Best practice palliative care is informed by the evidence. In this In Focus feature article, we look at the latest evidence on assessing and managing pain, and highlight some resources to support best practice at clinical point of care.
Assessment and management of physical symptoms is a major focus of palliative care. Poorly controlled pain or nausea can seriously affect a patient’s quality of life and functional ability.
More than half of all patients accessing palliative care services experience pain and it is the most common symptom in the terminal phase. 
In addition to the clinical challenges of meeting patient needs, health professionals may also be concerned about use of pain medications and the unintended effect of hastening death. 
For clinicians there is emerging evidence and resources to help guide current and future best practice.
'All people require evidence-based and person-centred care at the end of their lives'
Department of Health National Palliative Care Strategy 2018 (page 2)
National Palliative Care Strategy 2018
'Health services are expected to take practical steps to keep abreast with new and emerging evidence, and uses the best available evidence to inform clinical practice'
Palliative Care Australia National Palliative Care Standards 2018
Palliative Care Australia National Palliative Care Standards 2018 (page 16)
As outlined in our CareSearch Updated Evidence Summary, the evidence underpinning pain management is evolving and together with a better understanding of current clinical practice, novel approaches are emerging. Ensuring that pain is effectively and appropriately managed requires us to keep up with this evidence.
Read What is the best practice for managing pain in palliative care patients?
Evidence informs us of the most likely benefits and risks associated with approaches to care and intervention. It provides us with information that can be reasonably generalised at the population level. Moving from this to care for the individual requires judgement and expertise. In evidence based practice clinicians combine the best available evidence with their expertise and patient preferences and circumstances to plan care.  This is person-centred best practice, and each contributor alone is not enough.
Availability of resources based on evidence supports this process.
CareSearch is an important partner in the palliative care evidence cycle. Our online presence provides support across Australia including regional and remote centres where access to services may be more limited.
In support of clinical decision-making we have recently updated our Clinical Evidence section on Patient Management. This has involved extensive searching, appraisal and synthesis of the evidence across 15 common symptoms. Review of all content by experts including our CareSearch Advisory Group is part of our quality process and ensures information relevance to the Australian care context.
As part of this, the evidence relating to Pain has been substantially updated and here we guide you to some of the new content that can be used to support best practice in palliative care.
The first step in effective management is assessment of pain. Self-report is the gold standard and indicates intensity or severity, and there are tools available to assist with assessment.
There is no pain assessment tool which is regarded as ideal, but there are a number of options depending on the context of care.  We have examined the evidence underpinning available tools for across the life course and highlight validated tools for different age groups and populations. See Pain Assessment.
PBS/RPBS subsidised palliative care-related prescriptions for pain relief per 100,000 population, states and territories, 2017-2018. Source: Australian Institute of Health and Welfare
Pain management will include a multimodal approach, which means using a number of treatment options at the same time.
Both pharmacological and non-pharmacological approaches are available. Opioid analgesics provide effective relief and remain the mainstay of treatment for moderate to severe pain. Paracetamol is also frequently taken by people with palliative care-related pain, but the evidence on effectiveness is uncertain or lacking. 
As outlined in our CareSearch Updated Evidence Summary, as well as researching new routes of administration, the search for alternatives such as non-opioid analgesics continues. For many people with palliative care needs the oral medication cannabis or cannabinoids are currently of considerable interest for pain management. But, the best available evidence does not support its use in pain. Its best indication is as an anxiolytic. 
To learn more about the evidence and its implications for palliative care practice in pain and other symptom management visit the CareSearch clinical evidence section.
Acknowledgment: We would like to thank the CareSearch Advisory Group and external experts for their important contribution to this update of the CareSearch Clinical Evidence section.
The caring@home project provides training for nurses to support at home carers with the management of breakthrough symptoms.
QUT End of Life Law in Australia provides information on law relating to palliative medication.
The ELDAC Project has a Legal Toolkit that also explains the law about providing palliative medication.
Dr David Healey discusses the importance of integrating evidence into practice and some pointers based on his experience as a GP.
Susan Gravier and Paul Tait from CareSearch and Southern Adelaide Palliative Services discuss how the palliAGED Symptoms and Medicines section can help in symptom management in the last days of life.
Dr Katrina Erny-Albrecht of CareSearch discusses the importance of independent, critical appraisal and syntheses of evidence into reliable, practical guidance for recipients and providers of care.
Last updated 24 August 2021