Pain Management in Nursing Homes and Hospice Care

Despite the availability of a wide variety of effective pharmacologic and non-pharmacologic treatments, understanding of pain remains a significant problem in nursing homes and hospices.
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Hospice is a term given to specialized care that is intended to provide comfort and support to patients and their families when illness no longer responds to treatment and death is inevitable. Pain control is one of the central goals of hospice care. Federal guidelines regulating hospice require that the hospice make every reasonable effort to assure that the patient’s pain is controlled. Most state laws governing hospice also make pain control a primary and required component of hospice care.

Federal Regulations (42 CFR Section 418.54) state that: “The medical director…assumes overall responsibility for the medical component of the hospice’s patient care program.”

42 CFR Section 418.50 states: “A hospice must…make…drugs… routinely available on a 24 hour basis”; [and] “make…covered services available …to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions.” Palliation is the relief of symptoms, and pain is one of the main symptoms which hospice must focus on relieving.

Pain control during the last weeks of life can be a challenging patient management problem. Despite periodic entreaties in medical journals to improve pain control, inadequate pain management exists.1 In contrast to the simplicity of providing pain control, the cost of not providing it is high; both in terms of impaired function and quality of life. Patients with pain also are less able to commit to fighting their disease.

In most cases, hospice services assure that patients receive pain medication necessary to control pain. The hospice interdisciplinary team, including the certified hospice nurse, focuses on the patient’s comfort. A team approach is essential to address both the medical and psychosocial issues of patients. The attending physician should be focused on the same goal and, in most cases, does order pain medication.

Treatment of pain should be a top priority in end-of-life care. This must include the physical, emotional and spiritual aspects of pain management. However, excellence in pain control and symptom management has not been adopted as a “mission” of many physicians. Although patients do not die of pain, evidence suggests that untreated pain begets worse pain.2

Under-treatment of Pain Still an Issue

Unfortunately, for varying reasons, some physicians may not order the medication necessary to adequately control the patient’s pain. There is no doubt that opioid medications for pain are well accepted in the medical community. These medications are used successfully to control pain and keep patients comfortable. However, effective pain management for the terminally ill patient requires an understanding of pain control strategies.3

Under-treatment of pain is a persistent clinical problem. A recent study by Won, et al found that of 49% of nursing home residents with non-malignant persistent pain, 24.5% received no analgesics.5 Another study that investigated the treatment of pain in nursing home residents with cancer, 26% of the residents who were in daily pain received no analgesic medication.6 Other studies also have indicated indicated that patients older than 85 years, or minorities, were more likely to receive no analgesics.7-9

“Hospice’s goal is to reduce pain to a level that is acceptable to the patient—namely, a totally ‘subjective’ approach to care.”

Research by Miller, et al reported that “The prescribing practices portrayed by this study reveal[ed] that many dying nursing home residents in daily pain are receiving no analgesic treatment or are receiving analgesic treatment inconsistent with AMDA (American Medical Directors Association) and other pain management guidelines. Improving the analgesic management of pain in nursing homes is essential if high quality end-of-life care in nursing homes is to be achieved…”10

Hospice More Likely to Receive Higher Quality Pain Management

Hospice has become the accepted and welcome approach to providing care for terminally ill nursing home residents. It has been suggested that hospice care is associated with higher quality pain management and that patients enrolled in hospice are more likely than non-hospice patients to have a record of pain assessment and receive regular treatment for pain.11

Miller et al reported that “…controlling for clinical confounders, hospice residents were twice as likely as non-hospice residents to receive regular treatment for daily pain…”. They concluded that “… Findings suggest that analgesic management for daily pain is better for nursing home residents enrolled in hospice.’10

For patients to qualify for hospice, the attending physician must certify that if the disease process runs its normal course, life expectancy is less than six months. Unfortunately, referrals to hospice have a mean length of stay of 22 days, with 32% dying in a week or less.12 One week is not enough time to ensure good pain management. Clearly, prognosticating death is difficult for most physicians. Predictors of death, independent of age, gender and diagnosis, include:

  • decreased cognitive functioning
  • decrease in the ability to communicate
  • decrease in physical functioning
  • decrease in activities of daily living (ADL)
  • decrease in nutrition (weight loss)
  • incontinence

These factors may aid the attending physicians to help identify those patients who might be hospice eligible in a more timely manner.

Improved Training Needed in Pain Management

Despite the availability of a wide variety of effective pharmacologic and non-pharmacologic treatments, understanding of pain remains a significant problem in nursing homes and hospices.

Sources of ineffective pain management may be due to misconceptions, cultural mores, etc. For example, for physicians/nurses it may be inadequate knowledge of opioids coupled with a reluctance and even fear of using opioids. For patient and family there may be fear of addiction, fear of opioids in general and fear of being labeled.

Although it is unclear why healthcare professionals fail to use the best available pain management techniques for their patients, several factors contribute to the problem. Clinical training in pain management—other than for pain specialists—is almost non-existent. Few health care professionals feel that they have received adequate training in pain management in medical school or during their residency.

First published on: September 1, 2009