bluuebunny/crossref_metadata_2025 huggingface dataset:
It Takes Two to Tango
Authors: D’Urbano Elena
Published: March 2022

In Buenos Aires, Argentina, there is no support policy to allow Municipal Social Services to collaborate in an integrated manner with health services in order to ensure continuity, quality, and equity in the provision of palliative care. There are no respite resources for family caregivers. Over the course of illness, maladaptive emotions and/or behaviors may appear that hinder a healthy accompaniment for the sick person and will impact family caregivers, who may be affected in the mourning process if they have been unable to respond to what is expected of them. Family claudication involves the abandoning of one’s principles and expectations for self, and it is one of the frequent problems identified in palliative care. It is considered a social emergency and calls the social worker to develop useful intervention strategies to prevent it. This chapter shares a socio-family assessment model that, in addition to identifying risks of claudication, constitutes a therapeutic space.
Australian Palliative Social Work
Authors: Collins Patricia , Greathouse Julie , Myhill Brendan , Gough Lauren
Published: March 2022

Australian palliative social work is dynamic, responding to changing contexts and system challenges. Work in Australia requires an understanding of the history and experience of Aboriginal and Torres Strait Islander Australians, along with the many other cultural groups who have arrived since 1788 to make up Australia’s multicultural community. Palliative care and bereavement service delivery varies across the country, meaning social workers must be flexible and able to adapt in their roles, while assisting patients and their families to navigate systems in their local context. Therapeutic knowledge and interventions underpin the work of palliative social work in Australia; counseling and therapeutic work are often delivered alongside skilled practical resourcing, care planning, and provision.
Social Work and Palliative Care in Brazil
Authors: Lansttai Lena , Menezes Bevilaqua , Andrade Leticia
Published: March 2022

This chapter presents an analysis of palliative care in the Brazilian reality, providing an overview of its evolution from two programs in the 1980s to 191 in the last survey in 2019. Although palliative care services are still insufficient in view of the steadily increasing demand, there have been clear advances in the Unified Health System (Brazilian public health system) and the private sector, both with regard to the implementation of services in different modalities (outpatient clinics, nursing wards, home care, hospices) and regulations at the federal and state level. In view of the undeniable social inequality present in Brazil and the need of an approach that overarches total pain, a concept created by Cicely Saunders, it is important that professionals have a clear understanding of the existence of social pain. In this context, the assessment and actions of social workers, whose professional competence is aimed at this goal, are essential.
Palliative Social Work in Canada
Authors: Cadell Susan , Bosma Harvey
Published: March 2022

Canada is a large and sparsely populated country with two official languages and a history of colonization with the Indigenous peoples who were there before the arrival of settlers from Europe. Healthcare is universal and federally mandated to be provided; however, delivery is determined by each province and territory. Therefore, services vary from one area to another. Palliative care access is not uniformly available throughout the country. Medical assistance in dying (referred to as euthanasia elsewhere and referred to as MAiD in Canada) was legalized in 2016 and also has great variation across provinces and territories. Social workers are involved in various aspects of both palliative care and assisted dying. Social workers have also demonstrated leadership in competencies, education, and research.
Palliative Social Work in Israel
Authors: Samson Tali
Published: March 2022

Israel, a young country continually absorbing immigrants from various cultures, has a unique social structure. Its mosaic of cultures and values—the delicate balance existing between religion and state, processes of progressive legislation, and the central place of family in the life of the individual combined with the principles of autonomy by which the health system operates—presents a variety of challenges. The exclusive contribution of the palliative social workers is reflected through implementation of models for both individual and family assessment, and clinical interventions provided with cultural sensitivity and respect for the family unit as a system. The challenges which also enrich our practice must be dealt with in the absence of specific training for palliative social workers. Expending research and educational programs will positively influence the status of the palliative social worker whose skills are vital to meeting the needs of the rich mosaic of patients and families in Israel.
Culture, Social Determinants of Health, and Palliative Care in the Pacific Basin
Authors: Ka’opua Lana Sue , Scanlan Luana M. Y. , Duhaylongsod Yim Yvonne
Published: March 2022

The salience of cultural diversity in health/death literacy is consistently affirmed in both published literature and practice wisdom. Dying at home is a common desire across diverse cultures. For Pacific Islanders living in the United States diaspora, dying at home may involve return to the place of one’s ancestors and living relations, thus signifying the affirmation of Indigenous identity in completing the arc of one’s life. However, travel to the homeland may be complicated by medical risk and socioeconomic factors. Examples of health/death literacy approaches are described. A patient narrative illustrates how the palliative social worker applied health/death literacy approaches to facilitate a culturally acceptable solution in conflicts arising among an Indigenous Pacific Islander woman, her family, and the interprofessional palliative team. Resources are provided for additional learning and discussion at the nexus of culture, health/death literacy, cancer care disparities, and palliative social work.
Palliative Social Work in Romania
Authors: Anania Petruța , Dégi Csaba László
Published: March 2022

In Romania, palliative social work has gone a long way in the last decade, toward development and clarity. More than 150,000 people per year could benefit from palliative care in Romania if appropriate programs and providers were accessible and affordable. In 2012, only 6% of the need for palliative care was met; by 2018, it grew to 12%. The number of hospice facilities does not meet the needs of patients. Future planning by the Palliative Care Strategic Working Group includes increasing home care for support within the family. The Orthodox church in Romania previously funded little related to hospice and palliative care, but many new ongoing projects are now funded.

