Pain is one of the most important symptoms to target in palliative care. Up to two-thirds of patients with cancer experience pain severe enough to require a strong opioid, and this proportion is similar or higher in many other advanced and progressive conditions.1
Anxiety is also common, being a significant symptom in at least 25% of patients with cancer and 50% of those with congestive heart failure and COPD.2 The management of anxiety will be considered in detail in part two of this series.
A good understanding of the patient's pain forms the keystone of the development of a treatment plan. If not well controlled, pain can interfere with every aspect of the patient's day, from their ability to carry out simple activities of daily living, such as washing and dressing, to their tolerance of other treatments.
Without pain control, many other goals, for example, managing symptoms such as nausea, coping with interventions such as radiotherapy, or simply spending time with family or friends, may be unachievable.
Patients may have more than one type of pain, or pain at more than one location, and each needs to be identified and assessed before analgesics are started or changed.
Pain may be nociceptive (from damaged tissues) or neuropathic (from damage to nerves). It may be constant and predictable, or fluctuating and unforeseeable. Managing the pain of a headache may be very different to that of bony metastases or concurrent problems, such as osteoarthritis.
To formulate a treatment plan, the nature, geography and timing of pain must be considered, as well as an understanding of the specific benefits that different analgesic or pain treatments might offer in each case.
It is important to learn the patient's view about each pain, how much it contributes to their symptom load, what factors influence it and how they would prioritise its control.
Using this information to explore possible causes or aggravating factors can be valuable.
Pain assessment tools
Many pain assessment tools are available (see box) and it may be easier to use one with which you are familiar, to give a consistent picture.
Pain measurement tools
The British Pain Society is an excellent resource and you can find pain scales in a number of different languages on its website.
Unidimensional tools measure just one aspect of the pain experience, such as intensity, using visual analogue scales and verbal, graphic or numerical rating. They are quick and easy to use, and may be helpful for a spot check, but do not provide enough detailed information to guide a treatment plan.
Multidimensional pain assessment tools provide information about the qualitative and quantitative aspects of pain. They may take longer to complete and the patient may need more assistance, but the benefit is a much broader insight into the pain.
Observational pain tools are useful for patients who are unable to respond because they are unconscious, sedated or cognitively impaired. These focus on physiological responses or non-verbal behaviours, such as facial expression, restlessness and vocalisations.
Global scales may be particularly helpful in palliative care because they measure the patient's perception of the overall effectiveness of an intervention, addressing points such as the inconvenience or unpleasantness of the intervention and the meaningfulness to the patient of any improvement in pain and function.
One example of a multidimensional tool, providing all of the elements necessary to monitor pain in most cases, from a locator diagram to a visual analogue scale for each pain, comes from NHS Scotland's Palliative Care Guidelines.3
Neuropathic pain from a lesion, disease, or pathological change in the peripheral or central nervous system can be complicated to manage and responds poorly to standard analgesics, so identifying it may be critical.
Useful clues include pain in a dermatomal or neuroanatomical area, altered sensation such as allodynia (a painful response to light touch) and pain that is worse at night.
A neuropathic pain assessment tool, such as the Leeds Assessment of Neuropathic Symptoms and Signs, can be helpful.4
The patient's pain should be reviewed regularly at intervals determined by the stability of their condition. Initially, when analgesia is started or changed, assessment every day (or even more frequently) may be beneficial.
- Dr Macnair is a hospital doctor working part-time in medicine for the elderly for Surrey PCT at Milford Hospital.
- NICE. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. CG140. London, NICE, May 2012.
- Stoklosa J, Patterson K, Rosielle D et al. Anxiety in palliative care - causes and diagnosis. Fast Facts and Concepts 186, August 2007. www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_186.htm
- NHS Scotland. Palliative Care Guidelines, 2009.
- Bennett M. The LANSS Pain Scale: the Leeds Assessment of Neuropathic Symptoms and Signs. Pain 2001; 92(1-2): 147-57.