UNDERSTANDING
Palliative
Care
03.2023
Pain Management
It is important to anticipate and address concerns of pain early in the disease process for patients with a terminal disease or at end of life. Anxiety and other psychosocial stressors will play a role and must also be thought of.
Palliative Pain Management
The effective relief of pain in a palliative patient depends mainly on a comprehensive assessment to identify the different physical, psychological, social, and spiritual aspects that are specific to each patient, and optimally intervene on a multidisciplinary level.
The pain syndrome must be assessed with detail to ascertain which components of pain prevail, as this will lead to the optimal choice of intervention (i.e., pharmacological, interventional) for each individual.
A thorough assessment of the various components of pain is critical in being able to effectively manage it. The assessment should include a combination of the elements reported by the patient and/or his caregivers regarding his pain experience, as well as a physical exam, and laboratory or imaging studies appropriate to the patient’s condition.
The most important part of this assessment remains the information obtained by the patient and/or the caregivers regarding the patient’s pain syndrome.
In a majority of the cases, if well conducted, this gathering of information will give many of the necessary clues in understanding the pathophysiology and other relevant components of the patient’s pain in order to initiate the most appropriate treatment.
You will need to have all the following information available in addition to the usual present and past medical and surgical history:
Pain syndrome: In assessing the symptoms, one can use the OPQRSTUV mnemonic:
Onset-when did it start, was it acute or gradual and what was pattern?
Provoking or Palliating - what brings it on, makes it better or worse?
Quality - Identify type of pain such as neuropathic burning, tingling, numb?
Radiation or region - where is the primary location and does it radiate?
Severity – verbal descriptors or how severe is pain on a scale of 1-10?
Treatment – what are current or past treatments and or side effects?
Understanding - meaning of pain to the sufferer, total pain.
Validated and user-friendly tools may help you in this assessment such as the Brief Pain Inventory.
Palliative patients often present with several pain locations and types, and each of them needs to be assessed separately.
Pain medications:
Assess the current regimen; start date, dosage, and schedule, as described by the patient or the caregiver in charge, and do not overly rely on what is in the charts as the “true regimen”, as patients do not always take medicines as prescribed. Ideally, patients and families should bring in all the pill bottles to avoid confusion or polypharmacy. Assess past regimens with dosage, mode of administration, duration of treatment, effectiveness, and side effects. Assess allergies and particular reactions. Be sure to inquire about over-the-counter medications, including integrative or “alternative” therapies, herbal regimens, supplements and vitamins.
Non-pharmacological/interventional options (ongoing or past):
Assess history of palliative chemotherapy or radiation therapy, PT, psychotherapy, hypnosis, cognitive behavioural therapy, etc.
The evaluation should include:
– Diagnosis, prognosis, end of life or not
– Patient’s goals of care
– Comorbidities and other symptoms aside from pain
– Extensive list of current medications for pain as well as comorbid conditions
– Present/past adherence to treatments
– Previous experiences with pain meds, beliefs, cultural, spiritual dimensions
– Patient and family expectations regarding pain management
– Education level
– Evaluation of drug misuse in past or associated risk factors
– Socio-economical context, ability to obtain medications or treatment
– Contacts or support persons /transportation ability – Cognitive function
– Which medications or interventions are available at your facility?
The pain syndrome must be assessed with detail to ascertain which components of pain prevail, as this will lead to the optimal choice of intervention (i.e., pharmacological, interventional) for each individual.
A thorough assessment of the various components of pain is critical in being able to effectively manage it. The assessment should include a combination of the elements reported by the patient and/or his caregivers regarding his pain experience, as well as a physical exam, and laboratory or imaging studies appropriate to the patient’s condition.
The most important part of this assessment remains the information obtained by the patient and/or the caregivers regarding the patient’s pain syndrome.
In a majority of the cases, if well conducted, this gathering of information will give many of the necessary clues in understanding the pathophysiology and other relevant components of the patient’s pain in order to initiate the most appropriate treatment.
You will need to have all the following information available in addition to the usual present and past medical and surgical history:
Pain syndrome: In assessing the symptoms, one can use the OPQRSTUV mnemonic:
Onset-when did it start, was it acute or gradual and what was pattern?
Provoking or Palliating - what brings it on, makes it better or worse?
Quality - Identify type of pain such as neuropathic burning, tingling, numb?
Radiation or region - where is the primary location and does it radiate?
Severity – verbal descriptors or how severe is pain on a scale of 1-10?
Treatment – what are current or past treatments and or side effects?
Understanding - meaning of pain to the sufferer, total pain.
Validated and user-friendly tools may help you in this assessment such as the Brief Pain Inventory.
Palliative patients often present with several pain locations and types, and each of them needs to be assessed separately.
Pain medications:
Assess the current regimen; start date, dosage, and schedule, as described by the patient or the caregiver in charge, and do not overly rely on what is in the charts as the “true regimen”, as patients do not always take medicines as prescribed. Ideally, patients and families should bring in all the pill bottles to avoid confusion or polypharmacy. Assess past regimens with dosage, mode of administration, duration of treatment, effectiveness, and side effects. Assess allergies and particular reactions. Be sure to inquire about over-the-counter medications, including integrative or “alternative” therapies, herbal regimens, supplements and vitamins.
Non-pharmacological/interventional options (ongoing or past):
Assess history of palliative chemotherapy or radiation therapy, PT, psychotherapy, hypnosis, cognitive behavioural therapy, etc.
The evaluation should include:
– Diagnosis, prognosis, end of life or not
– Patient’s goals of care
– Comorbidities and other symptoms aside from pain
– Extensive list of current medications for pain as well as comorbid conditions
– Present/past adherence to treatments
– Previous experiences with pain meds, beliefs, cultural, spiritual dimensions
– Patient and family expectations regarding pain management
– Education level
– Evaluation of drug misuse in past or associated risk factors
– Socio-economical context, ability to obtain medications or treatment
– Contacts or support persons /transportation ability – Cognitive function
– Which medications or interventions are available at your facility?