Par Forest Tennant, MD, DrPH
Sudden and unexpected death can occur in a patient with severe chronic pain, and the terminal event may not be related to medical therapy. Fortunately, sudden death is not as common in pain patients as in previous years, possibly due to better access to at least some treatments. However, sudden death still occurs and practitioners need to know how to recognize a patient at “risk”.
Sudden and unexpected death from severe pain is not appreciated, as many observers still view severe pain as a harmless nuisance rather than a potential physiological disaster. In many cases, just before death, the patient lets his family know that he is feeling sicker than usual and seeks relief in his bed or on the couch. Unfortunately, some of these patients do not wake up. Other patients die in their sleep, without warning, or are found collapsed on the floor. The aggressive toxicology of modern medicine and forensic procedures after death have contributed to the misunderstanding of the death threat from pain. In some cases, a patient in pain and properly treated with an opioid or other agent at risk of overdose or abuse died unexpectedly and unexpectedly. Drugs have been found in body fluids after death,
Part of this article seeks to draw attention to the fact that the mere discovery of drugs of abuse at autopsy does not necessarily mean that the drugs have caused death. In fact, the drugs may have slowed death. Some doctors have been falsely accused of causing death as a result of over-treatment, when under-treatment of pain may actually have caused death. In addition, the blood levels of opioids assessed at the autopsy of a suddenly deceased patient are too often incorrectly regarded as an accidental overdose, because the pathologist does not know that patients suffering from chronic pain on a stable dose of opioids can fully work with serum levels of 1Click here to visit the store and find much more …
The mechanisms of sudden and unexpected death in patients in pain, as well as some protective measures that doctors must take to avoid being falsely accused of causing sudden and unexpected death, are given here. Most importantly, here are some clinical tips to help the chronic pain patient who is at high risk for sudden and unexpected death so that more aggressive pain treatment can be made.
A Brief Anecdotal History
As a medical student at the University of Kansas in the early 1960s, I had to take a nationwide preceptorship course with a country physician. One day as we passed through the retirement home, I heard a farmer’s wife say, “The pain killed my mother last night.” Since then, I’ve heard repeatedly that the pain had killed a loved one. Folklore often mentions that people die “from”, as well as “from” pain. However, there are few written details of these events.
In the early years of my pain practice, which I started in 1975, many patients died suddenly and unexpectedly. This rarely happens to me these days because I have learned to “expect the unexpected” and identify patients at high risk of sudden death. In recent years, I have investigated a number of lawsuits and misconduct related to sudden and unexpected death in patients with chronic pain. In some of these cases, doctors have been charged with prescribing or prescribing drugs and causing sudden and unexpected death, even if the patient had been taking stabilized doses of opioids and other drugs for extended periods of time. In addition, the autopsy showed no signs of pulmonary edema (a defining sign of overdose and respiratory depression).
Environment and cause
Unforeseen deaths in patients with chronic pain usually occur at home. Sometimes death lies in a hospital or addiction center. The story of these patients is quite typical. Most are too sick to leave home and spend a lot of time in bed or on a couch. Death often occurs during sleep or when the patient gets up to go to the toilet. In some cases, the family reports that the patient spent extraordinary time on the toilet just before his collapse and death. However, sudden and unexpected death can occur anytime, anywhere, like pain patients who died suddenly and were suddenly found at work or in a car.
Coronary spasms and / or cardiac arrhythmias leading to cardiac arrest or asystole are in most cases the clear cause of death, as no gross macroscopic pathology was found at autopsy. 2-5 Instant cardiac arrest appears to explain sudden collapse or death during sleep. Perhaps constipation and defecation can be factors of cardiac stress as some pain patients die during defecation. Acute sepsis due to adrenal insufficiency and immune suppression may explain some sudden deaths.
Two Mechanisms of Cardiac Death
Severe pain is terrible stress. 6,7 Acute or chronic pain attacks cause the formation of glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenaline and noradrenaline) on the hypothalamic-pituitary-adrenal axis to contain biological stress. 8,9 Catecholamines have a potent and direct effect on the cardiovascular system and on tachycardia and hypertension. ten Pulse rates can generally reach more than 100 beats per minute and even over 130 beats per minute. Blood pressure can reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to the release of adrenal catecholamines, rashes cause hyperactivity of the sympathetic autonomic nervous system, which adds additional stimulation to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic sympathetic hyperactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, cold limb vasoconstriction, hyperreflexia, hyperthermia, nausea, diarrhea, and vomiting.