Fosamax wouldn’t be indicated as this patient is terminal. On occasion radiation can be used to reduce pain in terminal patients, but sometimes just the act of getting them to a cancer center to do the treatment is too painful and cruel.
I’ve patients similar to this one at present, and I manage their pain. Long-acting morphine is quite useful as a fixed dose medication to provide constant levels of analgesia around the clock. Short-acting morphine can be given every 2- 3 hours, or even more often if needed for breakthrough pain. Oxycodone, it its long and short-acting forms could be used instead of morphine.
Fentanyl patches can also provide the constant analgesia once the patient is already habituated to opioids, and is especially useful if the patient has trouble swallowing pills. The long-acting pills must be swallowed whole to be effective, while the short-acting ones do have forms that dissolve on the tongue and are absorbed. Fentanyl even comes in ‘lollipops’ which are quickly absorbed in the mouth.
Other opioids could be employed too. Methadone and dilaudid are both effective. Codeine and hydrocodone would likely be insufficiently potent to treat this sort of end of life pain.
We try to avoid IVs and IM injections in end of life care, as it just adds more discomfort in order to give comfort. But if the patient needs rapid pain relief and isn’t getting it by other means, we’ll use it. And then try to figure out how to give better pain relief without needles.
Use of benzodiazepines to relieve anxiety is also helpful. Xanax and ativan are particularly effective.
