Wisconsin, Milwaukee,
USA
e-mail: lindia@mcw.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_18
287
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288 L. India
[2], and cancer survival rates continue to increase, with an estimated 22 million
cancer survivors in the United States predicted by 2030 [3]. It is important to note
that nearly 40% of all cancer patients report moderate-to-severe pain at some point,
which may persist even after curative treatment [4]. Therefore, it is essential for
anesthesiologists t o understand the unique perioperative considerations encountered
when caring for patients receiving palliative care and seeking to provide effective
pain management and improve the patient’s overall quality of life.
2 Case Presentation
Mrs. Arnold is an 83 kg, 54-year-old female, who was diagnosed with breast cancer
two years ago. She works full-time in the toddler room at a daycare center. She lives
alone and takes pride in driving herself to appointments. Unfortunately, her disease
has progressed despite multiple rounds of chemotherapy, resulting in bony and liver
metastases that cause constant pain currently managed by her palliative care doctor.
She also developed chemotherapy-induced peripheral neuropathy approximately one
year ago.
During her last visit to her palliative care doctor one month ago, Mrs. Arnold’s
extended-release morphine was increased to 45 mg every 12 h. She is also prescribed
oxycodone 20 mg every 4 h as needed, usually requiring two or three doses daily, and
pregabalin 150 mg twice daily. Mrs. Arnold is now presenting for surgical fixation
of a pathologic left femur fracture.
3 Palliative Approaches to Symptom Management
Pain
Managing physical pain requires distinguishing whether it is nociceptive, visceral,
or neuropathic. Due to its nociceptive and progressive nature, cancer pain manage-
ment heavily relies on the use of opioids. The World Health Organization (WHO)
analgesic ladder is a commonly followed algorithm for cancer pain management [5].
Non-opioid adjuvants like acetaminophen or non-steroidal anti-inflammatory drugs
(NSAIDs) are used to treat mild pain at the first step of the ladder. However, these
medications have certain limitations in the context of cancer pain management. For
instance, acetaminophen should be used cautiously in patients with risk factors for
hepatic toxicity and in the immunocompromised population as it can mask fever, an
early warning sign of infection [6]. Furthermore, preclinical studies suggested that
concomitant use of NSAIDs and immune checkpoint inhibitors may worsen patient
outcomes; however, the clinical effect may not be significant [7].
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Perioperative Considerations for Palliative and Terminally Ill Patients 289
Short-acting opioids, such as immediate-release morphine or oxycodone, are used
for moderate cancer-related pain. To achieve adequate pain control, oncologists or
palliative care doctors will frequently initiate short-acting opioid therapy and then
assess the average opioid amount required in a 24 h period. The total oral morphine
equivalents (OME) used in the course of this trial is then used to determine a starting
dose of long-acting opioid. Both the short- and long-acting opioids are then titrated
further as needed.
Currently, muscle relaxants are not included in the WHO analgesic ladder or other
national guidelines for treatment of cancer-related pain [5, 6], and thus they do not
have a large role in cancer pain management unless imaging specifically suggests
irritation of a muscle group by tumor involvement. Antiepileptics like pregabalin
or gabapentin, and SNRIs may be used to treat chemotherapy-induced peripheral
neuropathy [6].
Patients receiving outpatient palliative care have frequent contact with their health-
care team, and their pain management regimen is typically titrated over the course of
weeks or months. Therefore, the majority of patients treated by an anesthesiologist
will have been stable on their short- and long-acting opioids for some weeks. This
regimen stability is particularly important when considering acutely painful injuries
that may cause patients to present for a surgical intervention, such as repair of a patho-
logic fracture. A patient’s pre-existing pain management regimen is intended to meet
their baseline pain management requirements. As such, long-acting and short-acting
opioids should be continued in the perioperative period at equipotent doses. Although
patients may undergo procedures expected to result in an acute decrease in pain (such
as vertebroplasty or fracture fixation), their baseline pain is not expected to decrease
as their underlying disease remains unchanged.
