Pain is one of a range of common symptoms experienced by palliative patients. Keep in mind that a patient with a life-limiting illness can experience, on average, 12 or 13 different symptoms through their disease trajectory.
Pain is defined by the International Association for the Study of Pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’. Each of us has a number of influences that affect the way we perceive pain. The important thing to appreciate is that the perception of pain is unique to the individual.
The pathophysiology of pain is complex. Although it may help to classify pain as nociceptive or neuropathic to guide management, the reality is that pain is a syndrome with neuropathic, nociceptive, emotional, and psychosocial overlays. The cause of pain is often multifactorial and can involve the disease, its treatment, previous experience, and pre-existing morbidity. Not surprisingly, the management of pain is complex but it always begins and ends with assessment.
It’s invaluable to take time to assess pain in your patients. When you assess pain, keep in mind some of the following points:
- Pain means different things to different people. It’s important to try to understand what it means to each individual patient. Does the patient simply perceive it as an unpleasant physical sensation? Or is it perceived to mean the person’s life is coming to an end? Or that they will no longer be able to drive a car?
- Factors that will help inform your management of pain include the location and radiation of the pain, what makes the pain better or worse, the quality and severity of the pain, and the presence of breakthrough or incident pain. Breakthrough pain occurs between regular doses of an analgesic and may be an occasional natural fluctuation in pain, but it also may reflect inadequate background analgesia. Incident pain occurs, or is exacerbated by, activity. Obtaining collateral information from family and carers can be very useful, especially in patients who are unable to communicate their symptoms.
- The assessment of pain is a dynamic process that can be aided by using a validated clinical tool. There are a number of tools available; become familiar with tools that work for your practice.
Overall, the aim of pain management is to reduce the intensity of pain and so improve quality of life. In palliative care many issues impact on pain management, so I’ll just mention a few points that I consider important:
- Any management plan must be acceptable and appropriate to the patient within the context of their life and their goals for treatment.
- I can’t overemphasise the importance of a trusting therapeutic relationship with the patient. This, of course, helps to set realistic goals and warn patients that getting control of their pain may be an evolving, continuous process rather than a miracle cure after the first treatment.
- Even if a reversible cause of the pain is identified, you need to consider whether it is appropriate to try to reverse the cause at that particular time in the person’s illness trajectory.
- Pain can often be treated, at least in part, by non-pharmacological interventions. The range of these interventions is enormous, varying from yoga to CBT. Many are effective and preferred by patients, but to discuss all of them is well beyond the scope of this blog post.
- Importantly, psychological support and treatment value-adds, especially where existential issues predominate and where there is spiritual pain or depression. Clinicians need to be conscious of these factors and not give them any lesser attention.
The mainstay of moderate to severe palliative pain management is, of course, the use of pharmacological agents, and use needs to be embedded in evidence-based practice. When using pharmacotherapy, it’s always important to decide which agent will be most effective with the most acceptable side-effect profile, availability, and cost. There are many classes of these agents including NSAIDS, steroids, antidepressants, and anticonvulsants but for now I’d like to focus on opioids.
There are a number of different opioid-like products and formulations on the market, and myths and half-truths about product differentiation are widespread. This can make prescribing daunting. My suggestion is to become familiar with a small range of these that you can use confidently and effectively. Good starting points for assessing and managing pain in the palliative patient can be found at the following links:
A number of videos on the Decision Assist website address the management of common palliative care symptoms: pain, dyspnoea, nausea and vomiting, delirium. In the pain video I talk in more depth about:
- The individual nature of pain
- Principles of pain assessment and management
- Individualising pain management plans
- Initiating opioids in opioid naïve patients
- Managing refractory pain
Pain in the palliative care setting adds a huge burden to the patient’s quality of life and in fact it deprives them of valuable time. Good assessment and management early in the patient’s disease trajectory can reduce the burden for the patient.
We have the skill and tools to actively improve the patient’s symptom burden in this respect. Patients truly value our effort and time in striving to reduce their symptoms.
Dr Greg Parker, MBBCh FRACGP FAChPM, is a staff specialist based at the Metro South Palliative Care Service in Brisbane. He is involved in all aspects of palliative care practice and education. Dr Parker is also a senior lecturer with Griffith University and the University of Queensland, and is an advanced training supervisor.