Pain in palliative care

Tissue damage

Pain is most commonly the result of tissue damage, like from a wound or contusion. In the case of patients with advanced cancer, pain is often the result of tissue damage caused by the tumour growing. In some cases, the tumour may be putting pressure on the surrounding tissues.

Nerve damage

If a nerve is damaged or compressed, the patient experiences nerve pain (neuropathic pain). A nerve may become trapped due to a tumour or a compressed vertebra. Nerve damage may also be the result of damage to peripheral nerves caused by diabetes, stroke, or shingles.

More basic information about pain, including different kinds of pain and what causes the sensation of pain, can be found at Kivunhallintatalo (Pain Management Hub) in Finnish.

The experience of pain is unique to each individual. The only reliable judge of the intensity of pain and the sensations it causes is the patient.

Pain should be assessed on a regular basis. The assessment should be carried out in varying circumstances, such as at rest and while moving. Metastases in the bones, as well as conditions such as arthritis, may cause severe pain during movement, whereas the pain is milder while at rest. Pain assessment before and after taking medicines helps assess the effectiveness of pain medication.

There are many factors that may play into pain intensity and interference, such as decreased general condition, other interfering symptoms, mood, and social circumstances. The experience of pain is a highly multifaceted issue; terms used to capture this include “total pain” and “total suffering”.

Pain-assessment scales

Scales used for assessing the intensity and interference of pain may be verbal (mild, moderate, severe, unbearable), numerical from 0 to 10 (0 = no pain, 10 = worst possible pain), or a visual analogue scale (a 10-centimetre line). If the patient is unable to express their pain, signs to observe for making an assessment include the patient’s facial expressions (frowning, grimacing), noises and vocalisations (moaning, groaning), breathing, bodily posture (avoiding moving the part of the body where the pain is located, tension, stiffness), and restlessness.

The nature of pain

When assessing pain, things to consider include the nature, duration (continuous, intermittent), and scope of pain. Blunt or throbbing pain is often indicative of tissue damage, whereas pain that is burning, cutting, or resembles electric shocks, as well as referred pain (pain felt outside the site of the damage itself) might suggest nerve damage. To help locate the pain, it’s possible to use a pain drawing, where the location, intensity, and type of pain sensation is marked.

Factors worsening or causing pain (such as movement, eating, or bowel movements), or, conversely, those relieving it (such as rest, warm, or cold) are noted, since they may provide clues to determine the cause of pain as well as help with care planning.

Associated symptoms

Sometimes pain is accompanied by other symptoms, such as changes in sensation (e.g. lack of sensation, hypersensitivity, or distorted sensation) or nausea. Identifying these may help in determining the cause of the pain.

Plans for pain management are always made on an individual basis. Pain can be treated using both medications and other means, such as physical therapy and other pain management methods. Sometimes, invasive methods such as anaesthesia or surgical interventions are warranted.

Choice of treatment

The choice of pain management method depends on the cause, nature, and severity of pain. Common pain medications include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) that are used to treat mild to moderate pain, especially in cases where pain medication is necessary for long-term management of chronic pain.

Cancer often causes severe pain that is relieved using strong morphine-like medications (opioids). Opioids can even be used to relieve pain related to many other chronic illnesses, especially at the end of life.

Pain management at the end of life

For as long as the patient is able to take medication by mouth, administration by mouth is the preferred way to deliver pain medication. As the patient’s condition weakens or the ability to swallow decreases, it’s possible to switch to an infusion pump that administers pain medication and other symptom-specific medicines into the tissue beneath the skin.

Strong pain medications are used in end-of-life care for conditions other than cancer as well. In addition to pain, strong opioid-based medications can also be used to treat shortness of breath. The aim of treatment is to ensure that all patients receive good symptom relief regardless of their illness.

If a dying patient experiences unbearable pain even despite good pain management, they can be sedated for the last few days of life (palliative sedation), so that they don’t need to suffer from pain.

Medication for treating cancer pain

Pain caused by cancer is generally treated using strong morphine-like pain medication, i.e. opioids. They are effective in providing pain relief, even in the case of severe pain. Each patient is provided with an individual medication plan to relieve their pain as effectively as possible while also considering any other symptoms present.