While the competencies and the roles of the social worker are clear, palliative care services exist in Romania that do not include social workers on their care teams. The ongoing work to be done includes ensuring a standardization in the way professionals work with patients and families, the inclusion of a palliative care module in the university curricula, and providing continuous supervision and consultation for the palliative social workers.
Palliative Social Work in Singapore
Authors: Peh Cheng Wan , Ng Tzer Wee
Published: March 2022

Palliative social work is a growing specialty in healthcare social work and has seen significant milestones in development and growth in the past 10 years. Palliative social workers in Singapore possess a unique set of clinical skills to guide our work in a multiethnic and multicultural society. These include crucial elements such as leadership, supervision, mentoring, creativity in assessment, and interventions. In our society where family forms the basic unit of care, the assessment and interventions with patients occur within the context of families, including decision-making and truth-telling. In recent years, a lot of effort and focus had been on education and development, as well as enhancing collaboration and learning among social work practitioners across different settings providing palliative care.
Palliative Social Work in the United Kingdom
Authors: Chaddock Becky , Paul Sally , Cullen Anne
Published: March 2022

Palliative social work in the United Kingdom is woven into the fabric of palliative care and the modern hospice movement. UK palliative social workers are employed by various statutory and third-sector organizations. They undertake diverse roles and work with people of all ages. The four UK nations (England, Scotland, Wales, and Northern Ireland) register and regulate professional social workers. Legislation, codes of ethics, and a commitment to an evidence base govern practice. Core tenets include a focus on the wider social system of the person who has a serious or life-limiting condition, social justice, improving/disseminating specialist knowledge and expertise, and promoting a community-based, public health approach to end-of-life care. Palliative social workers use therapeutic skills and creativity to enable individuals and their families to process emotions and make informed decisions. They contribute to professional education and research and increasingly hold leadership positions from which they influence national policy.
The Social Work Role in Pain and Symptom Management
Authors: Cagle John G. , Altilio Terry
Published: March 2022

Providing relief from pain and symptoms is a central component of high-quality palliative care and a priority for patients, families, and providers. Serious illness is too often accompanied by debilitating physical symptoms such as pain, shortness of breath, fatigue, nausea, and agitation. In collaboration with their interprofessional colleagues, palliative social workers are charged with using evidence-informed strategies to identify, understand, and address such symptoms. They also can work with families to improve coping, troubleshoot obstacles to symptom management, and minimize risks of medication misuse. A strong ethical mandate to palliate symptom distress and core values of dignity and worth of the individual can serve as a cornerstone for social workers.
Sexual Expression and Physical Intimacy for Those Challenged with Serious Illness
Authors: Gallo-Silver Les Paul , Weiner Michael O.
Published: March 2022

Sexual expression and physical intimacy may be among the most satisfying parts of a person’s quality of life. Touch as an aspect of comfort, support, and affection is as crucial a human need as food and warmth. The touch continuum describes a progression that begins with the soothing touch enjoyed by infants, advances to more playful touch relished by maturing children, and evolves to the sensual and sexual touch appreciated by adolescents and adults. The centrality of touch in the human experience in all the phases of life demonstrates the importance of sustaining touch during times of illness and disability. The significance of sexual expression and physical intimacy is demonstrated by descriptions of patients and their partners using a counseling paradigm to assist people receiving palliative care who wish for more closeness and romance with their partners. In this way the patients reassert themselves as sexual beings with needs to touch and be touched.
Anticipatory Guidance
Authors: Gasca Stephanie , Schindel Rachel
Published: March 2022

Anticipatory guidance provides education and support related to the emotional, physiological, and behavioral changes in the life trajectory of persons with serious illness. The objective is to empower patients and families, and to enhance coping through education, advance care planning, and assistance with adaptation. Palliative social workers have a unique role in creating a collaborative environment between the patient, family, and the healthcare team to focus on the self-determined and informed goals and values to guide the direction of a care plan and influence the focus of anticipatory guidance. Assisting patients to increase their tolerance of ambiguity is a key foundation of anticipatory guidance as, by definition, this intervention encourages exploration of a range of possible outcomes—some of which may be desired while others are resisted. Anticipatory guidance titrates discussions to patient and family readiness, fosters adaptation, and utilizes the patient’s strengths in their journey of adjusting to serious illness.
Bibliotherapy
Authors: Cincotta Nancy F. , Moore Tracy
Published: March 2022

