Pain is one of the most common symptoms in palliative care. Pain can also be a much feared symptom which can contribute to its intensity. The aim of palliative care is to allow patients to be pain free or for their pain to be sufficiently controlled so that it does not interfere with their ability to function or detract from their quality of life.
Good pain control requires:
- accurate and detailed assessment, and reassessment, of each pain
- knowledge of the different types of pains
- a different therapeutic approach to chronic pain
- knowledge of which treatment modalities to use
- knowledge of the actions, adverse effects and pharmacology of analgesics
- multidisciplinary assessment and treatment of other aspects of suffering that may aggravate pain – physical, psychological, social, cultural and spiritual distress.
The use of medication for the treatment of acute pain is the same as for non-palliative care patients. The treatment of chronic pain, that is often poorly managed, requires a different approach to acute pain.
In palliative care:
- the analgesic program should be kept simple, even for patients in severe pain
- oral medication is the mainstay of treatment and should only be abandoned if the patient is unable to take or retain oral preparations.
There is a myriad of pain medications available as they treat different types of pain.
Nausea is unfortunately a common symptom in palliative care patients and its effective treatment can lead to significant improvements in quality of life. Nausea and vomiting can also impact on the management of other symptoms, (such as pain), if oral medications are unable to be tolerated.
Dyspnoea, or shortness of breath, is a subjective symptom which is common in palliative care patients. Its cause is often multifactorial and the severity of a patient's dyspnoea is not always related to their oxygen levels. It is often associated with a degree of anxiety or distress.
Management of Dyspnoea
Where appropriate, identify and treat potentially reversible causes of dyspnoea, (e.g. pneumonia, anaemia, pleural effusion etc). The use of medical interventions should be evaluated on an individual basis with the aim not to increase burden to the patient and to ensure treatments are in keeping with the patient's wishes.
Most important is to treat the patient's experience of the symptom through pharmacological or non-pharmacological means to ensure comfort is maintained. Non-pharmacological Pharmacological (e.g. opioid medications)
Delirium is a common and often under-recognized syndrome of symptoms with multiple causes. It is a frequent, distressing and serious complication of advanced illness. The symptoms can include disturbances of consciousness, changes in cognition and the onset is usually short (hours to days) and they can fluctuate with periods of lucidity.
Early recognition, investigation and management is vital in reducing the duration and severity of distress.
Constipation (stools that are decreased in frequency and/or difficult to evacuate) is a common problem in palliative care patients, and is frequently multifactorial.(caresearch) Enquiring about defaecation is easily overlooked but is important as constipation can lead to considerable patient suffering.(TG) Opioid and anti-cholinergic medications may both induce constipation and a laxative should be prescribed pre-emptively when commencing such treatments.
◾Counselling the family that the patient is unlikely to be aware of, or distressed, by symptom is often helpful
◾Repositioning the patient from side to side can sometimes help them clear the secretions
◾Suction is unlikely to be helpful in most cases, and can be distressing for the patient
Noisy breathing is an indicator of impending death, occurring in about half of people who are actively dying.
As death approaches, some people develop confusion or agitation, which can be distressing.
Any reversible causes of agitation, such as unbearable pain should be identified and managed appropriately.
Agitation and restlessness may accompany delirium. (careSearch)
Depression is common, but easily overlooked in the palliative care setting. It has been identified as one of 11 common symptoms in a review of end-stage patient symptoms across five diseases. For those patients living with cancer the prevalence rates for depression are reported to be as high as 25-35%. (CareSearch)