Opioids are usually taken by mouth as tablets, capsules, or oral solutions. Treatment usually begins with small doses taken at regular intervals, gradually increasing the doses until sufficient pain relief is achieved. Since the severity of pain often fluctuates over the course of the day, the regularly-administered pain medication can be supplemented with a previously determined dose of rapid-acting pain medication that the patient can take in case of unanticipated acute pain. To ensure that the medication is used safely, and to stop pain from limiting one’s life, it’s important to take the medication as instructed.

The most common adverse effects of opioids include constipation and dryness of mouth. That’s why medication to prevent constipation should always be taken alongside opioids. At first, the patient may also experience nausea and fatigue, but these are usually temporary. In order to treat pain successfully, it’s important to monitor and take a preventative approach to adverse effects.

The effectiveness of pain relief is monitored by the unit responsible for the patient’s care. If taking the medicines in the doses prescribed doesn’t relieve the pain sufficiently, or if the patient experiences adverse effects, it’s advisable to contact the unit responsible for the patient’s care so that the pain management regimen can be reassessed.

If the patient is unable to swallow medicines due to problems such as nausea or weakened general condition, pain medication can be administered by other routes, such as through the skin using a patch, into a vein as a continuous infusion, or beneath the skin.

In the case of severe pain, special techniques such as spinal pain management may be used. This means inserting a catheter to administer pain medicine and anaesthetics (substances numbing the pain) into the space around the spinal cord containing cerebrospinal fluid. This technique is used to treat pain in cases such as cancer that has spread to the pelvic area.

Medicine administered either beneath the skin or into the space around the spinal cord can be given at home, once the appropriate dosage has been established. The medicine is administered using a dispenser, also known as a “pump”, that can also be used to administer additional doses (boluses) in situations such as in case of sudden pain. The dispenser fits easily into a pocket or a small bag, and therefore doesn’t prevent the patient from moving around.

Radiation therapy in cancer pain management

Radiation therapy can be effective in relieving cancer pain. Pain caused by metastases in the bones is especially often treated with radiation therapy; however, it can also be effective in the case of tumours in other parts of the body, such as the brain, lungs, skin, lymph nodes, or the pelvic area.

In many cases, just one treatment is enough to relieve pain, but sometimes several (5 to 10) treatments (also called “fractions”) are needed. The pain-relieving effects appear about two weeks after the treatment, sometimes sooner. The effects last for several months. If radiation therapy causes swelling in the tissues surrounding the tumour, pain may increase at the start of radiation therapy. It’s advisable to prepare for this with rapid-acting pain medicine, and in some cases, with a course of corticosteroids prescribed by the doctor in charge of the radiation therapy (radiation oncologist). If the pain comes back after the radiation therapy, the treatment can usually be repeated.

Radiation therapy takes place in an Oncology unit. Before the treatment, a CT scan (a computerised imaging procedure) is performed to help make a treatment plan. The treatment only takes a few minutes at a time, and the radiation cannot be seen, heard, or felt.

During radiation therapy, the patient lies still on a treatment table, often using a cast prepared in advance or a soft pad, to ensure that the patient stays in the same position during all treatment sessions. The treatment team leaves the room for the duration of the treatment, but they are monitoring the patient on a screen from another room and the patient can talk to them the entire time.

Radiation therapy requires that the patient is able to hold still throughout the treatment, understands what’s going on, and can follow instructions. A patient whose condition is very poor, or who is dying, no longer has the strength to undergo radiation therapy or gain any potential benefits. At that point, medication is used to relieve symptoms.

Each patient has an individual experience of pain. The only person who can judge its intensity and interference in terms of daily activities is the patient. It’s important to keep the care staff and the attending physician informed about the pain experienced. Pain can be assessed using various scales that report the intensity and interference of pain either verbally, on a numerical scale (from 0 to 10), or placed on a line.

Using pain medication as prescribed forms the basis for successful pain management. More information about successful pain management, as well as frequently asked questions related to the topic, can be found at Kivunhallintatalo (“Pain Management Hub”, currently available in Finnish and Swedish).

Pain may lead to depression and anxiety, and at worst, limit the patient’s life. The patient’s loved ones have an important role in supporting and listening to the patient. Directing attention away from the pain and towards things such as spending time with loved ones, listening to music, or watching television may ease the experience of pain. Relaxation and exercises focusing on being present are helpful in pain management, as they relieve stress and tension in the body.