Bibliotherapy serves as a technique that employs books and other written materials to aid family members and professionals in the understanding and communication of unfamiliar and potentially uncomfortable concepts. This easily accessible tool helps to inform and empower individuals and can enable communication among family members. Bibliotherapy can be used by social workers and other medical professionals working with one or more family members, or independently by families at home. The art and practice of bibliotherapy may vary, but books can be used metaphorically, as psychoeducational tools, as vehicles of communication, for comfort, and to provide consistency and support. In essence, for many, books relevant to the situation at hand can enrich memory making, become part of a family’s armor, an important tool to help ease the burden and provide support during their illness journey and beyond.
Cognitive-Behavioral Therapy in the Palliative Care Setting
Authors: Oltmann Carina
Published: March 2022

Cognitive-behavioral therapy (CBT) is considered one of the most effective psychotherapeutic interventions to treat depression, anxiety, and physical distress in the palliative care setting. Individuals with serious disease face a multitude of stressors and may benefit from CBT with the purpose of alleviating psychological and physical symptoms. This chapter delineates evidence-based multimodal components of CBT and highlights special practice considerations when utilizing this effective form of therapy across different disease sites, cultural groups, and settings. Techniques such as recognition of automatic thoughts, thought stopping, cognitive restructuring, reality testing, behavioral activation, relaxation techniques, and the incorporation of mindfulness and meditation are discussed. Resources for continued practice and training with the purpose of utilizing CBT in the clinical practice setting are provided.
Care Coordination
Authors: Cammy Rebecca , LaTourette Lauren
Published: March 2022

Care coordination provides a framework to deliver quality care to the most complex and high-risk patients while simultaneously controlling resources and cost, particularly at the end of life. Through assessment and exploration of the social determinants of health, social workers can address barriers to shared decision-making; in turn, this boosts healthcare communication with the ultimate goal of improving care and health outcomes. A social work–led care coordination called the Ambulatory Integration of the Medical and Social (AIMS) model is presented through four areas: (1) patient engagement, (2) assessment and care plan development, (3) care coordination, and (4) care as needed. However, care coordination has not traditionally incorporated palliative care assessment and interventions. Models that integrate routine care coordination with palliative care can enhance effective healthcare service delivery. Health social workers have unique expertise to lead teams in implementing and engaging in care coordination activities that provide services and support patients, families, and caregivers.
Crisis Intervention
Authors: Ammon Esther
Published: March 2022

In palliative care, regardless of the setting, it is common for clinicians to encounter patients and families during times of heightened stress or crisis, when normal coping mechanisms may be compromised in the context of serious illness. Crisis intervention (CI) skills are critical to the palliative care clinician, and palliative care social workers are poised to implement them in order to support strengths, enhance resilience, and mitigate trauma. This chapter reviews the history of CI, the uniqueness of precipitating events that occur in palliative care settings, and the literature related to crisis situations in palliative care. It examines whether common CI models are well-suited for palliative care settings as well as ways in which best practice palliative care approaches may differ from existing CI models, highlighting areas for future inquiry.
The Doctor within
Authors: McBee Lucia
Published: March 2022

Integrative approaches to health and healing represent a paradigm shift from expectations of cure to caring and individual choice. This shift, in part, corresponds to an aging population with increasing chronic conditions and pain, conditions that require managing rather than curing. The values and approaches of integrative health, social work, and palliative care overlap and complement each other in a variety of ways. All are holistic, person and family centered, and strength based. In addition, both social work and integrative modalities are inclusive of a multicultural approach. This chapter will present an overview of this synergy; review integrative therapies as a whole; and describe examples of specific modalities and their applications to social work and palliative care.
Building the Complete Father Intervention
Authors: Weiner Michael O. , Gallo-Silver Les Paul
Published: March 2022

Receiving a medical prognosis that is expected to shorten a father’s life to a finite period upends many aspects of family life, including fathering roles and responsibilities, child–parent interactions, and a father’s ability to maintain previous activities. It places tremendously complex pressures on a fragile system to adapt and evolve. Successful fathering relies on balancing a father’s feelings and thoughts in relationship with those of his child(ren). A serious or terminal illness compromises this balance. A process of rebalancing during this mortal time can become the foundation for creating new lasting moments to add to both a father’s life and their child(ren)’s. Using Building the Complete Father, a cognitive-behavioral legacy planning activity, social workers can facilitate fathers to consider who they are as fathers and what they may still wish to be; and what they do as fathers and what they may still desire to do with their children.
Bereavement in the Beginning Phase of Life
Authors: Cincotta Nancy F.
Published: March 2022

