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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.
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 anti-inflammatory 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
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.
Rationale: Turning and repositioning reduces pain stimulation and pressure receptors and maximizes the response to pain-relieving interventions.
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.
Rationale: Side effects of analgesics may be controlled by reducing the dose, increasing time intervals between doses, or administering adjuvant analgesics.
Rationale: Signs of withdrawal in a patient who is receiving opioids may be a sign of insufficient dosing or frequency or diversion of medication.
World Health Organization (WHO). (2019). Statement on pain management guidance. Retrieved August 11, 2021, from https://www.who.int/news/item/14-06-2019-statement-on-pain-management-guidance (Level VII)
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