Managing an Acute Pain Crisis in a Patient With Advanced Cancer: Title and subTitle Break“This Is as Much of a Crisis as a Code”

Mr X is a 33-year-old man with a 4-year history of metastatic mucinous adenocarcinoma of the appendix. Over the course of his illness, Mr X completed several cycles of chemotherapy and had several percutaneous draining ostomies for small-bowel obstruction due to peritoneal carcinomatosis. His most recent admissions were triggered by protracted nausea and vomiting and recurrent small-bowel obstructions associated with increasing abdominal pain.

In recent months, Mr X's overall care had been managed by his medical oncologist and the anesthesia pain service. In addition, on the admission prior to this, he had been briefly seen by a palliative care physician. His wife reported that he had been “close to death” on several previous admissions. Mr X and his family were aware of the extent of his disease but wanted aggressive life-prolonging treatment to continue, including cardiopulmonary resuscitation. Mr X's baseline chronic abdominal pain had nociceptive, visceral, and neuropathic features and had been difficult to manage. After a variety of opioid trials, he had finally obtained some analgesia on escalating doses of intravenous (IV) methadone. His methadone dose at home after his last admission was 800 mg over 24 hours (200 mg IV every 6 hours), with his wife administering each 200-mg dose over a 20- to 30-minute period. A visiting nurse service and a home care infusion company oversaw his methadone administration.

One day before his final hospital admission, Mr X underwent a celiac plexus block in an attempt to improve his pain relief and decrease his opioid requirements. Two hours later he developed fever and severe abdominal pain, self-rated as “15 out of 10” on a 0-to-10 scale. The patient's unrelieved pain and the visiting nurse's concern that the methadone regimen was contraindicated because of the finding of a QTc prolongation on an electrocardiogram with the consequent potential for an arrhythmia led to the decision to bring the patient back to the hospital.

Upon his arrival at the hospital, the patient's temperature was 40.0°C, his blood pressure was 98/40 mm Hg, his heart rate was 116/min, and his respiratory rate was 34/min. When examined by Dr P, the attending physician on the medicine team, he was sitting up in bed in acute distress. He was cachectic and jaundiced and complained of severe abdominal pain. His abdominal examination revealed diffuse tenderness to palpation with rebound and guarding. There was pus draining through the skin sites of previous percutaneous draining ostomies.

The initial impression was that Mr X was in an acute pain crisis superimposed on chronic abdominal pain. The pain exacerbation was thought to be associated with acute peritonitis or bowel perforation due to the progressive metastatic disease or the recent celiac plexus block. The main priority of the medical team was pain crisis management and reestablishing the goals of care in the setting of the rapid worsening of the patient's condition. Despite the severity of his pain, Mr X was alert and oriented with clear capacity to engage in decision making about his care.

The medical team, in consultation with the anesthesia pain service, decided to transfer Mr X to the intensive care unit (ICU) because of plans to control his pain with high-dose IV opioids and ketamine. This would require a level of observation and monitoring not available on a medical ward. Mr X's electrocardiogram again showed a prolonged QTc interval. Because of the possibility that this was associated with the high dose of parenteral methadone, the decision was made to discontinue the methadone and rotate to IV hydromorphone. Hydromorphone infusion was titrated from 30 mg/h to 80 mg/h with IV boluses of 80 mg every 10 minutes over the early morning hours without any improvement in his pain. He was also given a racemic ketamine infusion titrated up to 7 mg/h. After almost 5 g of hydromorphone in a 10- to 12-hour period, the patient reported no improvement in pain.

Dr S, the palliative care consultant, met with the family and discussed the risks of restarting IV methadone despite QTc interval prolongation. Mr X and his wife acknowledged that he was dying, requested use of any medications necessary to stop his pain, and declined further life-prolonging measures such as cardiopulmonary resuscitation. Pain relief, other symptom control, and facilitating the opportunity for him to say good-bye to family and friends became the focus of his care. The immediate goal was to manage the acute pain crisis as quickly as possible. The hydromorphone was discontinued and the methadone was restarted with IV boluses of 40 mg every 15 minutes until pain relief was obtained. It had taken almost 12 hours to reduce his pain from 15 to 2 on a scale of 0 to 10. Within several hours, a total dose of 1.59 g of methadone was administered, and Mr X reported minimal and adequately controlled pain of 2 on a 0-to-10 scale. His mental status remained intact. His wife stayed with him throughout. During this period, the ICU staff created a private environment for Mr X and his family, as homelike as possible, in which all of the monitoring necessary to manage his pain and other symptoms was available. As he became more comfortable, his methadone dose was stabilized, and Mr X made telephone calls to say good-bye to family and friends.

