Vol. 50 No. 3 September 2015

Journal of Pain and Symptom Management

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Letters

Sudden Death in Palliative Care To the Editor: Lunney et al.1 defined four trajectories of functional decline at the end of life in the elderly by following more than 14,000 people and reporting on the functional status of nearly 5000 deceased people retrospectively from death. These four distinct trajectories were defined: sudden death, cancer, organ failure, and frailty. These trajectories of functional decline seen in four groups leading to death have excellent face validity for the deterioration seen in people with advanced life-limiting illnesses of all ages. In hospice/palliative care, it may be assumed that when a life-limiting illness is identified, patients, caregivers, and health professionals would share a similar understanding of prognosis. One challenge in prognostication is that the identified trajectories related to cancer, organ failure, and frailty can change unexpectedly to shorten lifedsudden death, which is, by definition, unexpected. Although unexpected changes in the trajectory are partly captured in the saw-tooth pattern of chronic exacerbating/remitting diseases of people with organ failure (with death more likely during any one of these exacerbations), sudden death can supervene in any of the outlined trajectories. This highlights the importance of adapting this model (derived retrospectively) to the process of providing information to patients and their families as they ask about their own future (prospectively). Given the value that patients attach to the opportunities that warning of their death allows in terms of spending time with family and having important conversations, anything that limits those encounters is likely to detract from the experience of the person who is dying and the family.2 Sudden death (no organ failure, no time in a skilled nursing facility, and no cancer) was a category in the work by Lunney et al., and, therefore, was distinct by definition from sudden death occurring in frailty, cancer, or end-stage organ failure. These three latter groups of Lunney et al. thus primarily reflect the trajectory of the person’s functional decline related to the natural history of the illness without another process Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

supervening. At a population level, prognosis is likely to be shorter and the trajectory more variable because of a proportion of sudden deaths in the hospice/palliative care population. We report findings from a random, community, faceto-face survey of caregivers for people at the end of life. The survey encompassed 15,148 respondents over a five-year period. The methods have been detailed elsewhere.3 If people had provided day-to-day or intermittent hands-on care for someone close to them at the end of life (n ¼ 877; 5.8% of all respondents) and knew that a hospice/palliative care service was not used (n ¼ 319 of 832; 38.3%; 14 did not know; 31 missing), they were asked why a service had not been engaged. Sixty-three respondents (of 319; 19.7%) indicated that the reason for not engaging with a hospice/palliative care service was because the death was sudden. The only data regarding the deceased were age and diagnosis, for which there were no statistically significant differences between people perceived to have died suddenly and the other deceased. Of note, these data do not pertain to people known to hospice/palliative care services, some of whom also may have been perceived by their caregivers to have died a sudden death. Do we have a definition of sudden death in this setting to complement that of Lunney et al. for use in the other three trajectories (frailty, cancer, and organ failure)? In the work by Lunney et al., it was that the decedent was highly functional within one month of death. In the specific setting of hospice/palliative care, one working definition of sudden death could be death within one week of a functional status (on the Australia-modified Karnofsky Performance Status scale) of 50 or greater.4 This is someone with a reasonable level of function who dies within that subsequent seven days. These would be people whose disease trajectory had deviated from the uncomplicated natural history of the disease outlined previously and, by definition, would not easily be predicted by the clinical team providing care in this setting. Death is an ongoing challenge for health professionals who have been asked to discuss prognosis. Dealing with the overall expected functional and physical decline is a reasonably easy process to 0885-3924/$ - see front matter

