IM13.{5,13,17-19} | Cancer Pain and End of Life Care — Summary & Reflection

KEY TAKEAWAYS

Palliative care indications: Stage IV cancer (from diagnosis), uncontrolled symptoms, ECOG PS 3–4, complex psychosocial needs, prognosis ≤12 months. Early integration (Temel 2010) improves quality of life AND survival.

Pain assessment: NRS 0–10 (self-report); BPI (intensity + interference); PAINAD for non-verbal patients; OPQRST dimensions. Pain types: somatic (bone — NSAID + opioid + bisphosphonate), visceral (opioid), neuropathic (gabapentin/amitriptyline + opioid), mixed.

WHO analgesic ladder: Step 1 = non-opioids; Step 2 = weak opioids (tramadol); Step 3 = strong opioids (morphine first-choice). Five principles: by mouth, by the clock, by the ladder, for the individual, with attention to detail. Starting dose: morphine IR 5–10 mg every 4h. Rescue dose = 10–15% total daily opioid. Increase baseline by 25–30% if >3 rescues/24h. Co-prescribe laxative from day 1.

Opioid side effects: constipation (universal, persistent — senna/lactulose); nausea (first 2 weeks — haloperidol/metoclopramide); sedation (48–72h — resolves); respiratory depression (rare in titrated patients — reverse with naloxone 0.04 mg IV increments). Renal failure: switch to fentanyl patch (not renally cleared).

EOLC common symptoms: dyspnoea (opioids + benzodiazepines); delirium/terminal agitation (haloperidol, midazolam); nausea (mechanism-guided); cachexia (dexamethasone for appetite; counsel family on futility of forced feeding); death rattle (glycopyrronium + repositioning).

Ethics and law in India: passive euthanasia lawful (Common Cause 2018); advance directives valid (magistrate countersignature required); active euthanasia illegal (IPC 300/306); DNAR orders legal, require documentation; opioids legal under NDPS Act Rule 14B; palliative sedation legal (doctrine of double effect); patient autonomy in disclosure decisions — patient's expressed preference for truth takes precedence over family protective requests.

REFLECT

Return to Suresh from the opening hook. He has severe, untreated cancer pain from a vertebral metastasis. His family refused morphine because 'people die when they get morphine.' You now know that this is a myth — and you know how to use morphine safely, how to counsel a frightened family, and how to cite the legal framework that supports you. But Suresh is not just a pharmacology problem. He is a man who is terrified and suffering, whose family is watching him suffer and feeling helpless. Think about what you would actually say to Suresh's family in the first few minutes of that conversation — not the clinical content, but the human opening that builds enough trust for them to hear what you have to say about morphine. And reflect on this: why does opiophobia persist in India despite clear guidelines, clear law, and clear evidence? What structural, cultural, and educational changes would be needed to ensure that a patient like Suresh never has to suffer from untreated pain? What will you personally commit to doing differently?