Over the ensuing hours, his pain again started to escalate and the doses of IV methadone were titrated up. Eventually, he became sedated without evidence of distress, but he developed myoclonic jerks. He was given a 60-mg dose of dantrolene intravenously and the myoclonus resolved. Approximately 36 hours after admission, Mr X died peacefully. His wife, their 2 dogs, and several family members and friends were present.

Dr P and Dr S were interviewed by a Perspectives editor in January 2005.

DR P: I think as a primary medical team, we were becoming uncomfortable with the dosage and the amount of pain medication the patient was requiring . . . 

DR S: The patient looked ashen and stressed. He was just holding his belly and he looked incredibly uncomfortable. He was sweating and basically telling us that he really, really wanted us to do whatever it took to get his pain under control.

The assessment and management of an acute pain crisis in the setting of advanced illness are challenging.^{1 - 2} Using Mr X's case, we outline a management strategy that focuses on (1) making a pain diagnosis, differentiating reversible from intractable causes of pain and making decisions about further workup, (2) selecting the opioid and monitoring and treating adverse opioid effects, (3) titrating and rotating opioids and coanalgesics, (4) consulting experts to treat a pain crisis as quickly as possible to prevent unnecessary suffering, and (5) identifying and co-opting the available institutional resources.

We define a pain crisis as an event in which the patient reports severe, uncontrolled pain that is causing the patient, family, or both severe distress. The pain may be acute in onset or may have progressed gradually to an intolerable threshold (as determined by the patient), but requires immediate intervention. National Comprehensive Cancer Network pain management guidelines identify a pain emergency as an event in which patients have severe pain (a numerical estimate of at least 7 on a 10-point scale) that requires rapid opioid titration to provide analgesia.³ There are no epidemiological data to suggest how commonly pain crises occur. Our own experience at Memorial Sloan-Kettering Cancer Center suggests that of about 120 inpatient consultations a month, our Pain and Palliative Care Service is called for what is identified as a pain crisis by the referring physician as frequently as 20 to 30 times a month—the message usually conveyed is that the patient needs to be seen “right now.” The treatment plan starts with a rapid clinical assessment, titration of analgesics, and direct supervision by a physician/nurse team. When the medications or doses are not familiar to the clinician providing direct patient care, appropriate experts and resources should be consulted to help outline a plan of care; guide medication titration; monitor the outcomes; and provide support to staff, patient, and family.^{3 - 5}

DR S (THEPALLIATIVECARECONSULTANT): The first thing was to understand what happened. Why was he saying that his pain was worse than it had ever been before? . . . I explained to them [patient and family] that something potentially catastrophic had happened since the celiac plexus block, and it might be a perforation. He very well might be dying of that, and then there was the severe pain we had to deal with.

A thorough assessment of a pain crisis is just like the evaluation of any other medical emergency. The basic pain assessment principles are outlined in Box 1.⁶ Pain intensity, pain relief, and adverse effects of the therapy should be monitored and recorded until the resolution of the pain crisis. Based on Mr X's description of severe abdominal pain and the associated fever, which started approximately 2 hours after receiving a celiac plexus block, bacterial peritonitis caused by perforation of an underlying malignant bowel obstruction was considered to be a likely contributing cause of his pain crisis. High fever and hypotension due to bacterial peritonitis can be a terminal event in a patient with advanced peritoneal carcinomatosis.

^aAdapted from Foley.⁶

In assessing both the pain experience and patients' desired goals of care, clinicians should use a communication approach that allows patients to lead the discussion, beginning with their understanding of the nature of the pain, its meaning to them, and how they prioritize its management in establishing treatment goals.^{7 - 8} Patients can often distinguish pain from their experience of suffering, which frequently stems from their multiple concerns about being a burden to their loved ones, fear of dying, and concerns about their family.⁹ Anxiety, depression, existential distress, and delirium are common psychological symptoms that can occur in a patient with severe cancer pain and need to be addressed.¹⁰

