Pain Management at the End of Life: Medications (Hospice and Palliative Care) - CE/NCPD

ALERT

An accurate pain assessment must be done on admission to hospice care and at regular intervals to ensure positive outcomes.

Dosing is always dependent on the patient’s individual characteristics and response.

OVERVIEW

Pain is a common symptom experienced at the end of life. Hospice nurses have the responsibility to advocate for the management of pain for their patients. There are three categories of pain medications that are used in end-of-life care, including opioids, nonopioids, and adjuvants. The World Health Organization (WHO) developed a three-step pain management ladder (Figure 1) for choosing appropriate pain medications for cancer pain relief in adults. This guide has been adopted for use in other specialties, including hospice and palliative care.^{undefined#ref1">1,3}

The first step in the three-step WHO ladder is to begin with a nonopioid medication and consider the use of an adjuvant medication (e.g., antiemetics, anxiolytics, antipyretic, stool softener). The nonopioid medications include acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs). Acetaminophen should be used with caution in patients with renal insufficiency or liver failure.⁵

NSAIDs include aspirin and ibuprofen. This class is particularly useful in the treatment of pain caused by inflammation. As with acetaminophen, NSAIDs are commonly used nonopioid medications at the end of life. Also, caution should be used when dosing NSAIDs for patients with decreased renal function or liver failure.¹

Adjuvant medications are not primarily used for pain management but can have the benefit of permitting a reduction of the opioid needs and treat symptoms associated with pain (e.g., nausea, cramping, itching, constipation, anxiety, fever). There is a wide variety of medications that may be used as an adjuvant to analgesia. Corticosteroids may be used to reduce inflammation that can cause pain. Antidepressants and anticonvulsants are used in managing neuropathic pain.

Opioid analgesics are used to treat moderate to severe pain. Opioid medication should not be the only pharmacologic pain management modality considered.

Many patients, families, and caregivers have concerns about addiction. Hospice nurses must understand the differences between addiction, physical dependence, and tolerance. Addiction is the psychological craving for the medication or drug. Dependence is when physical symptoms develop after a medication or drug is discontinued. Tolerance occurs when the body becomes accustomed to the medication or drug and a higher dose is required for the same level of pain relief.

The hospice care team should not underestimate the effect that psychological, emotional, or spiritual distress can have on pain and pain management. The hospice care team should collaborate with the patient, family, and caregivers to develop a comprehensive plan of care.^2,4

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Consider the patient’s, family’s, and caregivers’ values and goals in the decision-making process.
• Assist the patient, family, and caregivers to anticipate the patient’s needs at the end of life.
• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the progression of pain as the end of life approaches (e.g., increased need for medication, stronger medication, more frequent doses, alternative routes). Describe what the family and caregivers are likely to see, hear, and experience.
• Reassure the patient, family, and caregivers that the primary goal is to relieve anxiety and promote the patient’s comfort.
• Collaborate with the patient, family, and caregivers to develop a pain management plan and review pharmacologic and nonpharmacologic pain-relieving interventions.
• Explain that consistent and accurate assessments of pain are necessary to treat the patient’s pain appropriately.
• Provide information about the physiologic and psychological effects of undertreated pain.
• Collaborate with the family and caregivers to learn and identify the patient’s pain cues and behaviors.
• Collaborate with the patient, family, and caregivers to record medication administration for documenting and reporting control of pain to the health care team.
• Teach the patient, family, and caregivers about all medications, including indications for use, dosing, frequency, side effects, and signs of allergic reaction.
• For the patient on patient-controlled analgesia, explain the parameters and safeguards for use.
• Explain to the patient and caregivers about the safe use, handling, and storage of prescription opioids and other medications.
• Discuss the importance of a consistent bowel regimen for patients treated with opioids for pain management.
• Instruct the patient and caregivers how to dispose of unused, unwanted, or expired medications.
• Educate the family and caregivers regarding bereavement care and counseling for survivors.
• Assist the patient and family to engage and participate as drivers of the plan of care.
• Establish a rapport with the patient, family, and caregivers that encourages questions. Answer them as they arise.

ASSESSMENT

Consider the benefit of an intervention versus the burden to the patient. The goal of care is to reduce the patient’s anxiety and pain and increase the patient’s comfort and happiness at the end of life. Consider the impact to the family and caregivers.