Dyspnea
Anesthesiologists should be familiar with palliative strategies for managing dyspnea,
in addition to pain management. Chronic dyspnea is a common symptom in illnesses
such as COPD, heart failure, cancer, and ESRD, and refers to the sensation of
breathlessness over several weeks. After optimizing the underlying illness and
implementing non-pharmacological measures, opioids or benzodiazepines may be
prescribed to manage residual dyspnea. While opioids were historically used for
dyspnea management exclusively in patients with comfort-focused goals of care,
this practice is evolving. Patients managed by palliative care services may benefit
from dyspnea therapies and receive low-dose, long-acting opioids regardless of their
goals of care [8]. Managing chronic dyspnea in the perioperative period can be chal-
lenging, as the anesthesiologist must balance treating the patient’s baseline dyspnea
and postoperative pain while ensuring adequate respiratory drive for extubation at
the conclusion of the procedure. Long-acting opioids prescribed for this indication
should be continued throughout the perioperative period. Short-acting opioids and
benzodiazepines are intended to relieve acute dyspnea and do not provide lasting
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290 L. India
relief. Therefore, their continuation in the perioperative period is subject to the
anesthesiologist’s discretion.
4 Total Pain in Serious and Terminal Illness
Patients with serious or terminal illness may experience pain from causes beyond
nociception. This concept is known as total pain, which considers physical, psycho-
logical, social, and spiritual factors that together contribute to a patient’s overall
pain experience. Dame Cicely Saunders, the founder of the modern hospice move-
ment, developed this concept. While physical pain is often the primary focus of
clinicians, neglecting the spiritual, social, and psychological components may lead
to overmedication or unnecessary suffering [9].
Spiritual pain may manifest as feelings of despair or hopelessness regarding the
meaninglessness of life. Patients may feel disconnected from their spiritual commu-
nity or abandoned by God. Anesthesiologists may observe signs of spiritual pain
such as patients excessively worrying about death in the perioperative setting. Social
pain refers to the feeling of becoming a burden on loved ones and society, as well as
grieving the loss of roles or tasks that had previously defined the patient’s identity and
self-worth. Anesthesiologist may notice signs of social pain including expressions of
concern regarding the degree of necessary physical and occupational rehabilitation,
the expected time to recovery, and the anticipated level of physical function in the
postoperative phase of care.
Patients with serious or terminal illness may develop new anxiety related to the
uncertainty of their medical condition, which contributes to their psychological pain.
This anxiety may be compounded by the stress and uncertainty of surgery, making
psychological pain a condition frequently encountered by anesthesiologists. Mani-
festations of psychological pain include nervousness, restlessness, tearfulness, the
demonstration of a withdrawn affect, or expressions of generalized fear of surgery
and the future. In certain situations, preoperative anxiety can negatively affect patient
outcomes and therefore should be addressed prior to surgery [10].
Recognizing and addressing spiritual and social pain with appropriate interven-
tions can help to reduce patient suffering. These feelings are more easily identi-
fied during a longer visit, such as a preoperative clinic appointment, though the
observant anesthesiologist may also notice them in the immediate preoperative
setting. Providing additional support, as discussed later in this chapter, may alle-
viate non-nociceptive sources of pain and distress, thereby reducing the amount of
pharmacological intervention a patient requires [11].
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Perioperative Considerations for Palliative and Terminally Ill Patients 291
5 Case Considerations
When Mrs. Arnold is met by the anesthesiologist in the preoperative holding area,
she is very upset. She shares that the pain in her left leg is excruciating. Although
she took an extra dose of extended-release morphine in the middle of the night, the
pain remained too severe, leading her to the emergency room. She has also taken her
oxycodone every four hours for the past two days. After concluding the preoperative
assessment and offering reassurances that she will receive further pain management,
the anesthesiologist asks if she has any additional questions. Mrs. Arnold has several,
including how long it will be before she can walk again, return to work, and resume
chemotherapy.
