HFA Teleconference - Program Highlights
Pain Management at the End of Life
Bridging the Gap Between Knowledge and Practice
April 5, 2006
Teleconference Segment Highlights
Segment I
Understanding the Barriers to Pain Control
- Pain must be effectively managed throughout an illness. There are medical, ethical and psycho-social reasons for patients, families, health care providers, and allied professions to have this expectation.
- Pain at the end-of-life can be effectively managed. By employing adequate clinical care with proven pharmaceutical techniques, as well as other interventions, pain control can almost always be achieved with the individual remaining awake, alert, and interactive. Health professionals need to carefully follow established clinical guidelines for effective pain management, and continually reassess and re-evaluate the patient.
- There are many barriers to effective pain management, including: patient-related barriers, physician-related barriers, family and social barriers, as well as institutional barriers. These barriers have many different dimensions, including access, educational, policy, social, cultural, attitudinal, time, spiritual, ethical, and psychological. The first step in achieving effective pain management is to recognize and assess these barriers; open communication with patients and families is a critical part of this step. Only then can an effective pain management plan, including pharmaceutical and other interventive techniques, be successfully implemented.
- Most barriers can be effectively addressed through the hospice model of care, which provides a model of team-centered, holistic, home-based, family-centered care that facilitates pain management at the end-of-life.
Segment II
Assessing Pain at the End-of-Life
- Pain can almost always be managed, yet pain and its management needs to be continually reassessed throughout the illness. In rare circumstances palliative sedation may be considered to bring comfort to the patient and/or family. The assessment of pain should include the intensity, location, and character of pain, as well as duration and conditions that seem to worsen or relieve pain. Validated scales are commonly used in the assessment of pain, and are another essential component of a comprehensive pain assessment. Finally, this assessment should include not only a thorough medical history but also a review of current and past medications, including whether a history of substance abuse is present. Good and ongoing communication among patients, families, and health professionals is the key to effective pain assessment and management.
- Pain is what the patient says it is. Pain assessment should address “total pain” which includes fatigue, anxiety and depression as well as other social, psychological, spiritual, and existential distress. This assessment also needs to include other factors such as the patient and caregiver’s expectations, experiences attitudes, and anxieties toward pain as well as social, cultural, spiritual factors that might influence pain management.
- Considerable challenges exist in the assessment of pain for patients who are either unconscious or cognitively impaired. Very young children and persons who have a history of substance abuse may also be difficult to assess. A team approach is essential for assessing pain in these populations because the interpretation of non-verbal cues can vary among members of the medical team, caregivers, and others involved in the care of an individual.
- Health professionals should educate patients and families to be advocates for their own pain control – teaching patients and families to describe pain to health professionals. Patients and families should be made aware that there are health professionals such as pain specialists, palliative care professionals, and hospice professionals who specialize in the assessment and treatment of pain.
Intermission
Segment III
Pain Management at the End-of-Life
- Pain management should be fully integrated with the optimal treatment of the disease. It is a quality of care issue. Pain management begins as patients and families communicate their goals and experiences for the treatment of pain. It includes a multi-disciplinary team, multiple approaches, and continued reassessment. The treatment of pain should follow evidence-based guidelines, where possible.
- Pain is very treatable with medication and other interventional techniques. Opioids are an effective and proven method of pain control for pain that is moderate or severe in nature. The goal of pain management is to construct a consistent regimen with around-the-clock medication that provides effective pain control, a minimum of adverse effects, and that enables patients to make choices about how they wish to function on a day-to-day basis.
- There are many complementary therapies including massage, pet therapy, acupuncture, and music and art therapies, among others. While additional research on effectiveness is clearly needed, such therapies may decrease stress, provide comfort to the patient, and allow patients and families an enhanced sense of involvement and control.
- Health professionals should be aware that there are emerging legal and regulatory issues around the undertreatment of pain.
Segment IV
Pain Management: A Shared Responsibility
- Everyone on the team has a role in pain management. With physicians in the lead, nurses and pharmacists have a major role in the creation, implementation and monitoring of a patient’s medication care plan. Social workers, chaplains, clergy, volunteers, and all members of the team in all settings have a role in sharing assessments of pain and advocating for effective pain management.
- Family caregivers who are involved in administering pain medications need ongoing training and support to understand the importance of medication compliance. Defining the differences between opioid tolerance and addiction as well as providing education surrounding opioid “myths” (e.g. morphine = death) will help ensure an individual receives the pain medication prescribed.
- Hospices, nursing homes, hospitals and health care systems need to create policies and procedures that provide opportunities for patients, families, and health professionals to review pain management plans to prevent the further undertreatment of pain.
- Policies at every level need to be assessed for any unintended consequences that contribute to the inadequate and inappropriate treatment of pain. Health professionals should also play an important role by educating the media on the importance of, as well as obstacles to, appropriate pain management.
