Position Paper on Pain Management During End-of-Life Care

side effects occur (Strassels, 2014). Several factors influ- ence the selection of pharmacologic agents: the source of the child’s or adolescent’s pain, the ability to take oral medications, and other toxicities that could be exacer- bated by a specific medication. Pain management should be individualized according to the patient’s age and pre- vious experience with pain and analgesics (Duffy et al., 2019). For children or adolescents who have severe can- cer-related pain, the use of long-acting preparations, along with short-acting medications for breakthrough pain, is recommended (Morgan & Anghelescu, 2020). A common fear associated with escalated doses of opioids is that drug abuse or addiction will follow. Chil- dren and adolescents who are treated for terminal pain may build up a tolerance to the opioids they are receiv- ing and require higher doses to maintain adequate pain control. This dose tolerance is a pharmacological effect of pain management (Snaman et al., 2016). Effective pain management for the child or adolescent dying of can- cer may require aggressive dosing and sometimes rapid escalation of opioids. Unintended side effects, such as respiratory depression, and increasing dose toler- ance should not limit the use of opioids in the effort to relieve pain. If these measures do not alleviate the pain, alternative interventional techniques such as central or peripheral nerve blocks, continuous ketamine infusions, or palliative sedation therapy should be considered (Snaman et al., 2016). Adjuvant Therapies Adjuvant therapies are an essential component of multi- modal pain management; they enhance analgesic effects and assist in optimizing doses of opioids (White, 2017). Adjuvant therapies are typically prescribed in the setting of an interdisciplinary team composed of oncologists, palliative care providers, and advanced practice nurses. The choice of adjuvant should be guided by the under- lying pathology of the pain source (Snaman et al., 2016). Examples of adjuvant therapies are steroids (dexameth- asone), anticonvulsants (gabapentin, lorazepam), tricyclic antidepressants (amitriptyline), and such pharmaco- logic agents as ketamine and lidocaine. Some adjuvant therapies have a sedative effect and should be titrated carefully. Nonpharmacologic Therapies The Centers for Disease Control and Prevention recom- mends a holistic approach to pain management for chil- dren and adolescents with cancer, one that includes nonpharmacologic strategies (Brown et al., 2017). When used in combination with pharmacologic approaches, nonpharmacologic interventions can help children and

adolescents gain a sense of control over their pain and may reduce the need for medications (Snaman et al., 2016 ). Common nonpharmacologic interventions are mindfulness techniques, hypnosis, yoga, and acupunc- ture. All members of the interdisciplinary team (includ- ing nurses) should have a basic knowledge of common interventions and delivery methods and their clinical implications, so that they can provide patients and fam- ilies with a holistic pain management plan (Jong et al., 2020). Nurses should encourage open communication with families about their goals and desires for nonphar- macologic therapies. 4. The use of aggressive pharmacologic and non- pharmacologic interventions to achieve adequate pain control for children and adolescents dying of cancer is strongly supported by established ethi- cal principles. As the child or adolescent approaches the end of life, the goals of care shift from prolonging life to controlling pain and easing suffering. In these cases, the administration of necessary doses of analgesics to control pain is deemed appropriate, regardless of the possible consequence of increased respiratory depression. This principle of dou- ble effect permits the potential deleterious secondary side effect (respiratory depression) in cases where the intended result (pain control) is beneficial and is sincerely intended. Professional, religious, and bioethical organizations support the application of this principle to pain manage- ment at the end of life. In its Code of Ethics for Nurses, the American Nurses Association (2015) states that “The nurse should provide interventions to relieve pain and other symptoms in the dying patient consistent with pal- liative care practice standards and may not act with the sole intent to end life.” Both the United States Conference of Catholic Bishops (2018) and the Hastings Center (Ber- linger et al., 2013) endorse the optimization of pain man- agement through the aggressive use of medications, even though such use may shorten the patient’s life. 5. The pediatric oncology nurse’s role in caring for children with pain at the end of life includes assessment, planning, implementation, and evaluation. This role for nurses is articulated in Scope and Standards of Pediatric Hematology/Oncology Nursing Practice (APHON, 2014). By virtue of their direct patient care roles and frequent contact with patients (and their families) at the end of life, registered nurses and advanced prac- tice nurses are especially well positioned to identify pain. It is essential that the nurse collaborate with the child or