Understanding Physical Pain at End of Life: A Guide for the

Hospice IDT

National Hospice and Palliative Care Organization

Objectives• To teach non--medical interdisciplinary team (IDT)

members basic principles about pain and its’ medical management

• To teach IDT members their role in determining pain issues in their patients

• To teach documentation of pain by non--medical IDT members

Pain at End of Life• Physical pain– Physical manifestations of disruption of bodily functions

causing pain– Considered the fifth vital sign

• Psychosocial pain– Emotional pain which results from

spiritual/psychological/emotional conflicts/struggles

Pain is…• Subjective • Whatever the patient says it is• Affected by cultural beliefs• Common symptom at end of life• Controllable with proper management

Common Myths about Pain and Pain Relief

• Pain is my punishment or burden to bear– Reality - Being stoic about pain often is valued in our society.

This tendency may be more common among older persons. Patients need to be encouraged to report their pain so its management can take place.

• It is best to wait until the pain is severe before taking pain medications– Reality - It is best to stay ahead of the pain by taking

medications around the clock when treating persistent pain. The longer pain goes untreated, the harder it is to ease.

Common Myths, cont…• People who take strong narcotic pain medication

become addicted– Reality - Addiction is defined by a compulsive craving and

use of a drug, which results in physical, psychological, and social harm to the user. Addiction is NOT a problem for people who take opioid medications for persistent uncontrolled pain.

Common Myths, cont…• The side effects of strong pain medications make

people too sleepy which isn’t worth it…– Reality - The goal of pain management is to achieve

comfort while maintaining optimal alertness. Side effects of drowsiness will reduce or disappear within a few days.

Types of Pain - Somatic• Somatic pain– Localized in the skin, soft tissue, muscles, and bones– Somatic pain is caused by the activation of pain receptors

in either the body surface or musculoskeletal tissues

• Characteristics of somatic pain– Achy– Throbbing– Dull– Localized

Types of Pain - Visceral• Visceral pain

– Viscera refers to the internal areas of the body that are enclosed in a cavity (i.e.: lungs, liver, stomach)

– Visceral pain results from inflammation, distension, or stretching of the internal organs

• Characteristics of visceral pain– Squeezing, pressure– Cramping– Dull– Deep– Vague – in terms of location

Types of Pain - Neuropathic• Neuropathic pain– Neuropathic pain results from damage to the peripheral

nervous system or the central nervous system (CNS), or both

• Characteristics of neuropathic pain– Burning– Shooting– Tingling– Radiating– Numbness

Characteristics of pain• Pain can be constant or intermittent– “Breakthrough” pain happens when pain management

techniques fail to control pain

• Pain has intensity– Pain can be measured a variety of ways

• Pain can be controlled– Pharmacological methods– Non-pharmacological methods

Pain Assessment• Clinicians want to determine:– The type of pain– Location of pain– Intensity of pain– Quality of pain– Triggers of pain– What controls the pain– How the pain affects activities of daily living and quality of

life

Measuring Pain intensity• There are several types of pain measurement scales• 0–10 Numeric Pain Rating Scale – the patient is

asked to choose the number on the scale that rates their pain with “0” being no pain and “10” being the worst possible ever experienced

Measuring Pain intensity• Wong-Baker FACES Pain Rating Scale – the patient is

asked to choose the face on the scale that best describes the intensity of their pain. Faces range from no pain to the worst pain they ever experienced

Pain Assessment in Non-verbal Patients

• The following are non- verbal behaviors that can indicate the experience of pain:– Facial expressions: slight frown, sad, frightened face,

grimacing, wrinkled forehead, closed or tightened eyes, any distorted expression, rapid blinking

– Verbalizations, vocalizations: sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help

– Body movements: rigid, tense body posture, guarding, fidgeting increased pacing, rocking, restricted movement, gait, or mobility changes

Goals of pain management• Fulfill the patient’s right to pain management– What does the patient family/ caregiver want?

• Decrease pain experience and control pain

• Improve function and quality of life for patient

• Minimize side effects of pain management therapy

Pharmacological pain management• Opioids– An “opioid” is a family of morphine-like drugs used to treat

moderate to severe pain.– Are common narcotics

• Narcotics are chemicals which induce stupor, coma, or insensibility to pain

– Control pain when administered per physician order• On a schedule • Additional dosage for PRN breakthrough pain

Pharmacological pain management• Opioid use– Pain relief - when used in equivalent doses

• Opioids can also be used to treat…– Shortness of breath– Cough

Pharmacological pain management• Types of synthetic opioids for pain control – Hydrocodone– Oxycodone– Methadone– Fentanyl– Hydromorphone