To assess Mr X's pain, it was essential to establish a clear description of its onset, localization, pattern of referral, exacerbating and relieving factors, and relationship to the recent procedure and changes to his analgesic regimen (Box 1).⁶ Pain and symptom assessment tools that could be used to define and quantify pain include the Brief Pain Inventory,¹¹ the McGill Pain Questionnaire,¹² the Visual Analog Scale for the Management of Acute Pain,¹³ the Edmonton Symptom Assessment Scale,¹⁴ the Memorial Symptom Assessment Scale,¹⁵ and the Memorial Pain Assessment Card (MPAC).¹⁶ Of these, the MPAC (Figure) provides a validated method for rapid assessment of the patient; evaluation of the patient's pain intensity; and degree of relief, mood, and pain descriptors and takes only 15 seconds to complete, allowing for frequent repeated use.¹⁶ Studies using the MPAC have demonstrated that the perception of pain intensity contributes significantly to subjective distress, but the perception of inadequate pain relief was the more important factor. In Mr X's case, a numeric scale provided a useful outcome measure for the treating team, who observed the correlation of the scale representing decreased pain with the patient's appearance of improved comfort and pain relief.

This patient's pain was thought to be mixed nociceptive, visceral, and neuropathic with inflammatory components. This pain diagnosis was based on his previous pain history, his radiological studies consistent with malignant bowel obstruction, his ascites, his multiple draining infected ostomies, and the high likelihood of perineural tumor infiltration. These pain mechanisms can be inferred from animal and human studies of malignant bowel obstruction and tumor infiltration of the viscera.^{17 - 18}

Mr X presented as a medical emergency with severe intolerable pain as his major symptom. Rapid assessment of his medical status was necessary to establish a correct diagnosis and develop a treatment plan. Although this patient refused further diagnostic studies, a flat plate of the abdomen to assess for free air and bowel dilatation or a computed tomography scan to confirm bowel perforation to assess the severity of bowel obstruction may be appropriate diagnostic studies in this situation.¹⁹ Broad-spectrum antibiotics were a reasonable treatment option for one aspect of his pain exacerbation. The extent of the diagnostic workup to be done depends on the clinical situation (reversible crisis vs anticipated worsening of a progressive disease that led to the crisis), the goals of care, the patient's wishes, and the risk-benefit burden ratio of any diagnostic test considered. Clear documentation should specify the plan and rationale for the workup, congruent with the goals of care and options considered. This is particularly important if a decision regarding further workup and or management is focused on providing the patient with comfort.⁷ In a patient close to death, no further diagnostic studies should be ordered and “routine” orders should be rewritten to focus on patient comfort.

Congruent to the goals of care, rapid titration of the analgesias with close monitoring of the patient for pain and adverse effects is paramount. The main principles of opioid selection are outlined in Box 2. Opioids should be titrated aggressively (Box 3, Table 1, and Table 2). Nonopioids such as IV ketorolac or corticosteroids to address the inflammatory components of pain may be combined with opioids (Table 3).^{34 - 36} Spinal analgesia may be advantageous because of the lower opioid dose needed, along with the possibility of using a local anesthetic.

Group 1. Patients Who Have Inadequate Pain Relief and No Significant Opioid Adverse Effects

Group 2. Patients Who Have Significant Opioid Adverse Effects

In Mr X's case, the medical team in consultation with anesthesia and palliative care services developed a treatment strategy that reflected an end-of-life care pathway addressing the patient's physical, psychological, social, and spiritual needs with the needs of his family.^{37 - 38}

DR S: I feel that this is as much of a crisis as a code, and we have to be there by the bedside, supporting the primary team.

A rapid response to a pain crisis is essential for patients both with early stage disease and those at the end of life. Failure to adequately manage a pain crisis early in the disease course encumbers both the patient and family with the fear that escalating pain and lack of effective treatment will dominate their final days of life.

In cases of intractable pain refractory to rapid and expert interventions such as opioid escalation or rotation, use of coanalgesics, and anesthetic approaches, clinicians can consider sedation as a temporary measure while other pain relief measures are being explored. It is helpful to ask the patient (with the family present) if it is acceptable to be sedated if that is the only way to achieve adequate pain control. For some patients, sedation may be the treatment of choice. The use of sedation in the imminently dying has been previously reviewed.^{39 - 40}

DR S: I was giving her [Mrs X] that bad news and also explaining that if we gave him the pain medication he needed, he would probably go into a deep sleep and not wake up.

