Pain is defined as “a sensory and emotional experience that is generally associated with tissue damage or inflammation” (Hatfield, 2006, p. 34). Assessment of acute pain, especially in cancer patients, requires special attention and strategies to assure that accurate information is collected on which to base a plan of care (Mendoza, 2006). Pain control is considered vital for several reasons. First, unmitigated pain leads to unwarranted suffering due to the fact that it leads to loss of appetite and sleeplessness and it can further weaken already debilitated patients (Anderson, 2008). Terminal conditions such as cancer can cause mental effects that are at times too much for the patient to bear (Hatfield, 2006). In some instances, pain leads to loss of hope in terminal cancer patients, because they feel that this is the painful destruction caused by the incurable disease.
Chronic unrelieved pain can lead patients to rejecting active treatment and when the pain is severe or they become depressed and consider or commit suicide. Ensuring good quality of life (QOL) in these patients is paramount and has been in the major focus of research (Miranda, 2006). QOL for people suffering from pain has been conceptualized as a multi-dimensional phenomenon that requires multidisciplinary care (Simons, 2008). Palliative care aims to “achieve quality of life and a dignified death, preferably in the place of the patients choosing” (Chemy, 2008, p. 5). This paper seeks to identify and critically discuss the process of pain assessment and management in patients with an eventual fatal condition, then identify the associated barriers and give recommendations.
Just like any other syndrome that leads to pain, “accurate, thorough, and systematic assessment of cancer pain is crucial to identifying the underlying etiology and developing a treatment plan” (Chemy, 2008, p. 12). Different techniques have been advanced to assess pain resulting from cancerous cells. The methods used to assess pain should be appropriate for the patient’s age and cognitive abilities. Furthermore, attention should be focused on the patient’s language needs. Other factors to consider before pain evaluation include the medication use, their efficacy and side effects. In the case of cancer, the physician or medical practitioner should consider the common syndromes associated with it. The need for psychological evaluation should also be included. Conditions that can be predicted as being eventually fatal are almost always cancer related; therefore, this paper will deliberate on cancer pain assessment.
The following are essential components of pain assessment according to Chemy (2008): The parts(s) of the body in which the pain is being felt; the pain intensity; the quality of the pain which can be further classified as nociceptive, visceral and neuropathic; the temporal patterns associated with the pain should be identified; the aggravating and alleviating factors should be identified; the meaning of pain, presence of suffering or existential distress should be investigated; the cultural factors of the patient; and finally, the medication history ( 2008).
There are various scales that can be used in pain evaluation. These include unidimensional, multidimensional and symptom assessment tools. Unidimensional scales include the numeric rating scale, such as 0 to 10, and a verbal descriptor scale, for example ‘no pain’, ‘moderate pain’, ‘severe pain’, or the use of a visual scale, for example a 10 cm line with anchors such as ‘no pain’ on the left and the ‘severe pain on the right and the patient indicates the place on the line that best represents the intensity of their pain (Hueng, 2007). Several types of scales utilize sketches of faces “(from smiling to distress) for those patients who may find it difficult to use the above tools” (Hatfield, 2006, pp. 56).
Several multidimensional assessment tools can also be identified. This can include the “brief pain inventory (BPI) is a valid, clinically useful pain assessment tool that” has found widespread application in people suffering from cancer (Corn, 2006, p. 24). This may comprise following “a diagram to note the location of the pain, questions that regard the intensity of the pain (current average, average and worst using a 0 to 10 scale) and items that evaluate impairment due to pain” (Chemy, 2008, p. 23).
Symptom assessment tools can also be used in pain evaluation. Research conducted shows that there is “a significant correlation between pain, depression, fatigue and other typical symptoms that are seen in people suffering from cancer” (Armstrong, 2009, p. 18). These symptoms that occur together are often referred to as symptom clusters (Boffetta, 2010). The utilization “of multi-dimensional scales in identifying all the typical symptoms ensures a complete and systemic assessment”. (Hueng, 2007, 16). Several instruments that measure symptom clusters are available (Travell, 2009).
