Pain Management in a Palliative Care Setting
Palliative care is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse the progression of the disease itself, or provide a cure. The goal is to prevent and relieve suffering and to improve the quality of life for people facing serious, complex illness. It should not be confused with hospice care, which delivers palliative care to those at the end of life.1
While palliative care may seem to offer an incredibly broad range of services, the goals of palliative treatment are extremely concrete:
- relief from suffering
- treatment of pain
- treatment of other distressing symptoms
- psychological and spiritual care
- daily living support system
- support system for the patient’s family2
Recognizing, Monitoring and Documenting Pain
Pain, acute or chronic, is an element of the large majority of medical ailments that physicians see on a daily basis. Back pain alone has been suggested to affect “up to 84 percent of adults…at some point in their lives” and back pain still exists as “the second most common symptom-related reason for physician visits in the United States.”3 In addition, it is important to consider that pain can be a major contributing factor in the morbidity and mortality associated with many medical conditions—often being “associated with progressive decline in functioning and other complications such as weight loss.”4 It is therefore clear that pain is an important factor to address in the comprehensive care of patients within all fields of medicine.
It seems appropriate then, that physicians—whose primary objective is to “apply, for the benefit of the sick, all measures [that] are required,”5—would seek to make use of all available tools to address this prevalent and problematic element of patient suffering. However, even with a clear need for adequate treatment of pain and pain-associated morbidities, the needs of patients across the spectrum of healthcare are not being met. Even with “moderate to severe chronic pain [being] experienced by at least 70 percent of patients with advanced cancer,”6 it is reported that “under-treatment of cancer pain has been estimated to be as high as 40 percent.”7 Beyond cancer, “studies demonstrate poor control of post-operative and trauma pain…and chronic, non-cancer pain.”8 Therefore, there is a dilemma regarding pain recognition and management that must be examined and acted upon in order to serve the large population of patients who suffer from pain on an acute or chronic basis.
In order to ensure that pain is being properly addressed, it is essential to have an adequate system for initially recognizing pain so that it may be treated promptly. A system where pain is monitored and documented in a clear way—with a history of the time of onset, intensity of the pain, any alleviating or discomforting factors, and the progression of the symptoms—is an invaluable tool for creating continuity of care of patients in many different clinical settings. However, “assessment of pain intensity alone is insufficient and may lead to unsafe care.”9 Rather, one must gather information regarding the “impact of pain on physical [as well as] emotional function,” and use that to guide an individually-tailored treatment plan because, again, pain must be defined by the total subjective experience of the specific patient being monitored and treated.10 This often includes not only the impact of pain on the patient themselves, but also on family members and others who they interact with. Further, it is important to assess “outcomes of prior and existing analgesic therapies,” so that a more directed management approach can be taken. Overall, an all-encompassing history regarding the experience of the patient’s pain is an excellent initial step at providing efficient pain management.
Pain Management Planning
In an effort to provide comprehensive health care for those in need, it is also important for clinicians to encourage the patient to contribute to the development of their own personal management plan. Studies have suggested that “patients engaged in collaborative care, shared decision-making with their providers, and chronic disease self-management have improved health outcomes.”11 It is incumbent on the physician to involve the patient in their own healthcare so that patients become educated regarding their condition and the options that are available to them. It is the emphasis on the personalized nature of management that is essential for efficient delivery of pain management.
“It is incumbent on the physician to involve the patient in their own healthcare so that patients become educated regarding their condition and the options that are available to them.”
Once a treatment plan has been formulated, it is crucial that the treatment pattern be followed and constantly monitored to ensure that goals are being met as judged by the physician, as well as the patient. Often, this begins with an understanding that “although efforts can lower the percentage of patients with moderate to severe acute [pain] and cancer pain, the elimination of pain is, in many cases, impossible.’12 Instead, it is more important for patients to realize that the primary goal of treatment of pain is to use treatments that are both efficient and safe. With a treatment plan in place, it is then important to constantly evaluate and reassess the efficacy of treatment and investigate any problems that arise. In this way, physicians “ensure safety and efficacy…[with] quality improvement efforts [fostering] active patient and family engagement in the treatment plan.”13 With such care taken to ensure a comprehensive and safe plan, treatment of pain can be successful.
Pain Management Delivery Issues
At this point, we are still faced with an overwhelming void in the delivery of appropriate pain management due to several key issues, which must be understood before any measures can be taken to overcome them. Among these barriers to effective pain management lies “the combined effects of clinician’s lack of knowledge, attitudes that diminish the perceived importance of pain management, and fear of hastening death; patient underreporting and therapeutic non-adherence; patient or family belief in the inevitability of pain or fear of addiction or tolerance; and system-wide impediments to optimal analgesic therapy.”14 In addition, studies suggest that “minority status, female sex, and a history of substance abuse each increase the risk of under-treatment.”15 Furthermore, “among institutionalized elderly patients with cancer, under-treatment has been linked to age greater than 85…impaired cognition, and the requirement for multiple medications.”16 It is clear from the multiple barriers that impede adequate treatment of pain that an effort to correct this inefficiency of healthcare delivery is absolutely essential.