Pain
Pain is one of the most common symptoms in palliative care. Pain
can also be a much feared symptom which can contribute to its
intensity. The aim of palliative care is to allow patients to be
pain free or, for their pain to be sufficiently controlled so that
it does not interfere with their ability to function or detract
from their quality of life.
Good pain control requires:
- accurate and detailed assessment, and reassessment, of each
pain
- knowledge of the different types of pains
- a different therapeutic approach to chronic pain
- knowledge of which treatment modalities to use
- knowledge of the actions, adverse effects and pharmacology of
analgesics
- multidisciplinary assessment and treatment of other aspects of
suffering that may aggravate pain - physical, psychological,
social, cultural and spiritual distress.
The array of pain management options can be overwhelming and
more information is available Medications and
Symptom management.
The
Pain and Pain Management leaflet may be a useful resource to
give to patients when discussing pain.
For patients with pain that is difficult to control contact the
palliative care service in
your region.
Medications
The use of medication for the treatment of acute pain is the
same as for non-palliative care patients. The treatment of chronic
pain, that is often poorly managed, requires a different approach
to acute pain.
In palliative care
- the analgesic program should be kept simple, even for patients
in severe pain
- oral medication is the mainstay of treatment and should only be
abandoned if the patient is unable to take or retain oral
preparations.
There is a myriad of pain medications available as they treat
different types of pain. To access up to date, evidence-based
sources of advice on the appropriate use of analgesics and other
treatments in palliative care refer to Medications and
Symptom management.
For access to an opioid conversation chart refer to CareSearch.
Barriers to optimal pain
control
Given explanation and reassurance, a well titrated morphine
regime and the cover of antiemetics and aperients, most patients
can use morphine without ill effect.
The following information is offered to deal with some of the
misinformation and fear that exists about the use and effects of
opiates.
Professional
fears about opioid analgesia
Some reasons why doctors under-prescribe and nurses
under-administer opioid drugs follow in bold type. These reasons
are challenged by the points appearing beneath them.
A belief that morphine hastens death
- morphine may be used for months or years and, correctly
administered, is compatible with a normal lifestyle
- used properly, it does not hasten death
The fear of respiratory
depression
- used properly, morphine should not cause respiratory
depression, although care must be taken with patients who are at
risk of respiratory depression for other reasons
A belief that "Morphine
doesn't work"
Morphine will be ineffective in controlling pain if
- it is incorrectly administered
- it is used for morphine-insensitive pain
- matters of psychosocial concern have not been addressed
The belief that morphine causes unacceptable side effects
- side effects should not be severe
- respiratory depression is uncommon, except in opioid naive
patients commenced on parenteral therapy
- constipation occurs inevitably and requires explanation and
advice about diet and laxative therapy
- somnolence and nausea usually improve after several days
A fear of tolerance, physical dependence, psychological
dependence
- concerns about these are never a reason to delay treatment with
an opioid if it is clinically indicated.
Patient fears about
opioid analgesia
Patient education and participation in pain management is vital.
Correction of misconceptions about pain management and opioid use
is often necessary to achieve optimal use of analgesia.
Some of the concerns put forward by patients and their families
follow in bold type. These concerns need to be addressed, and
suggestions are given as to education and reassurance that can be
given.
"That means I'm going to die soon"
- requires explanation that morphine can be used for months or
years and is entirely compatible with a normal lifestyle
"Nothing left
for when the pain gets worse"
- requires reassurance that the therapeutic range of morphine is
sufficient to allow escalation of the dose if necessary
"I'll become an addict"
- requires explanation and reassurance about physical and
psychological dependence
"The morphine didn't work"
morphine may not relieve pain if
- the dose was too low
- it was given too infrequently
- there were no instructions for breakthrough pain
- it was given for copied-insensitive pain
- matters of psychosocial concern have not been addressed
"I couldn't take the
morphine"
- unacceptable side effects should not occur
- patients should be warned about somnolence and nausea and
reassured that they are likely to improve after several days
- constipation occurs inevitably and requires explanation and
advice about diet and laxative therapy.
"I'm allergic to morphine"
- usually relates to nausea or vomiting that occurred when
parenteral morphine was given to an opioid patient for acute
pain
- immunological allergy to morphine is rare
Symptom management
Symptom management in palliative care requires skilled
comprehensive assessment and attention to the whole person.
Strategies to improve symptoms should be based on what the patient
says is most distressing and should also be designed around the
patients psychological, spiritual, emotional, cultural and social
needs. Wherever possible, the patient should be the main source of
information as to his/her needs for symptom control.
Palliative care practice is evolving rapidly. Resources offering
up to date, evidence-based sources of advice can be found
under:
or contact the palliative
care service in your region for symptom management advice
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