Pain Management in Palliative Care – Care Example

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"Pain Management in Palliative Care" is a brilliant example of a paper on care. As part of the goals of palliative care in alleviating the symptoms of advanced disease stages or as part of end-of-life care, pain management is considered vital to enhance patient quality of life (Perron & Schonwetter, 2001). Due to the subjective and complex nature of pain it is of utmost importance to keep open communication with patients, and asking them about how the pain feels (i. e. scaling the pain threshold, describing the pain’ s origin, pain intensity, etc. )(Moore, 2012).

However, prior to providing medications all non-drug pain interventions must be exhausted first, considering that the patient might need a more holistic approach for treatment (e. g. undergo counseling, seek spiritual guidance, treat depression, etc. ) (Perron & Schonwetter, 2001; Tidy, 2012). It is also important to take note of verbal and non-verbal cues on how the patient reacts to the medication (e. g. patient uses medication as sedative instead of pain-relief, asks for increased and frequent dosage, exhibits irritability or anxiety without the medication) in order to assess drug efficacy and assure that patient has proper intentions on medication usage (Parsons & Preece, 2010).                       Pain management strategies such as symptom assessment and physical examination of the patient can be performed to find out if the patient will need oral analgesics for mild to moderate pain or if the pain is severe enough to warrant the use of opioids (Bennett, et al. , 2012; Payne, Seymour, and Ingleton, 2008).

The mnemonic OPQRSTUV by the British Columbia Medical Association (2011) can be used to assess patient pain during symptom assessment: O – Onset – Ask patient when the pain started, how it started (acute or gradual), and pattern since the onset P – Provoking/Palliating – Ask patient what initiates pain, and what makes it better/worse Q – Quality – Ask the patient how the pain feels (e. g.

burning, tingling, itching, etc. ) R – Region/Radiation - Ask patient where the pain comes from and how it spreads S – Severity – Ask the patient to describe pain severity (e. g. using a scale of 1-10) T - Treatment -  Check records of current and past pain treatment, identify side-effects U – Understanding – Ask patients what pain or “ total pain” makes them feel and think of V – Values – Establish goals and expectations in alleviating pain symptoms After establishing the above with each patient, each time the patient experiences pain a physical exam can be performed by checking for signs of trauma, tumor-progression, or neuropathic etiology (British Columbia Medical Association 2011).

Once it has been established that the patient does need pain management, how the patient perceives pain shall guide in determining its level and consequentially providing the appropriate medication based on pain severity.                       Upon proper assessment of patient pain, use pain management strategies via a three-step analgesic ladder for pain management (World Health Organization, 2002 in Klein, et al. , 2011; and Payne, et al. , 2008): Step 1 – Mild Pain (levels 1 & 2): use non-opioid analgesic (e. g.

acetaminophen, aspirin, dipyrone, other non-steroidal anti-inflammatory drugs/NSAID) + co-analgesics (e. g. Carbamazepine, Clonazepam, etc. ). If pain increases/persists, move up to the next step. Step 2 – Moderate Pain (levels 3-6): use “ weak” opioid such as codeine or tramadol in addition to the non-opioid analgesics + co-analgesics Step 3 – Severe Pain (above level 6): if maximum doses of “ weak” opioids have been reached and still did not control pain well, use strong opioids (e. g.

morphine) with non-opioid analgesics + co-analgesics In the use of opioids side effects such as constipation, nausea, pruritus, and drowsiness can be expected, thus the need for additional mitigating strategies (e. g. provide laxatives, prescribe anti-emetics and anti-histamine, advise patients on possible concentration impairment) Bennett, et al. , 2012; Tidy, 2012). Also, based on the guideline by British Columbia Medical Association (2011) it is recommended that patient issues must be looked at before selecting the appropriate opioid: Difficult constipation – use fentanyl transdermal or methadone Renal failure - use fentanyl transdermal or methadone, avoid morphine, codeine, meperidine Compliance and convenience – use time-release formulations (e. g.

morphine, oxycodone) Neuropathic pain – use oxycodone or methadone Opioid naï ve – use low dose morphine, hydromorphone, avoid fentanyl transdermal patch or sufentanil Injection route – use morphine, hydromorphone, with methadone as the second line In summing up pain management for palliative care, the following is a basic step-wise pain strategy method based on the Palliative Care Guideline by the British Columbia Medical Association (2011): Provide analgesia continuously for chronic pain on a regular basis Start with short-acting opioids, titrate to an effective dose for a few days, then switch to slow-release opioids Upon pain-control, use long-acting agents (e. g.

q12h oral or q3days transdermal) for improved sleep Provide appropriate breakthrough opioid medication dosages, around 10% of the total daily dose given q1h as needed Use the appropriate co-analgesics in each pain ladder step Keep records of administered medications to patients

References

Bennett, M. I., Graham, J., Schmidt-Hansen, M., Prettyjohns, M., & Arnold, S. (2012). Prescribing strong opioids for pain in adult palliative care: summary of NICE guidance.BMJ, 344(7858), 42-43.

British Columbia Medical Association. (2011). Palliative care for the patient with incurable cancer or advanced disease - Part 2: Pain and symptom management. Author.

Klein, C., Lang, U., Bükki, J., Sittl, R., & Ostgathe, C. (2011).Pain management and symptom-oriented drug therapy in palliative care. Breast Care, 6(1), 27-34.

Moore, R. (2012). Handbook of pain and palliative care: Biobehavioral approaches for the life course. New York: Springer.

Parsons, G., &Preece, W. (2010).Principles and practice of managing pain: A guide for nurses and allied health professionals. Berkshire and New York: McGraw-Hill International.

Payne, S., Seymour, J., &Ingleton, C. (2008).Palliative care nursing: principles and evidence for practice. Berkshire and New York: McGraw-Hill International.

Perron, V., &Schonwetter, R. (2001).assessment and management of pain in palliative care patients. Cancer Control, 8(1), 15-24.

Tidy, C. (2012, July 19). Pain control in palliative care. Retrieved from Patient Plus: http://www.patient.co.uk/doctor/pain-control-in-palliative-care

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