Principles of Opioid Selection. In a patient who has not been exposed to opioids in the past (opioid naïve), morphine is generally considered the standard starting drug of choice (Box 2).^{41 - 42} Morphine should be avoided or used with caution in patients with renal disease and hepatic insufficiency. Quiz Ref ID Morphine-6-glucoronide, an active metabolite of morphine, contributes to analgesia and may worsen adverse effects as it accumulates in patients with renal insufficiency.^{43 - 44} Morphine-3-glucuronide, a nonactive metabolite, produces neuroexcitatory effects and the accumulation of both of these metabolites is associated with confusion, sedation, and myoclonus.⁴⁵ For patients with hepatic or renal insufficiency, an opioid with a short half-life such as hydromorphone or fentanyl are appropriate choices.

Methadone has been found to provide effective analgesia for patients whose pain is uncontrolled with other opioids.^{46 - 49} In using methadone, the clinician must be aware that the half-life of the drug is highly variable, ranging from 17 to 50 hours up to 190 hours in some patients with cancer.^{46 ,48} More importantly, if switching to methadone, the equianalgesic ratio dose depends on the patient's degree of tolerance to the previous opioid and can also vary over 10-fold (see Table 2).^{25 - 28} The significant reduction in opioid doses when switching is thought also to be related, in part, to d-methadone being a noncompetitive antagonist at the N-methyl D-aspartate (NMDA) receptor.⁴⁹ The NMDA receptor antagonists are analgesic in neuropathic pain and have been shown to block the development of opioid tolerance.⁴⁹ In addition, methadone inhibits the uptake of serotonin and norepinephrine.⁵⁰ Therefore, methadone should be used with caution and consultation with a palliative care or pain consultation team is recommended.

Opioid Route.Table 1 provides equianalgesic guidelines for commonly used opioid drugs to be converted from the oral or transdermal route of administration to IV or from one opioid to another.⁴

Dose Escalation.Quiz Ref IDOnce an appropriate opioid has been selected, the dose should be rapidly titrated until the patient has relief of pain or excessive adverse effects develop (Box 3). Based on the pharmacokinetics of the specific opioids and current best practice identified in both the National Comprehensive Cancer Network Cancer Pain Guidelines³ and the American Pain Society Guidelines,⁴ parenteral opioids are usually administered to the patient every 15 minutes as needed. This time interval is based on the approximate time to analgesic effect with IV opioid administration.

To achieve adequate analgesia in opioid-tolerant patients, it is recommended that the IV dose be incrementally increased by 50% (Box 3). Because the analgesic effect is a logarithmic function of the dose of the opioid, a doubling of the dose in an opioid-tolerant patient may be needed.

Opioid Rotation. For patients unable to tolerate escalation of their current opioid dose because of adverse effects, an alternate opioid should be considered (opioid rotation; Box 3). Studies involving patients with cancer demonstrate wide interindividual variations in analgesic response and adverse effects, and thus it may require a trial of 2 or 3 opioid drugs to obtain effective analgesia with tolerable adverse effects.⁵¹ Tolerance to one opioid does not necessarily lead to complete tolerance to another (Table 2).^{25 - 28} This phenomena of incomplete cross-tolerance, as evidenced by improved pain relief or a reduction in adverse effects following opioid rotation, is thought to be related, in part, to a range of interindividual pharmacogenetic factors including genetic polymorphisms in the morphine gene and in drug metabolism.^{52 - 54}

When rotating from a short half-life opioid such as hydromorphone or fentanyl to another opioid, calculate the equianalgesic dose and estimate the safe starting dose (Table 1 and Table 2).^{20 - 25 ,27 ,55} In patients who have adequate analgesia on their current opioid dose but intolerable or unmanageable adverse effects, reduce the calculated equianalgesic dose by 25% to 50% or up to 90% in case of methadone (Box 3 and Table 2).

Opioid Adverse Effects. Nausea and vomiting, sedation, delirium, respiratory depression, constipation, multifocal myoclonus, and seizures are known adverse effects of opioid drugs (Table 4).^{1 ,56 ,63 ,68} Quiz Ref ID Tolerance develops to some of these adverse effects, although at varying rates. For example, tolerance may develop to nausea and vomiting, respiratory depression, and sedation but does not develop to constipation. Each adverse effect requires a careful assessment and treatment strategy.^{57 - 62 ,64 - 68}

Adjuvant coanalgesic medications should be considered early in pain crisis management (Table 3).⁶⁹ Quiz Ref ID The term adjuvant is used to describe different drugs and classes of drugs that may enhance the effects of opioids or nonsteroidal anti-inflammatory drugs.²⁹ Adjuvants exert independent analgesic activity in certain circumstances or counteract the adverse effects of analgesics.^{3 ,5} Introducing adjuvant coanalgesic agents concurrently with opioid titration is recommended based on the inferred mechanism of the pain crisis and their known effectiveness in these situations. Table 3 lists some of the adjuvant coanalgesic medications that can be administered through an IV when managing a pain crisis.^{29 - 34 ,70}