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Letters

outline, but consistently introducing the concept of potential pathologies, such as sepsis or thromboembolic disease that can shorten the natural history of the life-limiting illness and lead to sudden death, makes the conversation more difficult. Ultimately, as clinicians, we may not be able to predict sudden death, but we can ensure that patients, caregivers, and members of the clinical team are prepared for this possibility and learn the skills needed to do this with more ease as a standard part of our clinical practice.5 David C. Currow, BMed, MPH, PhD, FRACP Discipline, Palliative and Supportive Services Flinders University Adelaide, South Australia, Australia E-mail: [email protected] Maxwell T. Vergo, MD Palliative Medicine Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire, USA Magnus Ekstrom, MD, PhD Discipline, Palliative and Supportive Services Flinders University Adelaide, South Australia, Australia Clinical Sciences Lund University Lund, Sweden http://dx.doi.org/10.1016/j.jpainsymman.2015.06.009

References 1. Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA 2003;289: 2387e2392. 2. Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284:2476e2482. 3. Burns CM, Abernethy AP, Dal Grande E, Currow DC. Uncovering an invisible network of direct caregivers at the end of life: a population study. Palliat Med 2013;27:608e615. 4. Abernethy AP, Shelby-James T, Fazekas BS, Woods D, Currow DC. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]. BMC Palliat Care 2005;4:7. 5. Walczak A, Henselmans I, Tattersall MH, et al. A qualitative analysis of responses to a question prompt list and prognosis and end-of-life care discussion prompts delivered in a communication support program. Psychooncology 2015;24:287e293.

Topical L-Menthol for Postradiotherapy Neuropathic Pain: A Case Report To the Editor: We report the use of topical L-menthol for postradiotherapy neuropathic pain in a patient with breast cancer.

Vol. 50 No. 3 September 2015

Case A 62-year-old female patient was seen in the Unidad del Dolor del Hospital Universitario Central de Asturias for a distressing pain in the left breast. The pain appeared after local radiotherapy (50 Gy in total followed by a posterior boost of 16 Gy), which was received three months after lumpectomy and sentinel node surgery of a breast in situ ductal carcinoma with neither nodules nor metastases. The patient described the pain as itching, electric shocklike, and pins and needles. It was exacerbated by touch and disrupted her normal life, as she could not even wear underclothes. She said the pain was like a heavy painful weight that increased with normal walking. Although the whole breast was painful, the maximal pain was located in the axillary area. In addition to the breast pain, the patient had other painful symptoms related to a degenerative joint process. At the time of her first visit to the Pain Unit, she had had the breast pain for one year. She was receiving tramadol, oxycodone, desvenlafaxine, trazodone, lorazepam, and local lidocaine 5% patches at night on the breast. On a zero to 10 numerical rating scale (NRS), she reported pain that ranged from 3 in the morning to 7 in the afternoon and even 8 at night. Pain made it difficult to sleep. On initial evaluation, baseline scores on the Spanish versions of the Brief Pain Inventory-Short Form, the neuropathic pain diagnostic questionnaire (Douleur Neuropathique en 4 Questions, DN4), and the Lattinen scale were rather high (Table 1). The Brief Pain Inventory-Short Form measures pain intensity (at its worst, least, and average over the previous 24 hours, and ‘‘pain now’’) and pain interference with daily functions. The DN4 scale is a specific tool for assessing neuropathic pain that includes pain descriptors (burning, painful cold, electric shocks) and associated abnormal sensations (tingling, pins and needles, numbness, itching) and brief bedside tests of hypesthesia or allodynia. The Lattinen scale is a widely used tool for pain assessment in Spanish-speaking countries; it comprises five Likert-type subscales related to pain intensity, pain frequency, analgesic consumption, the level of general daytime activity, and difficulties with nocturnal sleep. Each item is scored from 0 to 4; scores are then summed. A total of 20 points represents the maximal severity. Based on the methodology previously described,1 we selected five points in the affected and contralateral breast (one point corresponded to the axillary area) to measure, in this order, the presence of hypesthesia or hyperalgesia by applying selected von Frey filaments (6.8, 11.8, 20.1, 53.9, 115.2, and 282.7 mN; Stoelting, Wood Dale, IL) in an ascending order, noting the filament where a positive response (sensing

Sudden Death in Palliative Care.

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