Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada.
Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada.
BMC Palliat Care. 2020 Nov 29;19(1):182. doi: 10.1186/s12904-020-00683-1.
Towards the end of life, use of opioid analgesics becomes more common in patients to control pain and improve quality of life. While pain medication may help manage pain, unwanted cognitive side effects are frequently noted. This balancing act presents a trade-off for patients between pain relief and adverse effects, where the desire to relieve pain must be evaluated against the desire to maintain cognitive clarity and may represent a difficult decision for patients receiving palliative care. Our goal was to understand how patients' decision making about pain medications balances the pain relief from those medications against the cognitive decline often associated with them.
We conducted qualitative semi-structured interviews with patients receiving home-based palliative care from a program in Toronto, Canada. Interview recordings were transcribed and analyzed using thematic analysis.
Thirty-one interviews were conducted. Some patients preferred cognitive preservation over pain management because of a sense that cognition is central to their identity, the desire to maintain lucidity, a desire to continue participating in work or hobbies, and fear of addiction. Conversely, some patients preferred pain management over cognitive preservation because of a desire to avoid suffering, an inability to sleep without medications, or an acceptance of some cognitive compromise. A few patients attempted to find balance through tapering drugs, limiting their use of breakthrough analgesic doses, or using alternative strategies.
Decision making around pain and pain management is a highly preference-sensitive process-with no clear right or wrong decisions, only the preferences of each patient. The findings from this study may influence the design of future patient-facing decision aids around pain management. Future studies should pilot interventions to better assist patients with this decision.
在生命末期，为了控制疼痛和提高生活质量，越来越多的患者开始使用阿片类镇痛药。虽然止痛药物可能有助于控制疼痛，但常常会出现意想不到的认知副作用。对于接受姑息治疗的患者来说，这是一个需要在缓解疼痛和不良反应之间进行权衡的问题，即缓解疼痛的愿望必须与保持认知清晰的愿望相权衡，这可能是患者面临的一个艰难决策。我们的目标是了解患者在决定使用止痛药物时如何在这些药物带来的止痛效果和它们常带来的认知能力下降之间进行平衡。
我们对加拿大多伦多一家姑息治疗项目中接受家庭姑息治疗的患者进行了定性半结构式访谈。采访录音经过转录后，采用主题分析法进行分析。
共进行了 31 次访谈。一些患者更倾向于保留认知能力而不是进行疼痛管理，因为他们认为认知能力是其身份的核心，希望保持清醒，希望继续参与工作或爱好，以及担心成瘾。相反，一些患者更倾向于进行疼痛管理而不是保留认知能力，因为他们渴望避免痛苦，没有药物就无法入睡，或者接受一些认知能力下降。少数患者试图通过逐渐减少药物剂量、限制使用突破性镇痛剂量或使用替代策略来寻找平衡。
围绕疼痛和疼痛管理的决策是一个高度偏好敏感的过程——没有明确的正确或错误的决策，只有每个患者的偏好。这项研究的结果可能会影响未来围绕疼痛管理的面向患者的决策辅助工具的设计。未来的研究应该试点干预措施，以更好地帮助患者做出这一决策。
