This presentation is a resource developed as

part of a face to face education event or

workshop.

The target audience is health and social care

professionals in roles providing palliative and

end of life care

The author has agreed to share the work to enable

best practice in the provision of end of life care

Definition

Common Myths and Fears

Challenges and Barriers

Assessment and basic Principles

Pharmacological and non

pharmacological treatment

Group work

Question Time

Years?

Months?

Weeks?

Days?

Hours?

“Pain is whatever the experiencing person

says it is, existing whenever and wherever the

person says it does”McCaffery

Cancer Pain the prevalence is about 79-90%

HIV – 50%

Other illnesses – anecdotally significant but no

specific data

https://youtu.be/8lPLkYHOSao

The World Health Organisation has

described pain as “an unpleasant sensory

or emotional experience associated with

actual or potential tissue damage, or

described in terms of “such damage”

https://youtu.be/y3xGcENVYM0

• The Leadership Alliance for the Care of Dying

People (LACDP) produced the report One chance

to get it right: improving people’s experience of

care in the last few days and hours of life in 2014.

• The report offers a comprehensive approach to

management of the dying patient in their final days

and hours.

• The ICO Strategy addresses issues regarding the

care of the patient who has been identified as

being at the end of their life, throughout the final

year and months of their life.

Only injections give you good pain relief.

Pain med use always leads to addiction.

Withdrawal is always a problem with pain meds.

Enduring pain and suffering can enhance one’s character.

Once they start giving you morphine, the end is near.

People have to be in a hospital to receive effective pain management with morphine.

Dying is always painful.

Some kinds of pain can’t be relieved.

Pain meds always cause heavy

sedation or hasten death.

I can get immune to the effects of

pain meds.

Failure to distinguish between causes of pain – cancer and non- cancer

Lack of attention to holistic issues/ Failure to use non-drug treatments

Failure to assess each pain individually and plan treatments separately

Failure to anticipate, monitor and control unwanted side effects

Failure to listen to patient and their agenda- Terminology

Chopping and changing regimens too quickly

Reluctance to use morphine / awareness that pain may not be non-opiate responsive

Fear of combining appropriate analgesics/ Combining analgesics inappropriately

P – Palliate - alleviating /aggravating factors (History

and physical – Visual / numerical analogue scales)

Q – Quality – what does it feel like? Describe?

(Patients experience)

R – Radiation – Where is it? Does it move?

S – Severity – How bad? How is it affecting you?

T - Timing – When did it start? Is it new? Always

there or intermittent?Use of Lab and radiological studies

History and physical

Numerical or visual analog scales

Patient’s description of pain and experience of pain

Use of appropriate lab and radiologic studies

Thorough assessment interview

Good Palliative Care involves –

Anticipatory decision making,

Clear and accurate information for families

Good and timely symptom control

Good communication between families

P: Physical symptoms or conditions Arthritis, constipation, bladder spasms, dementia, headache,

thrush, as well as cancer pain

A: Anxiety, anger, depression, hopelessness,

loneliness

I: Interpersonal issues – family tensions,

financial issues

N: Non - acceptance of approaching death,

spiritual or existential pain

1. Deal with “Total Pain” – Physical. Psychological, Family and social components

2. Educate patient and family to ensure active participation in the pain management plan –repeated conversation and supportive literature that is comprehensive but understandable

