All About Nursing · Hospice & Palliative Care

Pain Management at the End of Life (Reading and Sharing)

The prevalence of pain varies by dx, stage of disease, and setting of care. Approximately 1/3 of patients with cancer experience pain at the time of diagnosis, while 2/3 with metastatic disease report pain. Less is known about the prevalence of pain in those with diagnoses other than cancer.

Pain is described by the World Health Organization as a “multidimensional phenomenon with sensory, physiological, cognitive, affective, behavioral and spiritual components.” Pain is a complex biopsychosocial phenomenon, an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in these terms. (Pain is whatever the patient says it is.)

Concepts related to pain medication and pain management:

  • Misuse- use of a medication other than as directed or as indicated: whether willful or unintentional, and whether harm results or not. Examples may include the use of pain medications for sleep rather than pain control; can also include diversion of medications to others for use or sale.
  • Addiction– a primary, chronic, neurobiological disease with genetic, psychosocial, environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, and continued use despite harm and craving. Addiction represents a state of psychological dependence in which the patient exhibits a behavioral pattern that is characterized by craving for the drug and an overwhelming involvement in obtaining and using the drug for reasons other than pain relief.
  • Tolerance– a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.
  • Physical dependence– a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence is the universal, unavoidable altered physiologic adaptation to opioid use that requires continued use of the opioid to avoid that requires continued use of the opioid to avoid withdrawal reactions.
    • Signs and symptoms of abstinence syndrome (withdrawal) include anxiety, irritability, lacrimation, rhinorrhea, sweating, nausea, vomiting, diarrhea, abdominal cramps, insomnia, tachycardia, elevated blood pressure, and rarely multifocal myoclonus (multiple sites of mild to severe muscle twitching)
  • Opioid pseudoaddiction– iatrogenic syndrome in which patients develop certain behavioral characteristics of psychological dependence as a consequence of inadequate pain treatment. Patients with this syndrome must continually demonstrate their need for analgesics and are often described as difficult patients, chronic complainers, drug seekers, and /or “addicts'” Patients will often resort to bizarre or dramatic behavior (acting out) in an attempt to prove their pain is real so analgesics are provided.
  • Double effects-

In addition to the serious psychological harm caused by uncontrolled pain in the palliative care patient, there are several harmful physiologic effects of inadequate treatment of pain.

  • Increased heart rate and blood pressure lead to increased metabolic demand and increased myocardial stress.
  • Decreased mobility due to inadequate pain relief increases the patient’s risk of pressure ulcers, muscle wasting, and deep venous thrombosis.
  • Risk of atelectasis and pneumonia are increased in patients who are breathing shallowly because of uncontrolled chest/chest wall pain.

Excessive sedative effects of pain medications may impair the patient’s ability to interact with loved ones, but this should be managed with medication adjustments or use of psychoactive stimulants. uncontrolled pain dose not enhance a patient’s ability to have meaningful interactions with anyone. Finally, adequate pain control should not interfere with management of the patient’s primary disease.

***Methods about non-pharmacologic pain management ***

The application of heat to an area of pain: blood flow, tissue compliance, and muscle fiber relaxation increase in response to the application of a heat source. Heat also results in decreased nerve transmission of pain signals to the brain and spinal cord (via effects on both temperature and pressure receptors), which in turn enhances muscle relaxation and blood flow. Heat may be applied in a variety of ways, most of which are easy to use for both care providers and patients. Options include submersion (of either part of the body or the whole patient) in warm water, radiant heaters, hot packs, heating pads, hot water bottles, or heat wraps. Heat should not usually be applied over areas of decreased sensation because of the risk of burns.


Constipation should be anticipated and proactively treated whenever possible in the palliative care/ hospice patient. This involves regular assessments of the patient’s bowel habits and symptoms (e.g., bloating, abdominal pain, rectal pain) and monitoring for factors that predispose the patient to developing constipation (e.g., opioid therapy, decreased mobility, decreased oral intake). Because constipation is a universal adverse effect of opioid therapy, a bowel regimen should be started empirically with the initiation of opioid analgesics.

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