For Mr X, the anesthesia pain service recommended ketamine based on its reported efficacy in neuropathic and cancer pain.^{30 - 31} Ketamine, an NMDA antagonist and an anesthetic that does not interfere with respiratory drive, has been shown to be a potent analgesic in low doses.⁷¹ Multiple case series and small prospective studies using a double-blind, placebo-controlled approach suggest that very low-dose ketamine may potentiate opioid analgesia and reduce pain.^{30 - 32 ,34} The use of ketamine may not only provide greatly improved pain relief but also allow for significant decreases in the dose of current analgesics and sedatives. Some reports suggest that it is useful in visceral pain as well as neuropathic pain.

Ketamine should be started at a low dose of 0.02 to 0.05 mg/kg per hour by continuous IV infusion and rapidly titrated upward as needed, escalating the dose by up to 100% every 4 to 6 hours, depending on the pain intensity and adverse effect profile. In our experience, this dosing regimen is both safe and well-tolerated. Cognitive adverse effects have occurred infrequently at these doses. Because of the severity of his pain, Mr X eventually received 7 mg/h of IV ketamine, and because he was in a closely monitored setting, his dose could have been titrated upward even further in an attempt to increase his pain relief, had he desired, to allow for a decrease in his methadone requirements. However, at doses of 10 to 20 mg/h, 30% to 50% of patients are reported to develop drowsiness, nightmares, and hallucinations.⁷² Due to few published data, a Cochrane review concluded that the role of ketamine is not yet established.³³ To develop evidence-based guidelines for cancer patients, additional studies are needed.

Dr S: I told him that if he wanted us to get the pain under control and if the only way that we could do this was with IV methadone, then we thought that it did not make sense to follow his QT interval, or get EKGs, and we should just put that aside. He said he completely agreed, and his wife said she also agreed . . . 

Prior to this admission, methadone was the only opioid that was effective in at least partially controlling Mr X's pain. He had received 800 mg of parenteral methadone in the 24-hour period prior to his admission to the hospital in a pain crisis. Based on published pain practice guidelines,^{3 - 4} a bolus dose of 80 to 160 mg (10% to 20% of the 24-hour dose) of methadone should be repeated every 15 minutes until the patient experiences pain relief or dose-limiting toxicity. Because of the prolonged QTc interval, Mr X was rotated to parenteral hydromorphone and obtained no relief despite using 80 mg of hydromorphone per IV with boluses of 80 mg every 10 minutes. After reestablishing the goals of care and declining life-prolonging therapy, methadone was restarted and titrated up to analgesia over the next few hours.

This clinical predicament raises several questions:

The relationship between methadone and QTc prolongation is well described.^{73 - 79} Drug-induced long QT syndrome is characterized by a prolonged corrected QT interval (QTc) and increased risk of a polymorphic ventricular tachycardia, also known as torsades de pointes. Published studies suggest that QT prolongation is context-dependent and occurs more frequently with high doses of methadone, concomitant administration of CYP3A4 inhibitors such as erythromycin, dicumarol, and other drugs (which can inhibit the biotransformation of methadone), hypokalemia, hepatic failure, and administration of other QT-prolonging agents such as chlorobutanol, the preservative in parenteral methadone preparations.⁸⁰ Clearly, the benefit of methadone in the individual patient needs to be weighed against the potential for risk of arrhythmia. Each of the associated factors that could contribute to methadone toxicity need to be evaluated in patients with a history of significant QTc prolongation.

In Mr X, electrolyte correction and the use of preservative-free methadone would have been one approach to consider to reduce risk and to allow continuation of methadone.⁷⁵ Despite the potential risk and consequences of torsades de pointes, his goals of care and lack of pain control with other agents favored continuation of parenteral methadone.

Abrupt discontinuation of methadone has been reported to cause pain escalation in 12 of 13 patients who were receiving methadone as a third- or fourth-line opioid, despite titration of the alternative opioid to the highest tolerated dose.⁸¹ If rotation from high-dose methadone to an alternate opioid is necessary, frequent monitoring of the patient for pain escalation, withdrawal symptoms, or oversedation is essential. A step-wise approach is recommended, decreasing the methadone dose by one-third daily while adding the new opioid in equianalgesic doses. This approach helps to prevent symptoms of withdrawal from methadone as well as adverse effects from rapid up-titration of the alternate opioid. Mr X received almost 5 g of hydromorphone without evidence of analgesia or adverse effects, so it could have been further escalated. Practically speaking, using 80-mg boluses of a drug that comes in 2-mg and 10-mg vials is onerous for pharmacists to prepare, and often there are limited supplies available.

