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Knowledge Point Articles   

March 2007

Effective Pain Management at the End of Life

Chronic diseases bring about a host of difficult symptoms that can cause suffering. There are disease-mediated symptoms, such as immobility, dyspnea, fatigue, loss of mobility and pain. There are also emotional states, including anxiety, depression and the sense of despair that contribute to suffering. These emotional conditions are all intertwined, important and deserve our attention. 

Of these symptoms experienced by our patients, pain is the most common and most feared symptom. Pain is most often under treated, but it can be controlled through a careful assessment in most cases. Pain awareness and specialized interventions can ensure comfort to patients in the final stages of a terminal illness. These steps will assist in the prevention of prolonged and pathological grief for the survivors of a loved one. They often find themselves asking the questions, “Why did they suffer?” or “Wasn’t there anything else we could have done?” As practitioners, we can assist in answering these questions and alleviating not only the patient’s fear and anxiety but also the loved ones who are watching.

As members of the hospice and palliative team, everyone plays an important role in managing the pain of our patients. Both the physician’s and nurse’s role begins with the proper assessment of pain and continues throughout the development of the plan of care and its implementation. The members of the team all work together to improve the patient’s quality of life and maintain physical comfort. They also work with healing broken relationships, completing unfinished business and finding peace as death approaches. In order to provide optimal pain relief, all team members and health care professionals must understand the prevalence of pain at the end of life, the treatments being used and the barriers that prevent proper pain management.

The prevalence of pain in the terminally ill varies by diagnosis as well as  demographic. According to a recent study, approximately one-third of the people who are actively receiving treatment for cancer and two thirds of those with advanced malignant disease experience pain. It also shows that people dying from cardiac failure, Chronic Obstructive Pulmonary Disorder (COPD), end-stage renal disease and other end-stage diseases suffer from similar levels of pain as those with malignant disease.  

The assessment of pain includes a thorough history and evaluation of the patient. The primary source of information should be the patient’s self-report. There are many different types of pain scales to assist in assessing pain, from numeric to faces or visual analog scales. They are useful for helping patients identify pain and for documenting the effectiveness of the treatment.

A comprehensive evaluation of pain should include an assessment of the pain intensity, character, frequency, onset, duration and location. It should also include a detailed history of pain, such as a physical and neurological examination, a psychosocial assessment, labs and tests that assist in determining the cause of pain. We also need to take common co-morbidities like sleep disturbances, depression, suffering and general functioning into account. 

There is significant evidence that inadequate pain relief hastens death by increasing physiological stress, potentially diminishing immunocompetence, decreased mobility, increasing inclination toward pneumonia and thromboembolism and increasing the work of breathing and myocardial oxygen requirements.

Another important management strategy to keep in mind is the non-pharmacological interventions that can be utilized for pain management that are proven to be effective as well. They include but are not limited to re-positioning, therapeutic exercise, TENS, massage, heat and cold, music therapy and relaxation techniques.

These types of interventions depend on the source and the severity of the pain as well as the physical condition and openness of the patient. The non-pharmacological approaches need to be tailored to individual likes and dislikes as well as the effectiveness of the approach, knowledge of the various modalities, management of expectations and an open-minded “trial and error” approach needs to be embraced.

Also, the importance of communication in pain control with patients, their families and other members of the team is essential to provide effective pain management. It is so important to tell patients and families about the kinds of drugs that are available, how they will affect the patient, how they will be administered and how they may interact with the patient’s existing medication. Professional health care workers may have unsubstantiated strong beliefs regarding the use of pain medications. There are many surveys that show physicians, nurses and even pharmacists expressing concerns about addiction, tolerance and the side effects of morphine and other related drugs. These are also some of the same fears that family members and patients have themselves. Studies have shown that these fears are some of the main reasons that patients have increased pain and medications are being under utilized. Less educated or older patients are more likely to report these fears as well.

Effective pain management in advanced medical illness and at the end of life is a critical component in quality nursing and medical care to ensure a dignified, safe and comfortable passing. We need to believe and recognize that, as nurses, we can’t “fix” things like incurable disease, but we can make our patients much more comfortable on their final journey. 

 

Cyndi Rohret RN, BSN, CHPN
Clinical Consultant

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