This chapter addresses developmental and emotional issues experienced by children and their families in understanding and anticipating the loss of a significant person in their lives and their subsequent grief response. Changes imposed by illness and death create an altered framework which can have a major impact on children’s growth and development. Family memory is introduced as a particular component of the emotional structure shared by family members, part of the emotional adhesive that enables a sacred connection within families, a shared and valued memory bank. Memories are forever a part of the child’s internal knowledge base, and they are greatly influenced by illness and death experiences. Rituals and therapeutic activities which can assist children who have a loved one facing the end of life and those who have experienced a loss are identified.
Practice Considerations: Group Work
Authors: Cincotta Nancy F.
Published: March 2022

Group work, as a therapeutic modality, allows social workers the opportunity to bring individuals in similar situations together to offer each other support and inspiration. Group programs can range in number and age of participants (with distinct benefits to each group size, large or small) and in the situations they are facing. Groups provide forums for information/education, emotional support, and resource sharing. In many cases they can provide a feeling of community that is unequalled. The dynamic nature of group intervention makes them a valued addition to the other types of programming available to adults, adolescents, and children living with life-limiting illnesses.
Medical Crisis Counseling
Authors: Van Gerven Clara
Published: March 2022

Medical crisis counseling (MCC) is a structured, brief intervention created by a social worker aimed at supporting patients and their families as they adjust to and cope with chronic or progressive illness. It is typically delivered in collaboration with a medical team and is focused on the impact of the patient’s medical situation on their lives. MCC takes place with the patient and/or the members of their support system and can take anywhere from one to eight sessions. It focuses on eight key concerns: control, self-image, dependency, stigma, abandonment, anger, isolation, and death. It is ideally initiated at diagnosis, exacerbation, or discharge after hospitalization. MCC aims to mitigate the effects of the illness through the accomplishment of specific goals set by the patient and/or their support system.
Motivational Interviewing
Authors: Nichols Jordan
Published: March 2022

Palliative social workers and interprofessional colleagues join with patients and families to listen to their beliefs, values, and hopes. Linking beliefs and values to goals and a plan of care, and integrating the experience of significant illness, frequently involve working through ambivalence. Motivational interviewing (MI) is a person-centered, evidence-based, guiding intervention to support behavior change. It employs explicit conversational strategies and techniques to identify and resolve ambivalence. MI integrates well with core palliative social work skills. Through reflective listening, summarization, and elicitation, the clinician engages in a collaborative relationship to support patient autonomy. This chapter provides an overview of MI and its potential applications in the practice of palliative care. The theory and core skills are reviewed. Research most relevant to palliative care will be examined as will implications for practice.
Using Psychoeducation to Empower Patients, Their Families, and Care Partners
Authors: Santiago Bessy
Published: March 2022

Psychoeducation is a flexible intervention that allows interdisciplinary providers to be a supportive and helpful presence when individuals and families face serious illness. As more people live longer with chronic and serious illness, friends and family may be required to engage in caregiving over extended periods of time. Social workers can assist individuals and families to adapt to changing family roles and prepare for new roles by utilizing a variety of cognitive and educational tools such as psychoeducation. Psychoeducation can support and empower patients, families, and their care partners to integrate information related to disease management, individual and family adaptation, caregiving techniques, and coping strategies. The overarching goals are to maximize coping, mitigate preventable harms, and ensure that individuals receive care aligned with their wishes.
Structured Problem-Solving Interventions for Patients with Serious Illness and Their Care Partners
Authors: Cammy Rebecca , LaTourette Lauren
Published: March 2022

Problem-solving interventions have been found effective in treatment for patients with depression, chronic illness, and support for care partners. This framework, grounded in principles of cognitive-behavioral therapy, can be used both as a psychotherapeutic approach and in educational skill-building. Palliative social workers integrate biopsychosocial assessment and person-in-environment perspective into their conceptualization of the individual’s presenting issues as they incorporate social problem-solving theory framework and assess problem-solving style and orientation. Interventions such as ADAPT, SSTA, and COPE are tools aimed to increase positive problem orientation, develop internal and external coping resources, and to guide problem-solving. Palliative care patients and their care partners can benefit from the use of problem-solving interventions in an effort to improve quality of life.
Trauma Therapies for Palliative Care Practice
Authors: Brown Chelsea
Published: March 2022

Research and practice around trauma-informed care and trauma therapy have evolved and become more nuanced over time. Though the origins of trauma therapy centered on the veteran population who had been exposed to military combat, researchers and clinicians now understand that trauma happens across patient populations and communities, resulting from a vast array of stressful experiences; these may include intimate partner violence, sexual assault, historical and racial trauma, gun violence, medical illness, and motor vehicle accidents. When treating trauma in the palliative care setting, clinicians consider not only the overall goal of the trauma therapy but also the patient’s energy level, cognitive function, symptom burden, and how this impacts their ability to participate. For patients with serious life-limiting illness, the goal of trauma therapy is often not long-term cure, but rather the immediate palliation of emotional and psychological distress that results from a trauma response in the healthcare setting, or at end of life.
Ethics in Medical Decision-Making
Authors: Borgmeyer Tracy
Published: March 2022

