Principles of Palliative Care & Pain Management
Palliative care can last for many months or even years, and it might only be towards the end of their life that a person requires pain relief, or maybe not at all. For people who are experiencing pain though, it’s important it is managed appropriately by suitably qualified professionals using techniques that suit the person best. Pain relief is presumed to be all about medication but there are other types of pain relief that can be utilised, depending on the severity of the pain and how far along the palliative care pathway the individual is. These include cold and heat for targeting specific areas of the body, exercise, physio and occupational therapy, mind-body techniques, Yoga and tai chi, music therapy and therapeutic massage.
What Causes Pain?
According to the World Health Organisation, “The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Many other conditions may require palliative care, including kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological disease, dementia, congenital anomalies and drug-resistant tuberculosis.”
Not all conditions cause pain though and not everyone with advanced cancer will have pain for instance, although where pain is present it can be from “the tumour pressing on bones, nerves or other organs of the body” according to Cancer Research UK. Pain is felt when signals travel through nerve fibres to the brain for interpretation and is not just an unpleasant physical experience but an emotional one too. Consequently, palliative care pain management plans will usually consider not just your physical needs, but the effect pain may be having on you mentally as well.
How Is Pain Assessed?
Pain can be assessed in different ways, using uni-dimensional and multi-dimensional tools. According to Nursing Times, these tools’ differences can be seen as:
- measure one dimension of the pain experience, for example, intensity
- are accurate, simple, quick, easy to use and understand
- are commonly used for acute pain assessment
- have verbal rating scale and the verbal descriptor scales, for example, none, mild, moderate, severe and are commonly used for postoperative pain assessment
Uni-dimensional tool examples include verbal rating scales, graphic rating scales, numerical rating scales and body diagrams.
Multi-dimensional pain assessment tools
- provide information about the qualitative and quantitative aspects of pain
- may be useful if neuropathic pain is suspected
- require patients to have good verbal skills and sustained concentration, as they take longer to complete than uni-dimensional tools.
Examples of multi-dimensional tools include the McGill pain questionnaire (short and long), pain/comfort journal, pain information and beliefs questionnaire, pain beliefs and perceptions inventory.
For patients who are unconscious or sedated, or have cognitive impairment, these tools won’t be suitable, so alternatives would need to be used, such as observing facial expressions, limb movements, vocalisation and restlessness. For patients with cognitive impairment/dementia, there are specialist pain scales that can be used.
How Can This Pain Be Managed?
Unfortunately, pain is common in advanced stages of life-limiting diseases, and according to NICE, “Up to two-thirds of people with cancer experience pain that needs a strong opioid. This proportion is similar or higher in many other advanced and progressive conditions.” Opioids are medications used to treat severe or chronic pain (pain that persists for more than 12 weeks despite medication and/or treatment) and some are stronger than others. Opioids are effective at pain management but do carry a risk of dependence and addiction.
Opioids are classified as ‘mild’ or ‘strong’ and those considered mild include codeine and dihydrocodeine, whereas those labelled strong include tramadol, buprenorphine, methadone, diamorphine, fentanyl, hydromorphone, morphine, oxycodone, and pethidine. Non-opioid painkillers are medicines such as paracetamol. These medications can be given in a variety of ways but according to the NHS should “usually be given in the least invasive way possible. This means they’ll be given in a way that causes the least amount of discomfort, pain or distress.”
When the Pain Is an Emergency What Should I Do?
When receiving palliative care from Helping Hands, your carer will undoubtedly be just one person out of a whole multi-agency team who will be caring for you with a life-limiting condition, most of whom will be NHS healthcare professionals in your community. If you are living with complex care needs and require nursing care from us, then your carer will be under the supervision of one of our regional clinical lead nurses, who will train your carer to be able to undertake your specific care requirements.
If your pain is being managed then you’ll have a pain management plan and your pain medication will be strictly controlled. Therefore, if the pain was to suddenly become worse your carer would know who to contact and how to ensure that your pain management plan could be adjusted to take your new needs into consideration.
What to Do If the Patient Can't Take Oral Medication?
If the patient is unable to take pain medication orally there are other alternatives, such as through an injection under the skin (subcutaneous), through an injection into the muscle (intramuscular), or directly into a vein (intravenous). Another device called a syringe driver can give medication continuously under the skin, via a small, battery-operated pump.
Patches on the skin can also deliver strong painkillers when oral administration isn’t possible. This is usually because the patient cannot swallow or is being sick, rendering the oral medication ineffective.
Page reviewed by Deanna Lane, Senior Regional Clinical Lead on November 2, 2021