The anesthesiologist must approach both the physical and the non-physical aspects
of Mrs. Arnold’s pain. Injuries that threaten a patient’s mobility pose a significant
risk for social pain. Mrs. Arnold works a physically demanding job, and she may be
distressed over whether she can continue to work. More broadly, she may be anxious
about whether she can care for herself independently at home. Both these concerns
impact her role in her societal structure and her sense of dignity. If such worries are
identified in the immediate preoperative setting, the anesthesiologist should inform
the surgical team, who can plan appropriate interventions after surgery. If the patient
had presented to the preoperative clinic, then the anesthesiologist could have part-
nered with the patient, their caregiver(s), the surgical team, and social workers to
ensure that Mrs. Arnold was appropriately placed in a rehabilitation center after
surgery and that she had access to other necessary support services, such as a
psychologist or transportation to oncology appointments.
Mrs. Arnold is also likely experiencing psychological pain. Her questions at
the end of the interview demonstrate her concern about the uncertainty of her
medical situation. The psychological pain related to her metastatic cancer may be
compounded by the anxiety associated with the perioperative period. Suppose signif-
icant psychological distress is identified in the preoperative clinic. In that case, anes-
thesiologists may recommend further preoperative education or referral to a psychol-
ogist. Additional interventions such as music therapy, acupuncture, and hypnosis
may also reduce perioperative anxiety although further investigation is needed [10].
Anesthesiologists may use benzodiazepines to treat the psychological pain associated
with surgery; however, it is important to recognize the risk of postoperative delirium
associated with benzodiazepine use, particularly in elderly and frail patients [12].
Spiritual pain may become evident when patients use language around God and
prayer in the immediate preoperative setting. Anesthesiologists should feel comfort-
able being present for patient-led prayers and may even choose to participate in
said prayer. If available, it is also appropriate to ask chaplaincy to visit patients in the
preoperative holding area. However, there is no indication in Mrs. Arnold’s interview
that she is experiencing significant spiritual pain.
Developing an appropriate plan to manage Mrs. Arnold’s physical pain involves
considering several factors. One essential aspect is calculating her baseline preop-
erative opioid use, which can aid in achieving adequate pain control both during
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292 L. India
and after surgery. Mrs. Arnold reported taking her extended-release morphine as
prescribed, except for a one-time additional dose she took yesterday. This isolated
occurrence is not sufficient to alter her average OME and can therefore be disregarded
when determining her baseline opioid use. However, any longer-term deviations from
her prescribed opioid regimen must be considered. The situation is less clear when
considering her recent increase in oxycodone intake, from two-to-three tablets per
day to six per day, due to pain from the acute fracture. Because of the short-term nature
of this opioid increase in response to an acute injury, many clinicians would exclude
this change from the patient’s OME calculation. However, if increased short-acting
opioid use persists for several days to weeks, it should be included in the daily OME
calculation. The anesthesiologist may gain valuable information through exploring
how well oxycodone 20mg controlled her pain and using that feedback to guide
opioid dosing during and after surgery.
To determine Mrs. Arnold’s average opioid use, her total daily OME needs to be
calculated. This is shown in Table 1. Table 2 then shows a set of equipotent opioids
commonly used in anesthesia practice. It is important to note that individual patients
may have varying responses to different opioids, and any conversions should be
done with a dose reduction factor, usually between 25 and 50%. Dose reductions are
performed for patient safety, due in part to the incomplete understanding of relative
opioid potencies and individual genetic variation in drug metabolism [13]. Based
on the calculations, Mrs. Arnold requires a total daily OME of 180. An effective
perioperative pain management plan will ensure that she receives her OME through
a combination of oral and IV medications. Additional medication for intra- and
postoperative pain management can then be planned accordingly.
