Controlling pain and symptoms at end-of-life: a better way

The World Health Organization has defined Palliative Care as: “The active total care of patients whose disease is not responsive to curative treatment. The goal… is to achieve the best quality of life for patients and their families”

In palliative care, controlling pain and other distressing symptoms is one of the greatest concerns (and worries) for patients and families facing a serious, long term and/or terminal illness.  One method available for symptom management is Authorized Agent Controlled Analgesia (AACA) using an analgesic pump.

The analgesic infusion pump is useful when: someone can no longer swallow medication, the dose of medicine given by mouth can no longer control pain, the pain (or other symptom, such as shortness of breath, or confusion) is unpredictable and the patient needs an effective, immediate method of control.

This is a method of pain control which allows a patient’s designated ‘authorized agent’ to administer pre-set doses of a drug, when needed, by pressing a ‘clicker’ or ‘button’. The drugs are given through an IV (intravenous) or a subcutaneous (under the skin but not in a vein) needle. The pump is an electronic machine programmed to deliver a prescribed amount of drug with each press of the button at specified minimum intervals; it can also provide a continuous amount of the drug per hour in addition to those given by the button.

Patient controlled analgesia (PCA) operates the same way, but these patients are alert, oriented and able to determine their own pain/symptom needs. Vulnerable populations of patients (such as those with dementia or severe confusion or post-stroke) have the same needs for symptom management but are unable to act in their own behalf. Using AACA allows cognitive or physically impaired patients to have the same advantages as those able to use PCA.

Analgesic pumps have built in safety features- the pump can only deliver a predetermined (and safe) amount of medication and the machine records how much medication has been given. The nurse taking care of the patient does a careful assessment to determine sedation using a method called RASS (Richmond Agitation Sedation Scale). Authorized agents (someone other than the patient) must have education regarding the patient’s individual signs of pain/discomfort and the reasons for using AACA as well as for not (any purpose other than pain relief) using AACA. If, for example, a patient is sedated and the nurse observes the agent is continuing to use AACA, more education for the agent is needed. Conversely, if the patient is in constant distress and AACA is not being utilized, again, more education for the caregiver is necessary.

An AACA system has been highly successful for patients, families and staff, meeting the goals of 1) allowing patients with terminal illness to die comfortably and peacefully, 2) enabling families to share in the patient’s care at the end of life providing a more favorable memory at the end.

Shelton Cathy, RN and Webb Robert, MD
Palliative Care Services
Eliza Coffee Memorial Hospital
Florence, USA



The benefits of Authorized Agent Controlled Analgesia (AACA) to control pain and other symptoms at the end of life.
Webb RJ, Shelton CP.
J of Pain and Symptom Management. 2015 Sept.


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