Core Modules

module 3 | Activity 9: Assessing and managing pain in palliative care

This activity is designed to help you apply the principles of palliative care symptom management to a specific symptom: pain.

Pain occurs in over 50% of people with advanced cancer and can be a significant symptom for people with other nonmalignant life-limiting illnesses. It can be due to a life-limiting illness, its treatment, resulting debility or a comorbid illness.[1, 2]

Pain is a personal experience, occurring when and where the person says it does.

Therapeutic Guidelines [2]

Not all people experience pain – however many people are afraid of pain because they worry that pain cannot be controlled or that they will experience negative side effects from its treatment. [3]

Effective pain management requires appropriate clinical assessment to formulate a management plan.[2] As with the assessment of other palliative symptoms, this process should include:[4, 5]

  • Conversations with the person and their family
  • Physical examination and clinical investigations
  • Observation.

The assessment process should help determine:[2, 6]

  • How the person is managing their pain
  • The impact of pain
  • Pain quality
  • Personal pain knowledge.

Pain assessment tools enable ongoing assessment of symptoms from the person’s perspective. Pain severity scales offer a subjective measure of pain intensity and can be used to:[7]

  • Guide prescribing decisions
  • Monitor the person’s response to interventions
  • Adjust interventions (if required).

Scales for measuring pain severity include:[7]

  • Categorical or verbal descriptor scales (using descriptors such as no pain, mild, moderate, severe, worst ever pain)
  • Numbered scales (0 to 10, 0 to 100)
  • Visual analogue scales (simple lines with word anchors at each end)
  • Faces pain scales (for people who are unable to use other scales).

 

Pain management plan
The pain management plan is informed by the person’s expectations for pain management and goals of care.[2, 6, 8, 9]. Pain management approaches may need to be balanced against the person’s goals and preferences.[6]

A systematic approach to developing a comprehensive and individualised management plan considers:[6]

  • What is the nature, severity and cause of the pain(s) this person is experiencing
  • What medications are most likely to manage this person’s pain
  • What non-pharmacological measures might help relieve this person’s pain
  • Are there any personal or other practical concerns that might influence the management approach
  • Can pharmacological and non-pharmacological interventions be introduced one at a time, or should they be introduced simultaneously
  • What routes of drug administration are appropriate and possible for this person
  • What actions are required to ensure the medications are available and administered to this person in the appropriate manner
  • What information and education does this person, their family, carers and other healthcare providers need
  • What alternatives can be considered if the initial plan is not successful?
Supporting self-management
People with pain should be provided with verbal and written information on pain and its management, including:[1]

  • Causes and factors contributing to pain
  • Common experiences of pain (eg, onset, timing)
  • Effective therapies (including pharmacological and non-pharmacological management strategies and illness modification therapies (eg, radiation therapy)
  • Side-effects of therapies / medicines and how to prevent or manage them
  • Potential concerns (eg, mixing with alcohol, driving)
  • Ways to ensure that people have adequate access and supply to prescribed opioids
  • How to work with health professionals to achieve the best pain control possible (eg, the importance of reporting rather than concealing pain, side-effects and other concerns about medication)
  • Common attitudes and beliefs that may prevent people with life-limiting illnesses from receiving effective pain control (eg, fears that opioids are addictive and used only at the end of life, and that people will develop tolerance over time requiring dose escalation)
  • When to seek help (eg, if vomiting and unable to keep down fluids for one day, bowels not open 3 days, new pain, change in pain or pain not relieved by medication, difficulty waking the person from sleep during the daytime, confusion, difficulty accessing the medications).

Include the person’s family, carers and significant others in education about pain and its management including the benefits and risks of opioid medicines. (People with life-limiting illnesses, their families and health professionals commonly have concerns about addiction, tolerance and dependence that are disproportionate to the risks).[1]
Pharmacological approaches
The choice of analgesic medications for a person with a life-limiting illness should be based on the type and severity of pain. Take into account:[6]

  • The individual needs and illness requirements of the person
  • Any specific conditions which impact metabolism of medication (e.g. kidney or liver dysfunction)
  • The potential for adverse effects and the outcome for the person
  • The person’s complete medication list – as they may be taking preparations from multiple prescribers, alternative therapists or purchased over-the-counter.

Key pharmacological options include:

  • Paracetamol
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Opioids
  • Methadone.

