Pain Treatment in Palliative Care (incl. Hospice Care)

Palliative care focuses on patients of all ages with a chronic disorder – whether an illness, condition, or injury – that adversely affects daily functioning or reduces life expectancy. The main goals of palliative care are to prevent and relieve suffering and to enable the best quality of life possible for patients and their families, no matter what the stage of the disorder, the need for other treatments, or the setting in which care is delivered. Documents in this section focus on pain and associated symptom management during palliative care via approaches incorporating pharmacologic, nonpharmacologic, and/or complementary therapies. In addition to physical aspects of pain, palliative care takes into account the psychosocial, psychiatric, spiritual, and other aspects of a comprehensive pain management program.

Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.

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For additional and more specific palliative-care topics, see the following sections….

• Clinical Guidelines: <Click Here>
• Position/Policy Statements: <Click Here>
• CME Courses: <Click Here>

For more general information on pain, see "Overview - Pain Management & Tx" under Clinical Concepts:<Click Here>

For your patients see the Patient Resources tab section for special educational materials: <Click Here>

IAHPC List of Essential Medicines for Palliative Care

From: International Association for Hospice & Palliative Care (IAHPC); 2007. Access checked 1/5/08

PDF available for download: http://pain-topics.org/pdf/PalliativeCareMeds.pdf (38 KB)

In collaboration with other organizations, the International Association for Hospice and Palliative Care (IAHPC) developed a list of essential medicines for palliative care in response to a request from the Cancer Control Program of the World Health Organization (WHO). The IAHPC list includes 34 medications of which 14 are already included in the WHO list as essential in the treatment of several conditions, many of which are common in palliative care.

Article was also published as: De Lima L, Doyle D. The International Association for Hospice and Palliative Care list of essential medicines for palliative care. J Pain Palliat Care Pharmacother. 2007;21(3):29-36.

Principles of Effective Pain Management at the End of Life

By: Fine PG, Mac Low C. Medscape Today. Reviewed and renewed October 11, 2007; 27 pages. Access checked 12/28/07.

See HTML article at: http://www.medscape.com/viewprogram/6079  (Free site registration may be required.)

The goal of this CME/CE activity is to provide readers with a current and comprehensive overview of pain management at the end of life, offering guidance and detailed resources to practicing clinicians. The end stages of chronic, progressive, life-limiting diseases bring a host of difficult symptoms and causes of suffering. There are disease-mediated symptoms, such as pain, dyspnea, fatigue, and loss of mobility, and there are the accompanying emotional states, such as depression, anxiety, and a sense of uselessness. These symptoms and states intertwine and interact in a complex manner, and each one deserves attention. Of the many symptoms experienced by those at the end of life, pain is one of the most common and most feared. The benefits of pharmacologic and nonpharmacologic therapies are discussed, and resources for pain scales are provided.

Pain Management at the End of Life – A Physician’s Self-Study Packet

From: Maine Hospice Council; 2006. Access checked 1/08/08.

PDF available at: http://www.mainehospicecouncil.org/Pain%20Management%20web%20version.pdf (594 KB)

This CME monograph covers the basics of pain management, including pathophysiology, the need for continual assessment, and the administration of non-opioid and opioid drugs. Additionally, recommendations for changing routes of opioid administration, dosing conversions, and dosing modifications are presented and further explored through 9 patient cases. A section on the management of the adverse effects of opioids and a discussion of the challenges of palliative-pain relief are included. The monograph concludes with a discussion of the legal aspects of pain management and presents myths and realities taking federal laws and Maine state laws into account.

Pain Management at the End of Life [book]

From: Hospice Foundation of America (HFA). Pain Management at the End of Life: Bridging the Gap Between Knowledge and Practice. 2006. Access checked 1/07/08.

Chapter 7 - End-of-Life Pain Management in Children and Adolescents - PDF available for download:

http://www.hospicefoundation.org/teleconference/books/lwg2006/selove.pdf

Chapter 14 - The Ethical Dimensions of Pain and Suffering - PDF available for download:

http://www.hospicefoundation.org/teleconference/books/lwg2006/rich.pdf

The HFA offers several chapters of this book in full-text online without charge. Chapter 7 takes a look at the complex psychological and emotional elements of pediatric palliative care from infancy through adolescence. In addition to assessment techniques and analgesic dosing charts, approaches for dealing with childhood emotions are presented. Chapter 14 explores the rights of the dying patient in relation to pain management. The issues of undertreatment of end-of-life pain and fears regarding legal concerns over prescribing controlled substances are examined.

