Use of epidural and peripheral nerve blocks at the end of life in children and young adults with cancer: The collaboration between a pain service and a palliative care service

Background: Clinicians may avoid continuous pain blocks in pediatric cancer patients at the end of life for fear of complications or of interfering with the desired location of death. Objectives: To examine the impact of epidural or peripheral nerve catheters on pain control in children and young adults with cancer within the last 3 months of life. Methods: We retrospectively reviewed the medical records to assess pain scores, systemic opioid requirements, and impact on death at the preferred location. Results: Ten patients (4.4-21.3 years of age), nine with solid tumors, one with lymphoma, had 14 devices (11 epidural, 3 peripheral nerve catheters) for a range of 3-81 days. Twelve of 13 catheters provided improvement by at least one of three criteria: improved mean pain scores at 24 h (8 of 13) and decreased opioid requirement at 24 h in nine cases and at day 5 in nine cases. Eight patients died in their preferred setting. Six patients had catheters (five epidural, one peripheral) until death, including two who died at home. In some cases, typical contraindications for indwelling catheters (spinal metastasis, vertebral fracture, thrombocytopenia, fever) were superseded by palliative care needs. We found no bleeding, infectious, or neurological complications. Conclusions: Our findings suggest that continuous catheter-delivered pain blockade at the end of life contributes to analgesia, moderates opioid requirements, and usually does not preclude death at the preferred location.