Principles of managing pain in the last days of life

The experience of pain varies in the last days of life; although some patients develop pain, others will not experience pain at all. Patients with pre-existing pain may find it increases, while others may experience a reduction in pain, particularly if pain is movement-related (however, patients who are no longer mobile may still require analgesic therapy).

When patients are semiresponsive or unconscious in the last days of life, pain or discomfort is usually expressed nonverbally. For example, a patient may frown, appear restless and unable to find a comfortable position in bed, show discomfort when being turned, or appear agitated. Monitor the patient’s behaviour and assess for possible causes of pain (eg tenderness over a distended bladder or rectum, back pain due to immobility, pressure area pain, abdominal pain due to worsening ascites).

General measures can help manage pain or discomfort, including repositioning the patient, trying an alternative mattress, and addressing issues such as urinary retention and constipation—see General care and comfort in the last days of life.

Opioids are the mainstay of pain management in the last days of life. Follow the principles of drug therapy for symptoms in the last days of life when using an opioid. The initial regimen depends on whether the patient already takes an opioid; see:

Closely titrate opioids to effect because opioid requirements for pain relief vary between patients.

Consider starting an antiemetic to prevent nausea and vomiting associated with initial opioid use.

Patients who have been taking analgesic therapy (opioids and/or nonopioids) will require ongoing pain management in the last days of life. If pain has previously been well controlled, continue the management plan if possible, with monitoring and regular review. Drugs other than opioids that have been used for pain are usually stopped in the last days of life, or may be given subcutaneously or sublingually if a suitable formulation or alternative drug is available—seek specialist advice if needed.

For patients with severe, complex or difficult-to-control pain, alternative analgesic therapy or a different approach to management may be required; seek immediate specialist palliative care advice.

Note: For patients with severe, complex or difficult-to-control pain, seek immediate specialist palliative care advice.

For management of catastrophic terminal events, see Catastrophic terminal events in palliative care.

For general information about managing pain in palliative care, see Principles of managing pain in palliative care.