In recent decades, medical decision-making with persons with serious illness has focused on patient-directed treatment. Through informed consent, patients with decision-making capacity choose treatments according to their goals and values. When patients lack decision-making capacity, appointed surrogates or close family members make decision for them, sometimes consulting their written wishes, other times considering their wishes and values. More complex scenarios challenge normative ethical guidance. This chapter explores the stories of patients on a spectrum of decision-making capacity—including those who have a limited understanding of complex medical options but can express a preference or make a choice from among limited options. It presents the perspectives of surrogates and families who encounter barriers in respecting the wishes of patients. Through narrative, we examine situations which challenge clinicians to identify and communicate about limitations, working for resolutions which respect and mediate interests which are often held in tension.
Navigating in Swampy Lowlands
Authors: Browning David M. , Gerbino Susan
Published: March 2022

The authors describe an approach to learning and teaching in palliative care, based on their experience as social work educators, that is rooted in the pedagogy of relational learning. First, they emphasize that education should be immersed in the “swampy lowlands,” where everyday clinical practice occurs. Second, they stress that the learning context should be one in which practitioners can develop practical tools, insights, and ways of thinking in a user-friendly and collaborative manner. Third, they argue that education in palliative care with social workers must be grounded in a humility that recognizes the importance of being comfortable with uncertainty and with not having all the answers. The authors describe several “ingredients” of relational learning that they consider especially important: creating a safe and hospitable place for learning; validating experiential knowledge and already-existing competence; and inviting multiple perspectives while challenging fixed assumptions.
The Evolution of Advanced Certification for Palliative and Hospice Social Workers
Authors: Head Barbara Anderson , Middleton Alyssa A.
Published: March 2022

In 2019, certification as an Advanced Palliative and Hospice Social Worker (APHSW-C) became available for social workers experienced in the specialty who verified their competency by passing a written exam. Content of the exam was based on the results of a nationwide survey of palliative and hospice social workers. The survey results provide a comprehensive, clinically informed outline of the tasks, skills, and knowledge necessary for practice in this field. This outline can also be used to develop curricula, write job descriptions, and describe the role and benefits of having a social worker on the interdisciplinary team. This chapter tracks early efforts to define the role and develop related credentials. The process of developing an evidence-based certification program is outlined as are the benefits to the individual, employers, and the patients and members of their circles of support served.
Professional Self-Care, Resilience, and Well-Being
Authors: Mulkerin Colleen M.
Published: March 2022

Professional self-care, resilience, and well-being are analyzed with attention to the intersection between personal and organizational responsibilities in achieving workplace wellness. This chapter explores approaches aimed at individual well-being in the setting of organizational ethos. The models sampled range from health-oriented perspectives, cognitive approaches, and the review of a trauma framework. The crucial nature of symptom detection and their relationship to secondary trauma, moral distress, and compassion fatigue is discussed. Approaches to cultivate self-reflective practice and mindful self-compassion include micro, mezzo, and macro strategies. The chapter addresses the risk of trauma exposure inherent in practice and the impact when this exposure intersects with challenging work milieus. Burnout and compassion fatigue are distinguished to identify countermeasures to promote professional wellness, compassion satisfaction, meaningful work, resilience, and well-being.
Self-Care Practice Wisdom
Authors: Irish Kerry Cox
Published: March 2022

While palliative social work is often deeply fulfilling, there are costs and risks to this work, including compassion fatigue, secondary traumatic stress, and burnout syndrome. The contributors for the first two typically relate to the toll of witnessing the suffering of others, and they arise because of empathy and engagement, both of which are necessary to offer a true healing presence to those who are suffering, and both of which are also essential to sustaining one’s passion for the work. Given the challenges and risks of palliative social work, it is imperative to be intentional about cultivating resilience and well-being. Research suggests that for those who do, compassion satisfaction and vicarious posttraumatic growth are likely positive outcomes. This chapter explores practices that palliative social workers can use to build resilience and stay engaged, fulfilled, and well in work that can be—at times—demanding, stressful, and sorrowful.
Leadership in Palliative Social Work
Authors: Berkman Cathy , Christ Grace , Shukraft Allison
Published: March 2022

