People with advanced disease often experience many types of pain requiring multiple treatment approaches. It is one of the most common symptoms across all life-limiting conditions. Pain is reportedly experienced by:
Most people receiving palliative care can obtain good relief with available treatment options however, there is evidence that pain may go unrecognised or untreated.
Pain is an unpleasant sensory and emotional experience. It is what a person says it is.
It is frequently part of the total experience of suffering and grief. "Total pain" describes the physical, psychological, social, and spiritual components of pain that interact with one another.
Nurses have an important role in recognising, assessing, and managing symptoms related to pain. They can also help patients and families with sensitive and culturally appropriate pain relief, education, and support.
Pain is feared by many palliative care patients.
A person’s experience of pain is personal. It is influenced by many things including their culture, gender, age, education, socioeconomic status, their sense of relative power in the conversation, and whether they can express themself in their first/preferred language.
Culture also has an influence on how a person experiences pain. Some cultures encourage the expression of pain, whilst in others, stoicism is encouraged.
Visit the Diversity section on pain and palliative care around the world.
CareSearch Community - Diverse Populations
In the palliative care setting, some of the important contributors to pain to consider and treat are:
Pay particular attention to certain people including:
Palliative care to relieve pain and suffering is based on the assessment and treatment of a person’s total pain. There is currently no single pain assessment tool which is regarded as ideal, and the use of any pain assessment tool should be supported by a comprehensive clinical assessment which should include:
Remember that pain assessment includes the person describing their pain experience verbally or behaviourally, and clinicians and carers observing this expression. To hear the person's story including the most problematic aspects of their pain experience, use an open-ended question such as:
The use of question prompts to guide assessment can be helpful. The OPQRSTU mnemonic is one example but there are others.
Choose a validated assessment tool appropriate for the care context. Remember to use the same scale/s or tools for reassessment.
The distress that the pain causes is an important indicator and this is included in the Symptom Assessment Scale.
Using a pain assessment tool in the person’s own language or working with an interpreter has the potential to improve at least one element of this complex situation.
Pain management includes a multimodal approach combining different treatment options at the same time. As for any symptom in palliative care, developing a plan for pain management is important and must take into consideration the cause, potential benefits and burdens of treatment, the patient's place in the course of their illness, their overall goals of care and their wishes.
Both non-pharmacological and pharmacological approaches are available.
Fundamental nursing care that can make an important positive difference to the person includes:
Consult with a physiotherapist or occupational therapist who may recommend other approaches such as massage; TENS; the use of splints, braces, equipment; exercise; advice on positioning; heat and/or cold therapy.
Deep feelings such as fear and anxiety of having a life-limiting illness can be a significant part of a person’s pain. Nurses can support people through compassionate care. Support from a counsellor, psychologist, mental health professional, and/or pastoral care may also be helpful.
Psychological interventions include relaxation techniques, hypnosis, cognitive behavioural therapy, mindfulness and music and diversional therapies related to things the person likes to do.
A note on complementary therapies: There is evidence to support the use of patient education, cognitive behavioural therapy (CBT), relaxation, and music. There is limited evidence to support the use of TENS and acupuncture in cancer-related pain and neuropathic pain.
goals of care for pain management and developing a comprehensive and
individualised management plan are core principles of managing pain in
palliative care. Approaches to care need to be aware of patient preferences
such as avoidance of adverse effects or a desire to be fully awake and
Opioid analgesics provide effective relief and remain the mainstay of treatment for moderate to severe pain. The choice of opioid should be guided by the person’s preference, their previous history, and the clinical assessment. The use of simple non‐opioid analgesics may be useful to improve analgesic efficacy and reduce total opioid doses.
Opioids are effective in treating nociceptive pain and there are guidelines supporting this use in the palliative care setting.
Morphine is the opioid of first choice for palliative care patients. If this is not suitable, the person may be prescribed other opioids. Commonly used opioids in palliative care include:
If opioid requirements rapidly increase this may signify that there is a serious problem requiring specialist input. The use of non-opioid analgesics in combination with opioids is part of the multi-modal approach to pain control in palliative care. CareSearch has more on non-opioid analgesics.
Anti-depressant medications might be prescribed if the person has a diagnosis of anxiety or depression.
Visit CareSearch non-opioid analgesics for pain
CareSearch non-opioid analgesics for pain
Music therapists can employ music interventions to improve physical and emotional pain.
Occupational therapists can focus on education, counselling, task redesign and equipment prescription to assist the person.
Physiotherapists can use massage, exercise and passive movement, pain relief, mobility aids to help relieve pain and help, and education to help the person manage their pain.
Psychologists can use psychological strategies to address emotional aspects of pain.
Social workers may provide counselling to work through emotional pain.
This information was drawn from the following resources:
Watch the Agency for Clinical Innovation video, Pain management
Visit CareSearch Community section - Dealing with Pain
Access more Pain resources
Page created 25 August 2022