Any rotation to methadone requires frequent monitoring of the patient for undertreatment, withdrawal symptoms, or oversedation. Methadone is a unique opioid and an increasing number of case reports describe improved pain relief after rotation to methadone.^{25 - 28 ,82 - 83} Patients rotated to parenteral methadone may have incomplete cross-tolerance. The ratio for calculating the safe initial continuous infusion methadone dose can be much lower than the published single-dose equianalgesic dose ratios (Table 2).^{25 - 26 ,84 - 85}

Methadone, therefore, should be used with caution, and consultation with a palliative care or pain consultation team is recommended.

DR P: One of the pearls of wisdom that we talked about as a team the next day is that in situations at the end of life, it's really important to get people involved just as if someone was having a heart attack. In that case, you would call a cardiologist. If someone had a dropped lung, you would call a surgeon. In a similar way, you have to treat someone who is terminal, meaning death being imminent, as almost a code, in the sense that you have to get the people involved who can best provide care at that point.

Mr X presented a particular challenge because the dose of parenteral opioids that he was receiving was clearly beyond the house officer's experience and the house officer needed expert consultation. This case illustrates the critical need for a clinical pathway for an acute pain crisis and other symptom management in a dying patient.^{86 - 87} Such institutional guidelines are important for resource allocation both of staff time and ICU bed allocation, enabling continuous monitoring of the high-dose opioid and ketamine infusions. Such guidelines for management of an acute pain crisis frame a standard of care, informing both the patient and the health care professionals of a recommended approach, and help to distinguish the appropriate use of rapidly escalating high-dose opioids and other agents in a dying patient from inappropriate strategies of euthanasia and physician-assisted suicide (illegal in all states except Oregon).^{88 - 90} The Supreme Court decision on physician-assisted suicide endorses aggressive palliative care, even to the point of sedation, in the imminently dying and distinguishes it from physician-assisted suicide.^{88 ,91 - 93}

Quiz Ref ID The house officer's intent in rapidly titrating Mr X's opioid dose was to reduce his pain and to improve his quality of life, albeit recognizing that this approach could potentially hasten the patient's death.⁹⁴ Yet 2 studies involving terminally ill cancer patients receiving palliative care found no difference in the time to death when comparing patients sedated to control refractory symptoms with patients who were not sedated.^{86 ,91} A study of survival following withdrawal of life-sustaining measures in ICU patients who were dying observed that the patients receiving morphine lived longer than those who did not.⁹² Data from the National Hospice Outcomes Project found opioid dosing to be associated with the time of death but it was only a minor factor in the variation in survival.⁹³ Despite these data, health care professionals commonly have concerns about their role in hastening a patient's death.^{94 - 95} These concerns can be addressed by institutions in the form of guidelines or pathways that make transparent the indications for opioid titration and symptom outcome end points (eg, evidence of patient comfort) that allow for clear documentation of goals of treatment.

DR P: The day after he [Mr X] passed away, the resident, the medical student, the interns, and I got together, and we spent almost an hour debriefing about the experience. It was an experience that I hope was as helpful for them as it was for me. We talked about the medical aspects and what we learned. We talked about pain management and what we learned from our consulting services. We really spent a lot of time just talking about death and dying, communication at that stage, and what it was like to go home after an experience like that and to talk to our significant others.

The palliative care consultation team became actively involved with the patient when his goals of care changed to comfort care and when he was identified as dying. The standpoint that a palliative care team should only become “really involved” if the patients has a “no code” status is contrary to the current concept of palliative care for which the goal is to move palliative care upstream as part of comprehensive care. Although discussion of the management of this case has been focused on the medical management of the pain crisis, holistic care of the patient and the family needs the expertise of the other team members providing psychological support and behavioral approaches as well as spiritual care.^{2 ,96 - 98} Most of palliative care in oncology is provided by oncological teams. Routine comprehensive symptom assessment and management may help identify the areas for which palliative care specialists may provide direct care to the patient; support the primary service; or facilitate communications between the patient, caregivers, and medical team.^{96 ,98 - 101} Institutional guidelines can provide structure for routine palliative care assessment to identify and address unmet palliative care needs and to transition patients to hospice care.