As healthcare professionals, we can sometimes underestimate the need for pain management in certain patient populations. We seem to grasp the need for effective pain management in hospice patients, burn victims and post-surgical patients, but in other areas, such as palliative care, we can miss the opportunity to do our best work as “healthcare professionals” and dramatically improve a patient’s quality of life by effectively controlling their pain.
Palliative care is still a fairly new branch off the healthcare “tree.” However, some patients who require and are receiving palliative care will typically have pain issues that warrant more and more frequent treatment and sometimes aggressive interventions.
Pain — particularly chronic pain — can be difficult to manage. Compounded by the patient’s progressing disease state, this can result in unique challenges for healthcare professionals, especially nurses.
Palliative Pain Management Guidelines: The Goal
Where do we go from here?
Let’s start with the basics: determine the goal. Obviously, the primary goal of good pain management is to minimize the patient's pain. By using tried and true methods you will increase your success.
Pain assessments are critical to determining your goal. The healthcare professional should always perform a thorough pain assessment. Utilizing an appropriate and consistent pain scale for the same patient will reduce the chances for confusion or errors.
Ask the patient (if possible) what is an acceptable pain level or score for him or her. Once you have this information, you have your starting line.
If the patient is currently receiving pain medication, review the regimen. Begin with these questions:
- What analgesic has been given?
- How effective has it been?
- What were (if any) the unwanted side effects or adverse reactions to the regimen?
- How often has it been administered and at what dose?
- Has the patient been using a long-acting medication?
- Which medications have worked in the past and which ones weren’t as effective?
For those patients who have not been on a pain regimen and are opioid naive, utilize the WHO guidelines. Begin with a weak opioid and then titrate to a stronger dose or more potent medication until pain relief is obtained.
Once the patient becomes comfortable on a given dosing regimen, convert the patient to a long-acting medication. This will ensure sustained blood levels of the drug and will dramatically affect the patient’s pain and promote better pain control.
Pain Management: How Much Medication is Necessary?
Next, you will determine how much medication is necessary. By utilizing traditional equianalgesic dose calculation guidelines, ascertain the long-acting dose needed. First determine the total 24-hour dose of the current drug and then convert to the long-acting drug.
For example, you have a patient named Mrs. Rigby who has been admitted to palliative care for a multitude of medical issues warranting medical and pain management. Mrs. Rigby is currently receiving morphine.
The recent pain assessment shows the prescribed regimen of morphine sulfate-30 mg-po q four hours provides fairly good pain relief. Her documented pain scores are averaging a two on the numeric pain scale. Mrs. Rigby’s total 24-hour consumption was 180 mg morphine.
Therefore, based on the equianalgesic dosing and conversion guidelines, Mrs. Rigby’s long-acting medication regimen would suggest the medication regimen of morphine sulfate ER- 90 mg b.i.d. (= 180 mg in 24 hours).
Contact her physician and discuss the current regimen. After review, her physician provided an order and changed her current immediate release morphine order to a sustained-release morphine at 90 mg b.i.d.
Remember patients should always have access to breakthrough pain (BTP) medication. Studies have shown that up to two-thirds of patients with well-controlled chronic pain have transitory BTP. Therefore, patients should always be provided breakthrough medication at 10 percent to 20 percent of the current dose.
Now, in Mrs. Rigby’s case, this would be 10 percent to 20 percent of the 180 mg which would be 18mg* to 36mg* (* you will need to check tablet availability and round if necessary).
Based on the above, the dose for Mrs. Rigby would indicate 15 mg to 30 mg q four to six hours for BTP with constant, ongoing monitoring of the frequency of use.
If the patient — in this case Mrs. Rigby — continues to exhibit frequent BTP and requires breakthrough medication dosing, increase the long-acting morphine.
Pain Management Side Effects
As a healthcare professional, continue to reassess the patient’s pain level, medication tolerance, effectiveness and utilization. However, pain management in itself is not enough. Remember to monitor for side effects of the regimen being used such as:
- Nausea and vomiting
- Loss of appetite
- Urinary retention
Some elderly patients can also become agitated.
As with all opioids, constipation is a common problem. Therefore, it is essential to begin a bowel regimen immediately. The key to managing the patient’s pain and symptoms is to be proactive, remain vigilant and treat side effects aggressively and effectively.
Benefits of Palliative Care Support
As discussed, pain control is essential in all areas of healthcare. Crossroads Hospice & Palliative can offer patients an alternative option for their medical care and as necessary, pain management.
Nurse Practitioners, physicians, nurses, social workers and other required ancillary personnel as appropriate, will complete required pain scales, perform discipline-related assessments, and, as an IDG team, recommend and monitor the effectiveness of current medications and treatments to ensure comprehensive medical management of the patient and his or her condition.
When receiving palliative care, by allowing the patient to participate in the care planning process in coordination with the palliative care team, the opportunity to improve overall satisfaction of his or her medical care while allowing him or her to remain in the home or choice of residence as much and as long as possible.
Providing quality medical and pain management ultimately means ensuring the patient receives the quality healthcare that he or she deserves.
If you have a patient that may benefit from palliative care, contact Crossroads Hospice & Palliative Care at 1-888-564-3405.
DeAnna Looper RN, CHPN, CHPCA
Crossroads Hospice & Palliative Care
Senior Vice President of Clinical Operations
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