Severe pain can dramatically change the lives of patients and their family members. Patients with many kinds of illness — from chronic to terminal — can turn to palliative care for help. However, misconceptions about the specialty abound on top of low public awareness, even among healthcare professionals. Dr Mona Tareen, Geriatrician/Hospice and Palliative Care Consultant, discusses the importance of palliative care and challenges faced when working with the elderly.
Palliative care in the UAE has grown and I am happy to say that people are beginning to understand the value of a palliative programme, especially when integrated into oncology.
What is palliative care?
It’s an interdisciplinary approach for patients who may have life-limiting illness. It provides an extra layer of support and improves the quality of life and management of symptoms including but not limited to pain. It addresses all domains of care, including psychological, physical and existential.
What is the first step in managing pain in palliative care?
We identify the type of pain, location, patient age, and liver and renal function, as it will impact the medications we use. The approach is The Who ladder for pain. Acetaminophen works in mild osteoarthritis (age limits dose in elderly) and opioids wouldn’t be used for mild arthritis. We have to be careful using anti-inflammatory drugs in renal disease patients. We assess cancer patients’ opioid naive status to avoid using high doses, which cause confusion or sedation.
What challenges are faced with terminal illness?
The biggest challenge is the need for palliative programmes to integrate social workers, nurses and psychologists into the team. I often find that bereavement support on the death of a loved one is lacking. In the US there are bereavement counsellors based on severity, allowing for follow-ups in person and via phone. I also find the culture of not talking about death, which is ultimately inevitable, leads to more suffering as patients don’t wish to discuss prognosis or outcomes. Having a large expat population in the UAE helps plan formalities such as repatriation and burial. Another challenge is that families don’t want opioids for patients who have end-stage cancer and are in pain, insisting only on acetaminophen/non-opioids as they believe it shortens a patient’s lifespan.
What changes do you see in palliative care in the UAE?
It has grown and I am happy to say that people are beginning to understand the value of a palliative programme, especially when integrated into oncology. We now have the option of providing comfort at the end of life and allowing natural death in patients who will not benefit from resuscitation, which was initially developed for patients with heart disease.
What are the modern advances made in palliative care?
The specialty is being studied to the point of matching opioid receptors and which opioid should be used in developing new medications for intractable pain. Many programmes have integrated palliative care into their ICU/end-stage cardiac programmes in the US and it will only be a matter of time before we have an integrated programme in the UAE as the country also has an aging population.
What are the challenges of working with elderly people in pain?
Older adults typically don’t want to admit they have pain and most families are hesitant to start pain medication even with non-opioids. I think the most difficult group are the cognitively impaired, as they are unlikely to recall the pain but may grimace on walking or turning in bed if they have advanced dementia. We have to remember how the body changes with age; changes in liver and renal functions affect the medications prescribe. Geriatricians are better trained for this.