Enablers for pain management
These are factors that facilitate pain management. There are various methods through which the relief of pain can be achieved. These methods include explaining the situation to the patients to help them cope with it; modifying the pathological process that leads to the pain to relieve the patient; elevating the painful threshold; interrupting the pain pathways to prevent the actual feeling of pain; and finally modifying the lifestyle of the patient (Portenoy, 2005), for instance through immobilization. If the disease-modifying treatment is being prescribed, this does not mean that analgesics should not be used (Simons, 2008). Best results are usually obtained when a multi-modality approach that combines two or more treatments is adopted. The use of analgesics and other drugs is simply one way of elevating the patient’s pain threshold, thus reducing perception of pain (Miaskowski, 2005).
Goals of good pain management
The following are some of the desired end results for pain assessment.
- 50% pain relief is considered a good pain relief initially
- Relief at night when the patient wants to sleep
- Relief at rest during the day
- Relief on movement, which is not always completely possible.
Analgesics are the most commonly used drugs to manage pain in cancer patients in the long-term care facilities. The oral route is the preferred route for analgesics, including morphine. If patients are unable to take the drugs orally, the preferred alternative routes are rectal and subcutaneous (Parter, 2007). Persistent pain always requires preventive therapy. The WHO recommends the following ladder that guides the use of analgesics:
- Step 1: Non narcotics, NSAIDS,
- Step 2: Mild opioids,
- Step3: Strong opioids (morphine) (Miranda, 2006).
The following guideline is most suitable when analgesics are used. Morphine is still the gold standard analgesic for use in moderate to severe cancer pain. It may be started with 10 mg 4 hourly doses as per the patient’s physical status, age and pain intensity. However, individual variation does occur (Mendoza, 2006). It is also important to control side effects such as constipation, nausea and vomiting, pruritis and, rarely, respiratory depression (Lepore, 2005). Codeine may be used where morphine is not accessible. Codeine plus ibuprofen or paracetamol combination tablets may be prescribed effectively and are available as over-the-counter (OTC) drugs (Kadluber, 2007). Pharmacologically, pain in cancer can be divided into: 1. Opioid responsive, which refers to pain which is relieved by opioids; 2. Opioid semi-responsive, which is pain that is best relieved by concurrent use of opioids and an adjuvant drug (Corn, 2006); and 3. Opioid resistant, this is pain that is not relieved by opioids but by other drugs.
For the individual: The right dose of an analgesic is one that relieves the pain. The European Association for Palliative Care (EAPC) recommends that morphine be given by mouth every four hours and the same dose for breakthrough pain given as often as required. If pain returns consistently before the next regular dose is due, the regular dose should be increased. A double dose at bedtime is a simple and effective way of avoiding being woken by pain (Parter, 2007). As death approaches, pain diminishes. Patients may withdraw and may stop eating and drinking altogether. These days may be a time of intense personal and spiritual work and the focus of palliative care should be changed (Travell, 2009). A dying patient’s need for analgesics may sometimes increase. In such cases where high doses of opioids are needed, benzodiazepines and/or large doses of neurologic such as haloperidol may be added.
Monitor treatment: The response to treatment must be monitored to ensure that benefits of the treatment are maximized and adverse effects are minimized.
Use of adjuvants and drugs: A laxative is almost always necessary with opioid prescription. NSAIDS drugs should be added with H2 receptor blockers or proton pump inhibitors (Armstrong, 2009). COX-2 NSAIDS currently available in many parts of the world in the form of celecoxib, and Roficoxib may be safer as they do not cause gastritis and platelet dysfunction. However, even COX-2 be used with caution in renal-compromised patients (Hatfield, 2006). Tricyclic antidepressants (TCA) are very useful adjuvants in a majority of patients to provide psychological uplift. Amitirpyline 25 mg at bedtime is usually the starting dose (Armstrong, 2009), but should be avoided in cardiac patients. Side effects are dryness of mouth and giddiness in the morning. Some patients continue to experience pain on movement despite analgesics (Boffetta, 2010). Surgery, chemotherapy, radiotherapy and anesthetic approaches (nerve blocks) may sometimes be useful in controlling the pain optimally (Mendoza, 2006). Physiatic and psychological methods are used as good complementary tools in relieving pain. The situation may also be improved by suggesting modifications to the patient’s way of life by using various rehabilitative methods (Parter, 2007).