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s level of consciousness and ability to understand and participate in decisions. Include the patient as much as possible in all decisions.
5. Assess and discuss the patient’s, family’s, and caregivers’ goal for pain management.
6. Collaborate with the patient, family, and caregivers to develop a plan for pain management.
7. Assess the patient’s experiences with pain.
8. Assess for factors that may alter the patient’s ability to provide a pain response, such as immobilization, neurocognitive impairment, fatigue, anxiety, and medications affecting heart rate and blood pressure.
9. Assess the patient’s, family’s, and caregivers’ understanding of the reasons for and the risks and benefits of pain management.
10. Consider the patient’s culture, including beliefs and practices, in the pain assessment and plan accordingly.
11. Assess the patient’s response to pharmacologic and nonpharmacologic interventions.
12. Identify the nonpharmacologic pain treatment modalities that work best for the patient.
13. Assess for concomitant symptoms from the side effects of opioids, such as constipation, nausea, vomiting, pruritus, sedation, respiratory depression, confusion, hallucinations, and urinary retention.
14. Assess the family’s and caregivers’ understanding and expectations regarding physiologic and behavioral changes that are likely to occur as the patient approaches the end of life.
15. Assess the need for social work, counseling services, and spiritual care for the patient, family, and caregivers.

PREPARATION

1. Prepare the patient’s environment for any painful procedure or treatment (e.g., suctioning, dressing change).
   1. Adjust the temperature, lighting, and sound to suit the patient, family, and caregivers without interfering with the ability to perform the procedure.
   2. Minimize activity by preventing unnecessary interruptions, coordinating activities, and planning for rest periods. Consider clustering care around pain medication administration times.
2. Ensure that the patient, family, and caregivers understand the purpose of pain management at the end of life and that their questions are answered.
3. Create an environment of trust that allows conversation regarding the management of expectations, the right to die pain-free with dignity, and understanding of the process of caring, not curing.
4. Create an environment that advocates for the patient’s needs using a holistic interdisciplinary team. Engage the team to assist and support the patient, family, and caregivers during the last phase of life.
5. Prepare the family and caregivers for the progression of pain management as the end of life approaches, including the need for increasing doses or frequency of medication. Describe what the family and caregivers are likely to see, hear, and experience. Reassure the patient, family, and caregivers that the primary goal is to relieve anxiety and promote the patient’s comfort.
6. Prepare an area in a clean, convenient location, and assemble the necessary supplies.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Explain the procedure to the patient, family, and caregivers and ensure that the patient and family agree to pain management.
3. Remove as many uncomfortable stimuli as possible.
4. Assist the patient to a comfortable position.

   Rationale: Turning and repositioning reduces pain stimulation and pressure receptors and maximizes the response to pain-relieving interventions.

5. Provide appropriate psychosocial and nonpharmacologic interventions to help the patient relax.
6. Attempt nonpharmacologic interventions in conjunction with administering analgesic medication.
7. If nonpharmacologic interventions and current analgesics are ineffective, or none have been ordered, consult with the practitioner regarding an order for analgesics.
8. Verify the practitioner’s order.
9. Administer analgesics as ordered.
10. Premedicate for procedures known to be painful for the patient (e.g., repositioning, suctioning, dressing changes).
11. Reassess the patient’s pain status, allowing for sufficient onset of action per medication, route, and the patient’s condition.
12. Monitor the patient for adverse and allergic reactions to the medication. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction.
    1. Follow the organization’s practice for emergency response.
    2. For the hospice nurse in the home setting, activate emergency medical services; administer epinephrine in an autoinjector, if available; attempt to keep the patient calm; and position to keep the airway open, if possible.
13. Discard or store supplies, remove PPE, and perform hand hygiene.
14. Ask the patient and family if they have any further questions or concerns.
15. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Continue to assess, reassess, and treat the patient’s pain using an organization-approved pain assessment tool. Consider the patient’s age, condition, and ability to understand.
   1. Reassess pain after an intervention and regularly over time with methods of pain assessment and specific behavioral indicators that are appropriate for the individual patient.
   2. Reassess pain on a scheduled basis for a patient who reported pain on a previous assessment. Incorporate the assessment intervals into the treatment plan and base them on:
      1. Organization practice or guidelines for routine reassessments
      2. The patient’s condition, including the cause of the pain, pain severity, and comorbidities
      3. New pain, an exacerbation of reported pain, or change in activity
      4. If medication is administered, reassessment of pain status, per the medication’s expected onset of action
      5. A reasonable interval after an activity or procedure that causes or exacerbates pain
   3. Maintain a record of the patient’s assessment, including pain indicators and interventions. Keep this record in a location available to the hospice or palliative care team, as well as the patient, family, and caregivers.

