Managing Pain in Hospice Patients

Pain is an unwelcome experience we all live with from time-to-time. Pain varies anywhere from infrequent to chronic and ranges from mild to excruciating. One of the number one goals of the Hospice of Siouxland team is to manage pain. This article will look at pain types, the benefits of adjuvant medication and non-drug therapies, and tips on how to manage pain in Hospice patients.

Pain 101

The first question one must consider is how serious is the undertreatment of pain? According to the Center to Advance Palliative Care (CAPC), “Pain effects at least 116 million Americans each year, many of whom are inadequately treated by the healthcare system.”

Undertreated pain many populations of patients with pain including cancer patients, non-cancer patients with serious illness, and non-cancer patients with no concurrent serious illness (CAPC). There are several reasons pain is undertreated. If we look at recent news reports, it is easy to see why treating pain has become such a challenge. Included on the list of reasons are fear of diversion, fear of substance use disorders, clinician regulatory fears and misuse of prescription opioids.  In addition, it can be very difficult to assess pain.

As individuals we all have very different reactions to pain. Acute pain or pain that has a sudden onset will bring about a more immediate and recognizable reaction. Conversely, chronic pain reactions may be much harder to recognize. Another reason pain can be difficult to assess is the fact that patients don’t always report pain. Some relate pain to cultural or religious beliefs or practices. Others may fear pain medications because of stories related to negative experiences. There are many misconceptions related to pain medications and finally, dementia can make accurate pain assessment very difficult.

Structured Protocol for Choosing the Right Pain Medication

The first step to managing pain is a thorough pain assessment. Pain is assessed by looking at specific criteria; Quality, Region and Radiation, Aggravating/Alleviating Factors, Intensity, Temporal Characteristics and Functional Impact (CAPC).

Quality – How does the patient describe the pain? Is it sharp, dull, an ache, piercing, gnawing?

Region and Radiation – Where is the pain located and does it radiate or move to another area?

Aggravating/Alleviating Factors – What makes the pain better or worse; lying down, walking, sitting, ice, heat?

Intensity – How severe is the pain?

Temporal Characteristics – Duration – How long does the pain last? Pattern – is it worse at a certain time of day consistently?

Functional Impact – What does the pain keep the patient from doing? How is the patient’s daily function impacted?

One of the ways Hospice of Siouxland staff assess pain intensity is through a numeric pain scale. Patients are asked to assign a numeric value to their pain. This is done by using a numeric scale of 0-10 with 0 being none and 10 being the worst.

Equipped with this pain score, nurses are better able to decide the course of action to get the reported pain to the tolerable level as identified by the patient. This pain scale works well for most people but for patients suffering from dementia, the PAIN AD scale is used.

Use of the PAIN AD scale allows the nurse to objectively obtain a pain score from a patient who is unable to self-report. Again, this directs the nurse in treating pain symptoms appropriately based on actions of the patient.

Types of Pain – Somatic, Visceral, Neuropathic (According to the Centers to Advance Palliative Care)

Somatic Pain

Cause – Tissue damage to skin, soft tissue, muscle or bone  Example: shutting fingers in a door

Described as – aching, deep, dull, gnawing, sharp, stabbing

Somatic pain is usually well localized – patients can often point exactly to the location of the pain

Visceral Pain

Cause – Pain in the visceral organs i.e. gallbladder, intestine, liver

Described as – cramping, squeezing, pressure, full, bloating, all-over, gassy

May be accompanied by nausea, vomiting or sweating

Examples of visceral pain are jaw or arm pain from a myocardial infarction, back pain from a kidney stone, shoulder pain from the liver. It can be colicky such as abdominal pain that comes in waves associated with a bowel obstruction or gallstone.

Neuropathic Pain

Cause – Injury or inflammation of nerves, often coexists with somatic or visceral pain

Described as – burning, lancing, electric, radiating, shooting, stabbing

Examples can be diabetic neuropathy, the burning, tingling pain of herpes zoster, sciatica

Management of Pain

Pain Medications

Once a thorough assessment is completed, there must be determination as to what pain medication is appropriate and at what dosage. Medications like acetaminophen and non-steroidal anti-inflammatory analgesics are commonly used for mild pain rated 0-4 on the numeric pain scale. For moderate pain, level 5-6 and/or severe pain, level 7-10, the nurse will commonly choose medications such as morphine, oxycodone, hydromorphone and methadone.

It is not uncommon to use adjunct medication therapies such as anti-anxiety medications to enhance the effect of pain medication.

Non-drug Therapies for Pain

There are several other ways of managing pain in addition to medications. Non-drug therapies such as repositioning, application of heat or cold, massage, relaxation therapy, imagery, prayer and music have been found to be helpful.

Management of pain in Hospice patients can be challenging but with an appropriate and thorough pain assessment, determining the correct pain medication and dosage to use and adjunct non-drug therapies, the goal of pain management can certainly be achieved.

-Cheryl Deirup, RN, MSN, MHA, CHPN

Education Team Manager