Leadership in palliative social work is a responsibility, opportunity, and privilege. Strong leaders represent, advocate for, and advance social work values and principles. There are opportunities for leadership in palliative care throughout one’s career, at the bedside, in team, at different levels of the healthcare organization, social work profession, and other arenas. Social work leaders can promote equity and cultural humility and create a work environment that promotes social justice. Strong leadership has a synergistic effect, harnessing the strengths of individual team members to create something greater than the sum of the individual efforts, through harmony, creativity, dedication, fulfillment, shared learning, and openness. Leadership involves having a personal and shared vision and a mission, including excellence in patient care. This chapter reviews the different leadership styles, and their strengths and weaknesses, best practices of effective leaders, and the challenges and risks in serving as a leader.
Building a Lasting Legacy
Authors: Otis-Green Shirley
Published: March 2022

A commitment to “transformative professionalism” asks that palliative social workers have the courage to seek excellence in their delivery of care, which is enhanced when one regularly and intentfully reflects upon the impact one is having and the legacy one is creating. Applying the principles of palliative care lays a foundation for the transformation of healthcare. One’s unique integration of leadership, advocacy, research, policy, education, collaboration, resilience, and clinical skills synergistically increases one’s effectiveness as an agent of change. Examples of social work leadership are provided as well as a transformative professionalism toolkit to offer palliative social workers inspiration and guidance as they craft their careers and build their legacy with passion and purpose.
Pain in the Noncommunicative Adult
Authors: Chou Claudia Z.
Published: March 2022

Pain is highly prevalent in patients with dementia and is often due to musculoskeletal, neuropathic, gastrointestinal, and genitourinary etiologies. Impairments in cognition and communication make identification and assessment of pain difficult. Although a number of tools exist, there is no “gold standard” tool for assessment of pain in this population. These patients are at risk for improper assessment of and potential undertreatment of pain. They are also more susceptible to adverse effects from analgesic medication. Proper management often requires input from caregivers and members of a multidisciplinary care team. Frequent reassessment for benefits and side effects is crucial.
Acupuncture for Analgesia
Authors: Cooperstein Noah , Thoma Jonathan
Published: March 2022

The paradigm of allopathic medicine has focused largely on the management of physical pain during end-of-life care. There are, however, multiple dimensions of distress associated with dying. These include the physical sensations of pain, dyspnea, nausea, and anxiety as well as suffering that is psychological, social, or spiritual in nature. With its ability to address the multiple dimensions of pain, acupuncture integrates well with palliative care. While the concepts of acupuncture are pre-scientific in their origins, they are grounded in first-hand human experience and do no rely on mystical or supernatural thinking. Though the evidence is still emerging, it is reasonable to discuss acupuncture with patients receiving palliative care as a viable and safe adjunct therapy for pain and other symptom management.
Scar Deactivation as an Alternative Treatment for Pain Control
Authors: Farrell Jennifer , Schelby Thomas M.
Published: March 2022

Chronic, postsurgical pain (CPSP) is defined as pain that arises after a surgical procedure and that lasts at least 2 months and cannot be attributed to an alternative cause. Epidemiologic studies estimate that between 10% and 30% of patients undergoing surgery report persistent pain 1 year postoperatively. The etiology of CPSP does not have a clearly established or widely accepted pathophysiological cause, and diagnostic workups are often costly and fail to identify an identifiable etiology. CPSP may be treated with analgesics as the first-line therapy; however there are no well-established guidelines on management. In refractory cases, medications targeting neuropathic pain, further surgical evaluation, and acupuncture techniques can be considered.
Selecting an NSAID
Authors: Waldfogel Julie
Published: March 2022

Nonsteroidal anti-inflammatory drugs (NSAIDs) are an important part of multimodal analgesia. Choosing which NSAID to prescribe is determined by three major components: efficacy, adverse effects, and adherence. First, confirm that the pain is expected to respond to NSAIDs. NSAIDs are most useful for nociceptive pain, particularly from an inflammatory source. Where possible, reference the guidelines to evaluate strength of evidence and use their recommendations to guide medication use. Second, minimize risk of adverse effects. Consider COX-2 selective NSAIDs and proton pump inhibitors (PPIs) to minimize risk for gastrointestinal adverse effects. Avoid COX-2 selective agents in patients with a history of or high risk for cardiovascular disease. Consider the potential for drug interactions. And finally, remember the importance of cost, dosing frequency, route, and pill burden in selecting an agent.
Selecting the Antidepressant as an Adjuvant Analgesic
Authors: Cruz and Chris Herndon Tim
Published: March 2022

Depression and pain are common co-occurring conditions that can be devastating for patients and their loved ones, causing a large detriment to the patient’s quality of life. Up to 85% of patients with chronic pain also present with depression. Diagnosis of depression at the end of life can be difficult due to significant overlap of symptoms that are commonly attributed to both. Due to the significant number of medications that can be used for depression, it is important for the palliative clinician to be aware of how to use said medications. While the different drug classes all have additional actions that can be utilized for end-of-life patients, not all of them have utility in chronic pain. Serotonin norepinephrine reuptake inhibitors and tricyclic antidepressants are great options for patients with co-occurring chronic pain and depression.
Selecting the Anticonvulsant as an Adjuvant Analgesic
Authors: Macchi Zachary , Boehr Nathan
Published: March 2022