The complete book can be purchased for $24.95 from the HFA online book store at
http://store.hospicefoundation.org/home.php?cat=2 or by calling the HFA toll-free number 800-854-3402.

EPERC - Pain Topics from the “Fast Facts Index”

From: End of Life/Palliative Education Resource Center (EPERC); Medical College of Wisconsin; 2005-2007. Access checked 1/7/08.

See the complete list of available “Fast Facts”: http://www.eperc.mcw.edu/ff_index.htm

The EPERC was developed to share educational resource material within the community of health professionals and educators who are involved in palliative-care education. The main content areas of the “Fast Facts” include pain, non-pain symptoms, communications skills, ethics, terminal care, and clinical interventions used near the end-of-life. In accordance with the mission of Pain-Topics.org, links are provided here to the 3 “Fast Facts” sections on pain management:

• 36-item Opioid Section – http://www.eperc.mcw.edu/ff_paA.htm
• 11-item Non-Opioid Section – http://www.eperc.mcw.edu/ff_paB.htm
• 8-item Pain Evaluation/Assessment Section – http://www.eperc.mcw.edu/ff_paC.htm

Methadone, Pain Management, and Palliative Care

By: Mary Lynn McPherson, PharmD, BCPS. ASHP 2006: Highlights of the 2006 American Society of Health-System Pharmacists Midyear Clinical Meeting; Medscape.com. Access checked 1/4/08.

See HTML article at: http://www.medscape.com/viewarticle/550895 (Free site registration may be required.)

In addition to a brief discussion on the need for regular assessment of end-of-life pain, the advantages of using methadone in this patient population are reviewed. Methadone dosing for pain management can be challenging in spite of advantages that include analgesic efficacy, long half-life, convenient dosing schedule, and low cost. The author provides recommendations that can reduce specific concerns related to methadone-drug interactions, comorbid patient conditions, and metabolism variability. Additionally, the paper outlines ways in which the pharmacist’s role can be expanded to provide support in the effective administration of medications for palliative care.

The IAHPC Manual of Palliative Care [book]

By: Doyle D, Woodruff R. International Association for Hospice & Palliative Care (IAHPC); 2nd Edition; 2004. Accessed 12/29/07.

See entire manual at: http://www.hospicecare.com/manual/IAHPCmanual.htm

See the chapter on Pain at: http://www.hospicecare.com/manual/pain.html

This IAHPC Manual of Palliative Care is a free offering intended to contain much of what is necessary for the daily practice of palliative care. The text follows an outline format that is concise and quick to read, yet comprehensive. The IAHPC hopes that this Manual, like its bookshop, its traveling fellowships, and its newsletter will help to bring palliative care to the thousands of people worldwide who still suffer severely and unnecessarily at the end of life.

Managing Pain in the Dying Patient

By: Whitecar PS, Jonas AP, Clasen ME. American Family Physician. 2000. Access checked 1/9/08.

See HTML article at: http://www.aafp.org/afp/20000201/755.html

This article, written for physicians in family practice, covers basic pain physiology and assessment and provides several concise analgesic drug-dosing tables. Three tables present non-opioid drugs, weak opioids, and strong opioids according to the stepped approach recommended in the World Health Organization guidelines. The uses of adjuvant medications and therapies are covered briefly; additionally, treatment recommendations are offered for common side effects associated with opioids.

Note: Vioxx, listed in this paper as a Step 1 analgesic, was withdrawn from the market in 2004. It is also important to remember that recent studies on non-steroidal anti-inflammatory drugs (NSAIDs) have shown an increase in the risk of heart disease or stroke in certain patients who use these products.
For more information on the safety issues related to NSAIDs, please see the Pain-Topics.org tab on non-opioid therapies: http://pain-topics.org/non_opioid_therapies/nsaids.php#NSAIDs

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