The oral route is preferred. The transdermal / subcutaneous route of administration can be considered as an alternative to oral administration, if required.[1]

Suggested Resources
Non-Pharmacological approaches
When used in conjunction with conventional medicine, non-pharmacological approaches can be effective. People may use complementary therapies to gain a therapeutic response and a sense of control. Complementary therapies work by modifying the sensory input or altering the brain’s perception of pain.[10]

Non-pharmacological approaches include:[1]

  • Referral to a physiotherapist for assessment of functional ability and potential suitability of non-pharmacological pain management strategies
  • Support for any psychosocial and spiritual concerns identified during comprehensive assessment
  • Referral to an occupational therapist for assessment and management
  • Referral to a clinical psychologist for psychological therapies and support:
    • Cognitive–behavioural therapy
    • Relaxation techniques
    • Distraction techniques
    • Guided imagery therapy / hypnosis.
  • Music therapy – either pre-recorded or with a music therapist
  • Complementary therapies, including:[11-14]
    • Bed / bath/ walking aids
    • Heat / cold therapy
    • Massage
    • Transcutaneous electrical nerve stimulation (TENS)
    • Reflexology
    • Reiki
    • Relaxation.

When complementary therapies like herbs or supplements are taken orally, topically or by some other route, it is important to consider the possibility of pharmacological interactions and side effects.[8]

Case study

In the video Bassam’s Story from Palliative Care Australia, Bassam shares his story about being diagnosed with terminal cancer and his experience with palliative care and pain.

After being told that his cancer was incurable, Bassam tried different medical trials to ease his pain and discomfort – unfortunately with little success. Bassam chose to access palliative care to manage his emotional and physical needs – including his pain.

Watch the video and answer the following questions:

  1. Complete the following pain assessment table for Bassam:
    Characteristics of symptoms How does Bassam describe his experience with pain?

    How does Bassam differentiate between physical and psychological pain?
    Contributing factors What contributes to Bassam’s pain?
    Behavioural responses How is Bassam affected by his pain?
    Meaning of symptoms How would you assess the meaning of the symptoms to Bassam?
  2. Bassam knows that he’s dying and appears to draw comfort from being able to “live out his last days in peace”. How can a person’s perceptions and views about their circumstances influence how they experience and respond to symptoms?
  3. What sources of comfort does Bassam use to help relieve his pain?
  4. How would you use a physical assessment to help understand Bassam’s pain?
  5. Why is the oral route the preferred method for analgesics?
  6. What are the indications for the subcutaneous route?
  7. Why is it important to consider using complementary therapies to address pain?
  1. Australian Adult Cancer Pain Management Working Group. Cancer Pain Management in Adults: Assessment. Cancer Guidelines WIKI 2016  [cited 2017 April 20]; Available from: http://wiki.cancer.org.au/australia/Guidelines:Cancer_pain_management/Assessment.
  2. Therapeutic Guidelines Ltd, Pain: assessment in palliative care. 2019: Melbourne.
  3. Palliative Care Australia. Pain Management. 2018; Available from: https://palliativecare.org.au/resources/learn-more-about-pain-and-pain-management.
  4. Chang, V., Approach to symptom assessment in palliative care. UpToDate, 2015.
  5. Therapeutic Guidelines Ltd, Principles of symptom management in palliative care. 2018: Melbourne.
  6. Therapeutic Guidelines Ltd, Pain: management in palliative care. 2019: Melbourne.
  7. CareSearch. Pain. Information for GP’s 2017  March 28, 2017 ]; Available from: https://www.caresearch.com.au/caresearch/tabid/3469/Default.aspx.
  8. CareSearch. Pain. Clinical Evidence 2017  15 November 2017]; Available from: https://www.caresearch.com.au/caresearch/tabid/746/Default.aspx.
  9. Wilkie, D.J. and M.O. Ezenwa, Pain and Symptom Management in Palliative Care and at End of Life. Nursing outlook, 2012. 60(6): p. 357-364.
  10. Brant, J., Strategies to manage pain in palliative care, in Palliative care nursing: A guide to practice, M. O’Connor, S. Lee, and S. Aranda, Editors. 2012, Ausmed Publications: Ascot Vale, Vic.
  11. Singh, P. and A. Chaturvedi, Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian Journal of Palliative Care, 2015. 21(1): p. 105-115.
  12. International Association for the Study of Pain. IASP Terminology. 2018 2018 [cited 2018 8/10/2018]; The following pain terminology is updated from “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.]. Available from: http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698.
  13. Chen, L. and A. Michalsen, Management of chronic pain using complementary and integrative medicine. BMJ, 2017. 357.
  14. CareSearch. Non Pharmacological Approaches. Clinical Evidence 2018  [cited 2018 October 10]; Available from: https://www.caresearch.com.au/caresearch/tabid/751/Default.aspx.