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14 Articles in Volume 9, Issue #7
Anomalous Opiate Detection in Compliance Monitoring
Anticipating Biotechnological Trends in Pain Care
Continuous Lumbar Epidural Infusion of Steroid
Disordered Sacroiliac Joint Pain
Efficacy of Stimulants in Migraineurs with Comorbidities
Hand Tremor with Dental Medicine Implications
Helping Patients Understand the
Non-surgical Spinal Decompression (NSSD)
Pain Management in Nursing Homes and Hospice Care
Patients Who Require Ultra-high Opioid Doses
Relief of Symptoms Associated with Peripheral Neuropathy
Share the Risk Pain Management in a Dedicated Facility
The Multi-disciplinary Pain Medicine Fellowship
Thermal Imaging Guided Laser Therapy: Part 2

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.

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.

Yet most pain problems encountered in the nursing home or hospice can be managed with the careful use of medications and the effective use of non-pharmacologic pain management strategies (including integrative therapies such as imagery, therapeutic touch, repositioning, massage, relaxation techniques, distraction, and aroma therapy). A combination of pharmacologic and non-pharmacologic techniques result in more effective pain control and less reliance on medications that have major side effects in elderly patients.13 Nursing home and hospice residents may benefit most from physicians, nurses, and restorative care personnel who use an interdisciplinary approach to these complex problems.

But even with improved training, achieving adequate pain management will be difficult due to patient- and family-related issues.

Patient-related Issues in Treating Pain of the Terminally Ill

Although many patients freely express their pain, it is common for some patients to attempt to hide their level of pain, in order to protect the family from their own suffering or to help the patient appear “strong.” Some patients in hospice believe that suffering is a normal part of life. While each patient has the right to accept or refuse treatment for pain, hospice philosophy embraces the idea of relieving pain and bringing comfort to the patient who desires it. Hospice physicians and nurses are not there to “force” pain medications on patients who do not desire it.

Both patient and family may be under the assumption that pain is inevitable and may even become difficult to manage. Patients may resort to dealing with pain and discomfort silently in an attempt to deny that their physical condition is in a state of decline.19

In the terminally ill patient’s case, there is no basis for any fear regarding “becoming addicted” to a opioid given for pain. The legal use of opioid medications for pain is totally appropriate and a welcome relief from the severe pain that plagues many hospice patients. The terminally ill patient who suffers from severe pain needs these medications to relieve that pain. Using opioid medications for the terminally ill patient is truly compassionate and humane. Although the issue of addiction is of concern to many, it is important to stress that it is normal for patients in pain to require increasing doses of analgesics to manage pain. This is most often a reflection of inadequate dosage rather than addiction.

Opioids such as morphine have no ceiling and have been shown to relieve all types of pain.15 Short term studies have shown that elderly patients are more sensitive than younger patients to the pain relieving properties of these drugs.16,17 Advanced age is associated with a prolonged serum half-life for most opiate drugs.18 Thus, elderly patients may achieve pain relief from doses of opiate drugs that are smaller than those required by younger patients. Pain management in the elderly is often complicated by difficulties in pain assessment and under-reporting. It is important to help both families and patients understand that pain need not be present during care. Additionally, if pain is present, it can be controlled and managed quickly via both long and short acting opioids (short acting for “breakthrough” pain) by mouth (p.o.), or sub-lingual (s.l.), trans-dermal patch, suppository (p.r.), or intrathecal pump.

The best pain management requires an informed patient who is willing to report pain, and to voice complaints if pain is not controlled. Unfortunately, it is the rule rather than the exception that patients must volunteer that they are in pain before health professionals take notice. Unrecognized pain is untreated pain.

‘Subjective’ Pain Management Approach Needed

Treatment of pain must be one of the top priorities in hospice care. Changing medical practice is difficult, and improving pain management may be especially difficult. As our population of geriatric patients continues to rapidly expand, it is time to critically assess and remove the barriers to providing excellent palliative care and effective pain management to all patients.

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

Principles of pain management in hospice should include a recognition that pain is subjective and pain can be controlled at the end of life, and that care should:

  • assess and re-assess pain continually
  • use standardized pain assessment tools (such as Pain Diary)19
  • use “around the clock” analgesics as well as PRN “breakthrough” analgesics
  • include non-pharmaceutical interventions
  • provide ongoing instructions to patients and families


Ample evidence indicates that patients, their families, and the public are becoming less tolerant of poor pain management. That intolerance may prove to be the ultimate driving force behind improving care of terminally-ill patients with pain.

Three main principles should be followed in providing pain control at end of life when utilizing the hospice interdisciplinary team:

  1. Pain can be controlled in most patients by following the World Health Organization’s step care approach.20
  2. Acute or escalating pain is a medical emergency that requires prompt attention.
  3. Addiction is not an issue in patients with a terminal disease. When pain is treated appropriately, addiction problems are rare to non-existent.
Last updated on: December 20, 2011
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