3. Be flexible in your approach, clinical guidelines may need to be adjusted to the individual – be reflective

4. Use the MDT effectively

5. Develop/plan standards of pain control that may effectively prevent unnecessary suffering

It is of clinical importance to try and distinguish the

components of a patients pain – and essential to

effective management

Nocieceptive Pain

Neuropathic Pain

Caused by invasion and / or destruction &/or

pressure on superficial somatic structures like bone,

muscle, skin and visceral structures and organs

Types ; superficial somatic, deep somatic and

visceral

Superficial and deep nociceptive pain is usually

localized and non radiating

Visceral pain is more diffuse and can be referred

Caused by pressure on and or destruction

of peripheral, autonomic or central nervous

system structures

Radiation of pain along the dermatomal or

peripheral nerve distributions

Terminology – burning, shooting, deep

ache and associated with dysesthesia or

lancinating pain

Paracetamol

Morphine

Diamorphine Oxycodone

Fentanyl

Alfentanil

Chemotherapy Dexamethasone

Gabapentin / Pregabalin

Tricyclic’s

Bisphosphanates

NSAID Methadone

Nerve Blocks and ablative neurosurgical procedures

Radiotherapy

Surgical

Massage

Music Therapy

Heat Packs

Pet Therapy

Reflexology

Positioning

Diversion

Acupuncture

Crystal Healing

Reiki

Educate patient and family Investigate wisely

Do not delay treatment, immediate action

Use a pain diary

Use WHO analgesic ladder – adjuvant therapies, stepped

approach

Give medication orally where possible, give regularly

Prescribe analgesics that match the severity of the pain

Titrate dose upwards as needed

Always consider adjuvant modalities

Take a preventative approach to prevent adverse effects

Always prescribe a breakthrough dose

Morphine - gold standard opioid

Uses: Acute and chronic pain

Administered: Oral, subcutaneous,

intramuscular, intravenous

Modified release – 12hrly doses via mouth

Immediate release – prn, 4hrly intervals for

breakthrough pain

Diamorphine

Acute/ Chronic pain

Administered via intramuscular or

subcutaneous injection

Diamorphine is 3 times stronger than oral

morphine

Oxycodone – renal friendly (eGFR <30)

Acute/chronic pain

Administered: Oral, subcutaneous,

intravenous

Modified release – 12hrly dose via mouth

Immediate release – prn, 4hrly intervals for

breakthrough pain

Oxycodone is 4 times stronger than oral

Morphine

Fentanyl

Alfentanil

Buccal Fentanyl

Nasal

Indications eGFR - < 30

Patches – Topical opioid patches should not be started in the terminal stage since it takes too long to titrate against a patients pain

If the person is already established on a patch it may be appropriate to continue with it and add in additional medications via the SCSP

• McKinley T34 Syringe Pump

• Administers subcutaneous medications over a 24hr period

• Separate training workshop

Fentanyl is a strong opiod with high potency

providing good analgesic efficacy

Large dose range for increasing analgesia

It is lipophilic. This allows rapid transmucosal and

transdermal absorption, but poor absorption via

the gut. (Morphine is hydrophilic)

Short duration of action due rapid absorption

and fast tissue redistribution

Inactivated by the liver so not dependant on

renal excretion

The formulations can be self administered

All licenced for the treatment of breakthrough cancer pain

Patients must be on background opioid maintenance therapy

4 treatments a day

All have rapid onset of action

ALL NEED TO BE TITRATED

Doses are not interchangeable with other oral preparations

Difficult packaging

A rapidly absorbing nasal spray

Rapid action 5-10 minutes

Each spray contains 100mcg or 400mcg

Up to 2 sprays for each episode

Does not cause discomfort in the nose

Fine mist which gels on contact with the

nose

Easy to use

Nerve blocks, epidurals and ablative neurosurgical

trichotomies may be effective in pain

management

Pain can return within weeks to Months

Celiac plexus block – particularly pancreatic pain

Need to consider Prognosis and Benefit V Harm

A patient is in renal failure? What analgesics would

you use?

A patient is struggling with tablets, due to ongoing

nausea and poor swallow? Considerations

A patient is being discharged home and is likely to

get less well in the next few weeks. What

medication do they need to go home with in case

they develop symptoms as they become less well?

Spiritual Angst or Despair

› Meaning of pain and suffering

› Retribution

› Punishment

› Spiritual cleansing

Social and Relational Issues

› Family roles

› Physical appearance changes

› Sexual relationship issues

› Burden on family

Cultural approaches to pain management› Folk remedies

› Other techniques or approaches for pain relief

Ask – “Are you comfortable?” vs. “Are you in pain?”

Family approach to understanding illness and pain

Appropriate use of medical interpreters –verbal and written translation

Ask how this patient may want to incorporate cultural approaches to pain management

Know your own attitudes and beliefs

› Admire stoics or encourage sharing of pain

issues?

› What are your thoughts or beliefs about pain

meds?

› What are your thoughts about those who

abuse pain meds?

Develop relationship with patient and family

Build trust with patient and family

Assess patient’s cultural beliefs and practices

regarding illness and treatment of pain

In your groups discuss the two case studies given.

You have 20 mins

Groups will then feedback

1. Everyone’s experience of pain is different

2. Pain is common in people living with a terminal

illness but not all patients will have pain

3. Pain is subjective – Pain is what the patient says it is

4. Physical pain can be worsened by psychological

worries and distress

5. There are many different painkillers and non –

pharmacological techniques to manage pain

6. Explain rationale and address misconceptions

“You matter because

you are you. You

matter to the last

moment of your life

and we will do what

we can not only to help

you die peacefully but

to live until you die”

(Dame Cicely Saunders)

South West Devon Joint Formulary

Palliativedrugs.com

Palliative Formulary

HSPCT / CSPCT

BNF