Palliative care can also be offered from home, where the patients are treated for pain and given emotional and spiritual support by their family members in the last days of their life (Mendoza, 2006). Home-based palliative care makes the patients feel more comfortable as they are in constant touch with their loved ones. However, this can be challenging in times of acute pain when physicians are required to assess and provide medical assistance (Armstrong, 2009). Home-based care is often complemented by visitations from nurses who train family members on how to assess the pain and offer solutions.
Barriers and recommendations to pain assessment and management
Cancer sufferers are in most cases older patients who often present with multiple barriers to pain assessment. The barriers can be outlined in several categories as follows: awareness of the patient-associated barriers that interfere with effective assessment and management of pain is important in creating a plan of care that will enhance comfort in the older cancer sufferer (Armstrong, 2009). People from different cultures have different belief systems. This has led to misconceptions and fears being exhibited by patients, especially those suffering from cancer (Miranda, 2006). If the presence of the misconceptions can be established, then a physician or any other medical practitioner may have an easy time in developing more open communication. This will enhance determining the presence of pain and increasing the patient’s chances of agreeing to the treatment plans (Portenoy, 2005). The selected assessment approaches should take into account the culture and beliefs of the patient.
The barriers that are related to the patient may come in the following forms: 1. the fear of the patient and their family members that they can get addicted to pain medication is common (Parter, 2007). Education on the differences between physical dependence and tolerance to analgesia and addiction should be provided. A second associated fear is that the use of opioids may lead to respiratory depression and arrest (Anderson, 2008). Other cancer patients may fear the diagnostic investigation that is needed to assess the pain and being hospitalized for “diagnostic testing or therapy, and loss of independence and consequences of a serious diagnosis” (Parter, 2007, p. 114). Another common misconception is the fear that if the pain medications are used early, then they may not work when the pain worsens (Portenoy, 2005). If the concerns that lead to this fear can be established, then the health provider will be better placed to discuss possible solutions with the patient.
3. “Older cancer sufferers may usually “believe that their primary care provider is omniscient and will know if they any problems that can be treated and will treat them if they can” (Jacobson, 2005, p. 15). In this case, the patient does not want to appear as a bother to the physician. 4. When the patient shows with multiple comorbid medical problems the assessment may be complicated due to the multiple pains felt (Travell, 2009, p. 22). This complicates the pain evaluation and treatment process, especially when the different conditions require distinct pharmacological interventions.
It is generally observed that healthcare providers are least prepared to assess pain in the older patients suffering from cancer. This is because the medical courses offered have not included education on pain approaches in relation to age changes.
Some barriers are brought about by the design of the health care. Cautious and routine assessment “for the presence of pain and its relief following intervention should be the main aim” (Boffetta, 2010). Unfortunately, the provision of palliative care and pain management has not been featured prominently in the priorities of long-term care (LTC) facilities (Travell, 2009). Thus, the institutions need to increase their commitment in ensuring that proper techniques of assessing pain are developed for older cancer patients, especially those who are nearing the end of their lives.
This paper sought to describe the process of pain assessment and management in patients with eventual fatal condition. It has been established that appropriate methods based on the patient’s factors should be used to assess the pain and proper management planned to help the patient in the best way possible. Several tools that can be used for pain evaluation have been shown above. The associated difficulties to pain assessment and management, mostly related to the patient have also been identified. Important recommendations in regard to pain assessment and management have also been made. In a nut shell, it is important that a patient suffering from a terminal condition receive adequate care just like those who do who have a chance of healing. This should include emotional and spiritual support is also vital in the patient’s last days.
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