Pain Assessment at End of Life

Overview

  1. Pain is prevalent in palliative care, but the majority of patients have good pain management with available treatment options
  2. An awareness of barriers to adequate pain management is essential for the healthcare proider as it allows the nurse to assess for and plan interventions for potential obstacles which may arisis in delivering good pain managment and overall paitnet care. Strong patient advocacy is essential for a palliative care nurse.
  3. A combination of thorough history and physical exam guides the pharmacologic and nonpharmacologic interventions
  4. Pharmacologic therapies: nonopioids, opioids, coanalgesics, chemotherapeutic agents and other intervention techniques
  5. Intractable pain and symptoms, although not common, must be treated aggressively. In some cases, palliative sedation may be warranted.

Pain is one of the most common and most feared symptoms at the end of life. However, this fear is largely unwarranted as the majority of patients can obtain relief. Nurses play a pivotol role in assessment and providing pain management.
1/3rd of patients receiving active cancer treatment and 2/3rds of those with advanced malignancies experience pain.
Understanding barriers to pain management will help better educate patient, family and professionals involved to ensure that effective pain management is achieved.
It is important to note that unrelieved pain hastens death by increasing the physicological stress, has the potential to diminish immune response, decreases mobility which tends towards complications such as pneumonia and thromboembolisims. It also increases respiratory effort and myocardial oxygen requirements.
Unrelieved pain can also crush the spirit resulting in “spiritual death” as the individual’s quality of life is significantly impaired.
Pharmacologic Managment
Non opioid analgesics
Acetaminophen is one of the safest analgesics for long term managment of mild pain.
  • It can also be supplemented  in the management of more intense pain syndomes.
  • It should be considered an adjunct in any chronic pain regime.
  • It has limited anti-inflammatory capabilities.
  • It should be used in low doses or avoided in cases of renal insufficiency or liver failure, and in individuals with significant alcohol abuse.
Nonsteroidal antiinflammatories are effective analgesics in their limitation of prostaglandin synthesis, inhibiting the inflammatory cascade.
“Classic” NSAIDs such as asprin or ibuprophen are relatively nonselective in their inhibitory effects on the enzymes that convert arachidonic acid to prosteglandins, resulting GI ulceration, renal dysfunction and imparied platelet aggregation is common.
The addition of NSAIDs to opioid analagesic therapy allows for a reduced opioid dose to be used when sedation, confusion and dizziness has become bothersome.
Like acetomenophen, decreased renal or hepatic function contraindicated NSAID use.
Platelet dysfunctioin or other potential bellding disorders contraindicate the use of non-selective NSAIDs.
Proton pump inhibitors can be given to prevent GI bleeding.
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