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 
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. 
Effective pain management requires appropriate clinical assessment to formulate a management plan. 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
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:
- Guide prescribing decisions
- Monitor the person’s response to interventions
- Adjust interventions (if required).
Scales for measuring pain severity include:
- 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).
|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.
A systematic approach to developing a comprehensive and individualised management plan considers:
|People with pain should be provided with verbal and written information on pain and its management, including:
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).
|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:
Key pharmacological options include:
The oral route is preferred. The transdermal / subcutaneous route of administration can be considered as an alternative to oral administration, if required.
|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.
Non-pharmacological approaches include:
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:
- 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?
- 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?
- What sources of comfort does Bassam use to help relieve his pain?
- How would you use a physical assessment to help understand Bassam’s pain?
- Why is the oral route the preferred method for analgesics?
- What are the indications for the subcutaneous route?
- Why is it important to consider using complementary therapies to address pain?
- 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.
- Therapeutic Guidelines Ltd, Pain: assessment in palliative care. 2019: Melbourne.
- Palliative Care Australia. Pain Management. 2018; Available from: https://palliativecare.org.au/resources/learn-more-about-pain-and-pain-management.
- Chang, V., Approach to symptom assessment in palliative care. UpToDate, 2015.
- Therapeutic Guidelines Ltd, Principles of symptom management in palliative care. 2018: Melbourne.
- Therapeutic Guidelines Ltd, Pain: management in palliative care. 2019: Melbourne.
- CareSearch. Pain. Information for GP’s 2017 March 28, 2017 ]; Available from: https://www.caresearch.com.au/caresearch/tabid/3469/Default.aspx.
- CareSearch. Pain. Clinical Evidence 2017 15 November 2017]; Available from: https://www.caresearch.com.au/caresearch/tabid/746/Default.aspx.
- 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.
- 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.
- 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.
- 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.
- Chen, L. and A. Michalsen, Management of chronic pain using complementary and integrative medicine. BMJ, 2017. 357.
- CareSearch. Non Pharmacological Approaches. Clinical Evidence 2018 [cited 2018 October 10]; Available from: https://www.caresearch.com.au/caresearch/tabid/751/Default.aspx.