Pain

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.

In the palliative care setting, some of the important contributors to pain to consider and treat are:

• bone metastases and their complications including pathological fractures and spinal cord compression
• malignant or non-healing wounds
• infection
• neuropathic pain
• radiotherapy / chemotherapy effects (usually short term)
• lymphoedema
• depression / anxiety / fear
• frailty, decreasing mobility or becoming bed-bound
• constipation and urinary retention.

Pay particular attention to certain people including:

• elderly people, particularly those living in residential care settings and those with cognitive impairment
• those in neonatal, paediatric, and adult intensive care units
• members of ethnic communities and those who speak English as a second or subsequent language
• people unfamiliar with the Australian health system and/or unaware of what help is available
• patients with an elevated risk of opioid misuse.

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:

• pain intensity
• temporal pattern
• treatment and exacerbating / relieving factors
• pain location
• pain interference

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:

• ‘Tell me what you are experiencing’

The use of question prompts to guide assessment can be helpful. The OPQRSTU mnemonic is one example but there are others.

Assessment tools

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.

Simple pain assessment tools – pain intensity only

• Verbal numeric rating scale (0 to 10) (for adults and children 8yo and older)
• Pain thermometer (numeric and/or descriptive (105kb pdf) – a visual tool for older people
• Verbal descriptor scales (VDS)
• Faces pain scale for children (for children 3yo and older)
• Visual analog scale (for children 8yo and older)

More complex pain assessment tools – pain intensity and how pain interferes with activity, mood, sleep, enjoyment of life, and relationships

• Brief pain inventory
• Modified Resident’s Verbal Brief Pain Inventory (112kb pdf)
• Consider neuropathic screening – LANNS and sLANNS, Neuropathic Pain Diagnostic Questionnaire (NPQ) 201kb pdf or the painDETECT tools

Pain assessment tools for non-verbal

• Abbey Pain Scale (240kb pdf), PAINAD (43kb pdf) and Doloplus 2 for older people with cognitive impairment
• Modified PAINad for younger people who are non-verbal (e.g. people with a disability)

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.

Non-pharmacological approaches

Fundamental nursing care that can make an important positive difference to the person includes:

• an unhurried approach to care
• careful positioning
• gentle massage
• reassuring the person
• timing activity or care procedures in alignment with analgesia
• listening to a person’s experience of pain and acknowledging their discomfort, distress, or fear
• preventing and managing adverse effects of analgesia, including constipation.
• regularly reviewing pain control.

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.

Pharmacological approaches

Setting 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 responsive

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:

• Oxycodone
• Hydromorphone
• Fentanyl
• Methadone

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 Clinical evidence summary for pain.

This information was drawn from the following resources:

• CareSearch. Pain [Internet]. Adelaide, SA: CareSearch, Flinders University; [updated 2021 Aug 27; cited 2022 Aug 8].
• Coyne P, Mulvenon C, Paice JA. American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain management at the end of life. Pain Manag Nurs. 2018 Feb;19(1):3-7. doi: 10.1016/j.pmn.2017.10.019. Epub 2017 Dec 16.
• Fink RM, Gates RA, Jeffers KD. Pain assessment. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing [Internet]. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Aug 8].
• Hølen JC, Hjermstad MJ, Loge JH, Fayers PM, Caraceni A, De Conno F, et al. Pain assessment tools: Is the content appropriate for use in palliative care? J Pain Symptom Manage. 2006 Dec;32(6):567-80. doi: 10.1016/j.jpainsymman.2006.05.025.
• Paice JA. Pain management. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing [Internet]. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Aug 8].
• palliAGED. Pain [Internet]. Adelaide, SA: palliAGED, Flinders University; 2019 [updated 2019 Feb 21; cited 2022 Aug 8].
• Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med. 2019;33(1):24-36. doi: 10.1177/0269216318807051. Epub 2018 Oct 22.
• Royal Australian College of General Practitioners (RACGP). RACGP aged care clinical guide (Silver Book) – Part A – Pain [Internet]. Melbourne: RACGP. [cited 2022 Aug 8].
• Sabin CA, Harding R, Bagkeris E, Nkhoma K, Post FA, Sachikonye M, et al. Pain in people living with HIV and its association with healthcare resource use, well being and functional status. AIDS. 2018 Nov 28;32(18):2697-2706. doi: 10.1097/QAD.0000000000002021.
• Schüchen RH, Mücke M, Marinova M, Kravchenko D, Häuser W, Radbruch L, et al. Systematic review and meta-analysis on non-opioid analgesics in palliative medicine. J Cachexia Sarcopenia Muscle. 2018 Dec;9(7):1235-1254. doi: 10.1002/jcsm.12352. Epub 2018 Oct 29.
• The Australian Pain Society (APS). Pain in residential aged care facilities: Management strategies, 2nd edition – Resourses [Internet]. 2019 [cited 2022 Aug 8].
• Therapeutic Guidelines Limited. Pain in palliative care patients [Internet]. 2016 [cited 2022 Aug 8].
• Therapeutic Guidelines Limited. Pain: management in palliative care [Internet]. 2016 [cited 2022 Aug 8].
• Therapeutic Guidelines Limited. Pain: Opiod therapy in palliative care [Internet]. 2016 cited 2022 Aug
• Thomas R, Phillips M, Hamilton RJ. Pain Management in the Pediatric Palliative Care Population. J Nurs Scholarsh. 2018 Jul;50(4):375-382. doi: 10.1111/jnu.12389. Epub 2018 May 5.
• van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage. 2016 Jun;51(6):1070-1090.e9. doi: 10.1016/j.jpainsymman.2015.12.340. Epub 2016 Apr 23.
• Watson MS, Ward S, Vallath N, Wells J, Campbell R, editors. Oxford Handbook of Palliative Care. 3rd ed. Oxford: Oxford University Press; 2019.
• Woods JA, Johnson CE, Ngo HT, Katzenellenbogen JM, Murray K, Thompson SC. Symptom-Related Distress among Indigenous Australians in Specialist End-of-Life Care: Findings from the Multi-Jurisdictional Palliative Care Outcomes Collaboration Data. Int J Environ Res Public Health. 2020 Apr 30;17(9):3131. doi: 10.3390/ijerph17093131.