Patients with malignant brain tumors commonly develop seizures at all stages of disease. In the home hospice setting, choosing the anticonvulsant to control seizures and simultaneously augment pain control requires weighing the patients’ goals of care, medical comorbidities, and concomitant medications. For acute seizure management, benzodiazepines like midazolam and diazepam come in formulations that are easy to use by informal caregivers and avoid the need for intravenous access. The best understood medications for long-term use in more prolonged end-of-life courses include gabapentin and pregabalin, both of which have analgesic and antiepileptic properties. Other antiepileptics like carbamazepine, oxcarbazepine, lacosamide, and valproic acid have also been shown to have analgesic effects and may be options for concurrent seizure and pain control.
Lidocaine as an Analgesic in Palliative Care
Authors: Geiger Jessica , Naidu Dharma
Published: March 2022

Lidocaine was developed as a local anesthetic in 1943, and the earliest report of pain relief was published in 1961. This medication blocks sodium channels, which are part of the pain pathway. This makes lidocaine a useful adjuvant analgesic. Lidocaine infusion can result in decreased pain as well as decreased opioid requirements. Most institutions have adopted dosing that includes a bolus dose of 1–3 mg/kg administered over 10–20 minutes followed by an infusion of 1–2 mg/kg/hr for pain management. Patients can be transitioned from lidocaine to mexiletine if an oral agent is desired because mexiletine has a similar mechanism of action.
Choosing the Opioid
Authors: Krichbaum Michelle , Miransky Neil
Published: March 2022

Opioids work primarily by agonizing mu opioid receptors in the central nervous system (CNS), gastrointestinal tract, and immune cells. This agonism throughout the body accounts for their side-effect profile, including sedation, constipation, endocrine dysfunction, immunosuppression, and respiratory depression that can lead to death. Opioids alleviate a variety of symptoms experienced by patients in the palliative setting including pain, dyspnea, diarrhea, anxiety, and agitation. Sensible opioid selection requires a consideration of a multitude of factors. The quality, type, and timing of the pain or other indications; the drug specifics related to pharmacokinetics, routes of administration, and tolerability of dosing route and schedule; and, finally, patient-specific factors including age, allergies, and current and past medical history all influence drug selection to ensure safe and effective use.
Opioid Side Effects
Authors: Fazio Elise , Moore Dominic
Published: March 2022

Opioids are a powerful tool to manage a variety of symptoms related to advanced illness, such as dyspnea and cancer-related pain. Common side effects seen in 15–25% of patients include drowsiness, sleep disturbance, and sedation. Rare side effects seen in 1–5% of cases include hyperalgesia, opioid-induced neurotoxicity, and overdose. Management of central nervous system side effects include dose reduction, symptomatic management with additional medications, opioid rotation, and cessation of opioid administration. The most severe side effect, overdose, is treated with naloxone. The development of adverse effects from opioids should always guide clinicians to weigh the treatment risks against the expected benefits.
Opioid Tolerance and Hyperalgesia
Authors: DiScala Sandra , Vartan Christine M.
Published: March 2022

Tolerance and hyperalgesia are two potential effects that may occur with opioid use. Distinguishing between them may be difficult since patients present with worsening pain in both cases. Adding to the challenge is that there are no specific diagnostic criteria. While tolerance can be mitigated with an increase in opioid dose, this is not the case with hyperalgesia, where pain worsens with opioid increases. Another distinguishing factor for hyperalgesia is reports of more generalized pain compared to the original condition without any specific incident or reason for the occurrence of allodynia. Management of opioid-induced hyperalgesia can be through opioid dose reduction, tapering, or rotation. Additionally, adjuvant agents may be added to the opioid regimen to assist with this condition as well. These include but are not limited to options such as acetaminophen, clonidine, dexmedetomidine, gabapentinoids, nonsteroidal anti-inflammatory drugs (NSAIDs), N-methyl-D-aspartate (NMDA) receptor antagonists, or steroids.
Treatment of Pain in Palliative Care with Co-Occurring Opioid Use Disorder
Authors: Mullins Amanda
Published: March 2022

Medication-assisted treatment in palliative care is an extremely gray area that requires familiarity with both legal aspects and pharmacokinetic and pharmacodynamic parameters of the agent being used. Additionally, the incidence of substance use disorders in palliative care can be expected to rise given the rate of misuse of opioids in the community, and many providers feel uncomfortable managing pain in individuals with opioid use disorder. This chapter aims to provide the clinician with initial steps when encountering opioid use disorder in the palliative care setting because pain management in these individuals can be extremely challenging. Providers should remember to employ non-opioid pain management strategies but should also not shy away from prescribing opioids if needed.
Radiopharmaceuticals in the Treatment of Pain in Palliative Care
Authors: Uritsky Tanya J. , McMenamin Erin
Published: March 2022