Table 1 Calculation of Mrs. Arnold’s baseline oral morphine equivalents
Opioid Route of
administration
Daily total dose Conversion ratio to
oral morphine
OME (mg)
Extended-release
morphine
Oral 90 mg (45 mg
twice daily)
N/A 90
Oxycodone Oral 60 mg (20 mg
three times daily)
3:2 90
Table 2 Equipotent doses of select short-acting oral opioids and select IV opioids commonly used
in anesthesia practice
Opioid Equipotent oral dose (mg) Equipotent IV dose (mg)
Morphine 30 10
Codeine 130 75
Fentanyl – 0.1
Hydromorphone 7.5 1.5
Oxycodone 20 –
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Perioperative Considerations for Palliative and Terminally Ill Patients 293
If Mrs. Arnold has missed her extended-release morphine dose, then she should
either receive the missed dose or an equipotent dose of another opioid prior to
proceeding to surgery. Depending on her current pain level, an additional dose of
her home oxycodone or an equipotent dose of an IV opioid may also be considered
before surgery.
6 Additional Analgesic Options
Multimodal analgesia is recommended in the perioperative period, which includes
the use of adjuvant medications such as acetaminophen or NSAIDs in addition to
opioids. While long-term use of these medications is often avoided in certain patient
populations, they are generally tolerable for short-term use surrounding surgery.
Furthermore, patients on high doses of opioids at baseline may also benefit from IV
ketamine during and after surgery.
Depending on the timing of the patient’s presentation and their specific serious
illness, interventional pain management procedures may be considered before under-
going surgery. For example, patients with certain abdominal cancers such as pancre-
atic cancer may derive benefit from a celiac plexus block. This procedure may reduce
pre-procedure opioid use, thus assisting in greater postoperative pain control.
7 Risk of Opioid Misuse
Although patients receiving palliative or hospice care have definitive reasons for
experiencing pain, they are still at risk for developing opioid use disorder. Addition-
ally, the issue of diversion of hospice-prescribed opioids is not yet fully researched
[14]. Anesthesiologists may become aware of these issues based on their observa-
tions of a patient’s response to perioperative opioids. For example, if a patient’s pain
is not effectively managed with a calculated opioid dose based on their OME, it may
signal an opioid use disorder. Conversely, if a dose is overly sedating, it may indi-
cate that the patient is not taking the prescribed opioids themselves. Such concerns
should be discussed with the patient’s palliative care doctor for further assessment
and management.
8 Additional Roles for the Anesthesiologist
In addition to providing excellence in pain management, anesthesiologists are poised
to ensure that patients who are terminally ill or receiving palliative care receive goal-
concordant care in the perioperative period. While these patients often discuss their
goals of care and set treatment limitations with other clinicians in various settings,
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294 L. India
the unique nature of the perioperative period requires additional conversations. Such
conversations may include a patient’s preferences on resuscitation, emphasizing the
aspects of the perioperative period that promote successful resuscitation compared
to resuscitation in any other setting.
In addition to resuscitation preferences, anesthesiologists may also verify any
other treatment preferences expressed in a patient’s advance directive, such as a
living will or healthcare power of attorney document. If a patient does not have an
advance directive on file prior to surgery, the anesthesiologist should at least confirm
the designation of a surrogate decision maker, in the event that the patient loses the
capacity for medical decision-making in the postoperative period.
The anesthesiologist’s role in these patients’ care may continue to expand, as more
work is conducted on the optimization of frailty, nutrition, and physical function.
Key Takeaway Points
•
Opioid therapy, including both short- and long-acting formulations, is essential
to managing moderate-to-severe cancer pain.
•
Anesthesiologists must thoroughly understand the patient’s baseline opioid use
to ensure effective perioperative pain control.
•
Thoughtful conversions of oral opioid doses to IV formulations enables improved
intraoperative pain management.
•
Patients who are terminally ill or receiving palliative care are also at risk for
non-physical pain complaints, including spiritual, social, and psychological pain.
These components may arise during the perioperative period, necessitating the
anesthesiologist to address and treat these aspects of pain.
References
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detail/palliative-care. Accessed 20 March 2023.
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erstanding/statistics. Accessed 20 Mar 2023.
3. Miller KD, Nogueira L, Mariotto AB, et al. Cancer treatment and survivorship statistics. CA
Cancer J Clin. 2019;69(5):363–85.
4. van den Beuken-van Everdingen MH, Hochstenbach LM, et al. Update on prevalence of
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