      Rationale: Making this record available to the patient, family, and caregivers helps them continue adequate pain management when the hospice or palliative care team is not present.

2. Monitor the completeness and accuracy of the home medication administration record provided by the family and caregivers.
3. Compare the patient’s current pain level with the previously set goal.
4. Compare the patient’s ability to function, perform activities of daily living (ADL), and interact before and after pain-relieving interventions.
5. Evaluate for the presence of analgesic side effects.

   Rationale: Side effects of analgesics may be controlled by reducing the dose, increasing time intervals between doses, or administering adjuvant analgesics.

6. Evaluate and assist the family’s and caregivers’ ability to cope with the patient’s pain and to perform pain-relieving interventions.
7. Monitor a patient who has received opioid or benzodiazepine medication for several days for withdrawal behaviors (e.g., shaking, irritability, nausea, vomiting, diaphoresis).

   Rationale: Signs of withdrawal in a patient who is receiving opioids may be a sign of insufficient dosing or frequency or diversion of medication.

8. Assist the patient, family, and caregivers with resources to support emotional, psychosocial, and spiritual needs. Encourage them to use available community resources and volunteers.
9. Encourage the patient, family, and caregivers to use the 24-hour telephone line for questions and concerns as they arise.

EXPECTED OUTCOMES

• Patient verbalizes or manifests relief from pain.
• Patient exhibits nonverbal pain relief, such as relaxed body, smiling face, or interest in playing.
• Patient’s function improves as evidenced by more restful sleep, improved nutrition, increased developmentally appropriate activity, and interactions with others.
• Patient is free from side effects of pain medication.

UNEXPECTED OUTCOMES

• Patient, family, or caregivers verbalize continued patient’s pain that exceeds pain level goal, describe worsening of pain, or identify pain in a different location; or patient displays nonverbal behavior reflecting pain (i.e., regresses further).
• Patient experiences adverse reaction(s) to medication or other interventions, such as apnea or bradypnea, nausea, vomiting, constipation, itching, sleepiness, or withdrawal.

DOCUMENTATION

• Patient’s vital signs per the organization’s practice
• Patient’s level of consciousness
• Patient’s response to medication, including any adverse reactions
• Patient’s, family’s, or caregivers’ report of pain level, using an organization-approved pain assessment tool, desired pain level, level of consciousness, and description of pain
• Nonpharmacologic methods used for pain management and their effectiveness
• Date and time pain is assessed, location, and type of pain
• Date and time of administration of pain medication (name, route, dose, location of injection if applicable)
• Patient’s behaviors before administration of pain medication and after administration
• Pain-relieving interventions implemented and their effectiveness (e.g., adequate or inadequate)
• Reductions in the patient’s function if determined (adverse reactions from pain interventions [pharmacologic and nonpharmacologic, or both])
• Findings of ongoing assessments, interventions completed (including notification of practitioner, if done), and patient’s response to interventions
• Unexpected outcomes and related interventions
• Education
• Patient’s, family’s, and caregivers’ progress toward goals
• Assessment of pain, treatment if necessary, and reassessment

REFERENCES

1. Coyne, P. and others. (2017). Pain management guidelines. Retrieved November 28, 2022, from https://prc.coh.org/NRE%20Pain%20Card%20revised%2010.17.17.pdf (Level VII)
2. Coyne, P., Mulvenon, C., Paice, J.A. (2018). American Society for Pain Management Nursing and Hospice and Palliative Nurses Association position statement: Pain management at the end of life. Pain Management Nursing, 19(1), 3-7. doi:10.1016/j.pmn.2017.10.019 (Level VII)
3. Lilley, L.L., Collins, S.R., Snyder, J.S. (2023). Chapter 10: Analgesic drugs. In Pharmacology and the nursing process (10th ed., pp. 135-164). St. Louis: Elsevier.
4. Miner, M.B. and others. (2018). Enhancing cancer pain assessment and management in hospice. Journal of Hospice & Palliative Nursing, 20(5), 452-458. doi:10.1097/NJH.0000000000000467 (Level VI)
5. Ramachandran, A., Jaeschke, H. (2018). Acetaminophen toxicity: Novel insights into mechanisms and future perspectives. Gene Expression, 18(1), 19-30. doi:10.3727/105221617X15084371374138

ADDITIONAL READINGS

World Health Organization (WHO). (2019). Statement on pain management guidance. Retrieved November 8, 2023, from https://www.who.int/news/item/14-06-2019-statement-on-pain-management-guidance

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Suzanne M. Casey, MSN-Ed, RN
Published: December 2023