Opioid Brand NamesGeneric Name Brand Namefentanyl Duragesichydrocodone Norco, Vicodinhydromorphone Dilaudid, Exalgomorphine Astramorph, Avinzaoxycodone OxyContin, Percocet

Pharmacological pain management• Opioid side effects– Sedation or drowsiness– Constipation – patient should begin a bowel regimen

simultaneously with opioid – Itching– Nausea– Confusion– Myoclonus -irregular involuntary contraction of a muscle

Adjuvant Medications• Acetaminophen (NSAIDS)

– Tylenol and Motrin

• Steroids– Relieve swelling and inflammation

• Anti-emetics– Treatment for nausea and vomiting

• Stimulants – Combats opioid induced drowsiness

• Antianxiety medications– Decreases experience of agitation or restlessness

Non-pharmacologic pain management• Examples of non-pharmacologic therapies include:– Hot-cold treatments– Positioning – Movement restriction-resting– Acupuncture – Hydrotherapy – TENS (Transcutaneous Electrical Nerve Stimulation)– Massage – Therapeutic touch

The Pain Management Plan• Developed jointly between IDT, the patient, and

family/caregiver• Based on continuous pain assessment outcomes • Includes consideration of patient’s cultural beliefs• Includes measurable goals for pain control on the

patient’s palliative plan of care• Includes pharmacologic and non-pharmacologic

interventions per patient’s preferences

IDT Member Role in Pain Assessment• IDT members may not function outside of their scope

of legal practice, but they can ask about pain when they visit the patient

• IDT members can document observations and subjective comments made by the patient and family/caregiver regarding the patient’s pain experience

• IDT members should report concerns about a patient’s pain experience to the RN case manager per organization policy

Asking about Pain• “Are you in pain?” or “Do you have pain?”

• “How would you describe your pain?”

• “What does your pain prevent you from doing?”

• “You seem to be frowning today…are you experiencing any pain?”

Documenting Pain• Documentation forms for social workers, chaplains,

and hospice aides should not contain prompts for pain assessment

• Documentation about pain from these disciplines should contain observations made by the team member, subjective comments made by the patient, family/caregiver, and feedback provided to the RN case manager as needed (per organization policy)

Documenting Observations – Case Study

• Mr. Smith is a 79 year old man with metastatic prostate cancer who lives with his 75 year old wife who has multiple health problems. His pain has been controlled on a long acting dosage of morphine. On your visit as the Social Worker (SW), you observe Mr. Smith’s behavior as restless, he exhibits intermittent grimacing, and frequently closes his eyes.

• You ask Mr. Smith if he experiencing pain or discomfort and Mr. Smith states that he is fine. You ask if he taking his pain medication as prescribed and he states “yes”.

Documenting Observations - SW• The social worker should include the following

information in the documentation for the visit:– That he/she observed Mr. Smith as restless, exhibiting

intermittent grimacing, and frequently closing his eyes– That Mr. Smith stated he was fine when asked about pain

experience and that he stated he was taking his pain medication as prescribed

– That he/she reported observations to the RN case manager

Mr. Smith – Follow Up• The RN will need to assess Mr. Smith’s pain for changes and

communicate changes to the physician for possible new orders and an update to the plan of care

• Mr. Smith may be experiencing breakthrough pain and the dosage of his medication can be increased or a medication for breakthrough pain can be added to his current pain management regime

Documenting Subjective Comments• The chaplain visits Mr. Smith the following week and she asks,

“Do you have any pain today?” Mr. Smith responds, “Since the doctor increased my pain medicine, I feel much better”.

• Mrs. Smith added, “He is sleeping more soundly at night too.”• Chaplain note should include: Mr. Smith stated, “I am feeling

much better since the doctor increased pain medicine”. And Mrs. Smith stated, “he is sleeping more soundly at night.”

Education for IDT Members• Before social workers, chaplains, hospice aides, or

other members of the IDT begin documenting about pain in the clinical record, they will require education about:– How to document– What to document– Where to document– When to document; when to alert RN case manager– Why to document

Policy for IDT Members• The hospice organization should develop a policy for

the IDT about observation of patient pain experience and documentation of pain in the clinical record

• The policy should include reference to IDT members functioning only within their legal scope of practice and that education is provided about the policy and documentation parameters

Let’s Review!

Questions

Resources• Palliative and End-Of-Life Care: Clinical Practice Guidelines, Kim

K. Kuebler, Debra E. Heidrich, Elsevier Health Sciences, 2007

• Partners Against Pain, Measuring Pain, www.partnersagainstpain.com, 2012

• Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review, Keela Herr, PhD, RN, FAAN, Karen Bjoro, RN, MSN, PhDc, Sheila Decker, PhD, APRN-BC, Journal of Pain and Symptom Management, Volume 31, Issue 2, Pages 170-192, February 2006