Assessing pain in palliative care
Pain is ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’1Raja, 2020. It is a subjective perception resulting from the brain’s interpretation of inputs and expectations.
Pain is common in patients with palliative care needs; it occurs in approximately two-thirds of patients with advanced cancervan den Beuken-van Everdingen, 2017 and is a significant symptom in other life-limiting illnesses.
Although pain is a feared symptom, patients may under-report it for many reasons, including:
- fear that pain indicates treatment failure or advancing disease
- a desire to be seen as ‘a good patient who does not complain’
- concerns about opioid use
- apprehension that the treating doctor’s attention might be diverted from life-prolonging interventions to pain management
- stoicism despite being uncomfortable.
An understanding of the pathophysiology of pain and the relevance of sociopsychobiomedical factors to the pain experience is essential for effective assessment and treatment—see Understanding pain. In addition to the sociopsychobiomedical factors listed in the Pain and Analgesia guidelines, the physical, emotional, social, existential and spiritual challenges associated with a life-limiting illness can influence the pain experience for patients with palliative care needs. For more information on challenges commonly experienced in palliative care, see Overview of emotional, psychological and behavioural symptoms in palliative care.
The approach to pain assessment described in the Pain and Analgesia guidelines, which employs a sociopsychobiomedical framework to assess a patient’s pain experience, can be applied to patients with palliative care needs. Patients with palliative care needs often experience multiple types of pain, sometimes simultaneously (eg neuropathic pain, incident pain, breakthrough pain, persistent nociceptive pain). Take a multidimensional approach to identify and address concurrent types of pain as well as other symptoms. For example, for patients experiencing both poor sleep and pain, it is likely that the pain exacerbates poor sleep and vice versa—simultaneously addressing sleep disturbance and pain can provide effective management of symptoms faster than if they were addressed separately. For a guide to symptom assessment in palliative care, see Symptom assessment in palliative care.
In patients with reduced responsiveness who are close to death, continue to assess, monitor and manage pain—see Pain in the last days of life.