The incidence of neuroendocrine neoplasm (NEN) has been increasing over the past few decades due to improved diagnostic abilities. NENs secrete large amounts of serotonin and polypeptides, resulting in carcinoid syndrome. While surgical resection is the treatment of choice when feasible, somatostatins have been the primary treatment for control of tumor growth and symptoms of hypersecretion. For patients who have progressed on somatostatin analogues, peptide receptor radionuclide therapy (PRRT) may be another option. This chapter discusses the role of PRRT through application to the case of GJ, a 36-year-old who presents with NEN of the small intestine, which is no longer responding to treatment with octreotide long-acting repeatable (LAR) and who may benefit from treatment with the PRRT, 177Lu-dotatate.
Rectal Administration of Analgesics
Authors: Brock Cara , Murray Patti
Published: March 2022

When the oral route is no longer viable, and intravenous or subcutaneous routes are undesirable, the rectal administration of opioids and other analgesics is a viable option for pain management. Rectal anatomy and blood flow allow for the absorption and distribution of opioids via this route. Although the rectum has a smaller surface area, higher pH, and decreased fluid content compared to the upper gastrointestinal tract, rectally administered opioids are absorbed in a similar manner by passive diffusion. Opioids in the form of suppositories, tablets, and oral solutions may all be administered via a stoma or the rectum as an alternate route.
Epidural and Intrathecal Analgesia in Palliative Care
Authors: Nguyen Theodore Pham
Published: March 2022

Neuraxial interventions include the use of external or implanted pumps via the epidural or intrathecal route. Many factors are taken into consideration when evaluating the potential benefits neuraxial analgesia would provide, including the etiology of pain, location of pain, systemic exposure to opioids, comorbidities, ability to tolerate an implant procedure, coagulation status, and psychosocial support available to the patient. Currently, there is evidence to support epidural and intrathecal use of opioids, baclofen, ziconotide, bupivacaine, and clonidine for pain management. However, there are no consensus guidelines or substantial stability data for the use of combination mixtures. Despite the associated costs of procedures and medication refills, neuraxial analgesia may be ideal in patients receiving analgesia benefits limited by systemic medication toxicities and be cost neutral in patients with a prognosis of 6 months or greater.
Chemotherapy-Induced Peripheral Neuropathy
Authors: Caplan Rachel , Brizzi Kate
Published: March 2022

Chemotherapy-induced peripheral neuropathy (CIPN) is a disabling sequelae of numerous chemotherapeutic agents used in the treatment of cancers. When it occurs during treatment, it may lead to early cessation of chemotherapy and thus increased risk of cancer mortality. As a chronic illness, it can have serious effects on independence and quality of life for years after chemotherapy has ended. While the incidence of acute neuropathic pain during treatment can approach 90%, more than half of patients may experience prolonged neuropathy symptoms following cessation of therapy. Prior to attributing neuropathic pain to chemotherapy, clinicians should be vigilant to rule out other common causes. Pharmacologic and nonpharmacologic modalities exist for both the prevention and treatment of CIPN, and judicious monitoring must be conducted.
Pain in Amyotrophic Lateral Sclerosis
Authors: Everett Elyse A. , Brizzi Kate
Published: March 2022

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting the motor neurons. It leads to progressive limb weakness, dysphagia, dysarthria, and respiratory failure. Although ALS is described as a disease of “painless weakness,” more recent literature has revealed that pain is a prevalent part of the disease. Commonly, patients may report pain associated with ALS that can be described as either nociceptive, neuropathic, or spasticity/cramping. A thorough pain assessment in patients with ALS should always be undertaken. While evidence to support their use is largely lacking, anecdotal reports support several nonpharmacologic and pharmacologic treatment options that may be offered.
Uremic Neuropathy
Authors: Pina-Escudero Stefanie
Published: March 2022

Uremic neuropathy is a distal symmetric sensorimotor polyneuropathy that presents in patients with chronic kidney disease as a consequence of severe axonal degeneration in distal nerve trunks with secondary segmental demyelination. Nerve conduction velocity tests show a reduction of motor and sensory-motor unit potential amplitudes. Regarding treatment, in patients who are not receiving dialytic therapy, conservative management of the kidney disease might have a positive impact on uremic neuropathy. Physical therapy may prevent the loss of muscle power and prevent or improve functional loss caused by uremic neuropathy. To address pain and dysesthesias, judicious use of gabapentin and pregabalin is advised to prevent adverse outcomes. In more severe pain or scenarios of concomitant dyspnea, opioids such as fentanyl and methadone could play an important role. The end goals of treatment are to relieve symptoms to a tolerable level that allows acceptable function and quality of life in these patients.