Managing pain in children at the end of life: What the GP should know

Abstract

Managing disease-and procedure-related pain in children is paramount. Chronically ill children, especially those requiring repeated procedures or admissions, experience a significant burden of pain. If poorly managed, it has a negative impact on quality of life and parent-child relationships. [1] This article discusses aspects of pain management relevant to most stages of illness, but focuses on the terminal stage. According to the World Health Organization (WHO), the principles of palliative care are applicable to all children with chronic illnesses from the time of diagnosis. [2] Several studies demonstrate the importance of good pain management-not only for the child, but also for the parents and siblings. [3] Failure to manage terminal pain adequately may have a lasting impact on the family and result in complicated grief. [4] One of the most commonly expressed wishes of families of dying children is that the death is as pain-free as possible. This can be challenging for professionals and family alike. Some patients and families may request a home death, adding challenges that require creative solutions to try to meet this goal. In these situations, the general practitioner, who is often more accessible to the family, may be called upon to provide support. This may be daunting for the generalist, especially if the child has been cared for mainly by paediatricians. Nonetheless, with good forward planning, excellent communication between generalist and specialist, and access to hospice-or homebased care services in the community, this can be achieved, as demonstrated by the case study below. From the outset, however, families must realise that sometimes matters just don't develop according to plan. Short-term hospitalisation may be required to manage some complications, families may not be able to cope, or the impact on younger siblings may be too overwhelming. Admissions to a hospital or hospice may be necessary and should not be regarded as a failure. Case study John Daniels is the 11-year-old son of Mr and Mrs Daniels, a farming family from a rural area in South Africa. John was first diagnosed In managing the terminal phase of any chronic illness, it is useful to understand the natural pattern of progression of the specific underlying condition and plan for possible scenarios based on an understanding of the pathophysiology. Advance care planning may be a useful tool to help parents prepare themselves for any eventuality. [5] General practitioners can acquire the necessary knowledge, drugs and resources to successfully manage most complications and avoid unnecessary stress for themselves and the family.

Análise do conhecimento dos residentes sobre cuidados paliativos em um hospital pediátrico de referência

“…Outro ponto importante a ser considerado no manejo da dor é o impacto negativo que o controle inadequado desse sintoma pode causar nas famílias, como por exemplo, resultar em luto complicado, já que um dos desejos mais comuns dessas famílias é que a morte seja a menos dolorosa possível 18 .…”

“…No entanto, a Organização Mundial da Saúde (OMS), em 2012, reformulou a "escada analgésica" para a população pediátrica 1 . De acordo com as novas diretrizes propostas, o segundo degrau, anteriormente composto por opioides fracos como codeína e tramadol, foi removido e a recomendação atual é o uso de pequenas doses de opioides fortes para o tratamento da dor moderada ou dor leve que não foi resolvida com as medicações utilizadas no primeiro degrau 14,18,19,[21][22][23][24] . Essa mudança é embasada na conclusão de que não há evidências científicas suficientes para recomendar o uso seguro de codeína e tramadol em crianças 14 .…”