Approach to managing pain in palliative care

Pain in patients with palliative care needs differs from pain experienced by other patients because curative treatment is not possible and death is the foreseeable outcome of the illness.

Management of pain in palliative care is guided by comprehensive assessment and understanding of the following factors:

  • cause of pain
  • type(s) of pain
  • severity of pain—Features of mild, moderate and severe pain in palliative care describes features of mild, moderate and severe pain
  • potential benefits and burdens of management options (including the patient’s ability to engage with treatment)
  • patient’s prognosis, preferences and goals of care
  • the multiple influences on the way the patient experiences pain—see Sociopsychobiomedical (biopsychosocial) understanding of pain in the Pain and Analgesia guidelines
  • patient’s response to previous interventions
  • underlying disease and disease-related changes in physiology, pharmacodynamics and pharmacokinetics (eg kidney or liver dysfunction).

See Assessing pain in palliative care for more information on assessing and understanding pain in palliative care.

Figure 1. Features of mild, moderate and severe pain in palliative care

Pain severity is determined by patient-reported pain severity, anticipated pain severity, and functional activity scores [NB1].

Mild pain—minimal difficulty carrying out activities despite pain. A low pain score may be reported [NB2].

Moderate pain—pain causes some difficulty carrying out activities.

Severe pain—pain causes considerable difficulty carrying out activities. A high pain score may be reported [NB2].

Note:

NB1: Pain severity occurs on a spectrum between no pain and worst pain imaginable. To help practitioners choose the treatment regimen that best matches the pain experienced by their patient, these guidelines include specific definitions of mild, moderate and severe pain. However, there are no universal definitions of mild, moderate and severe pain, and other organisations (including the Therapeutic Goods Administration) and literature define these categories differently.

NB2: Pain scores alone should never be used to determine pain severity.

For patients with palliative care needs, pain is frequently part of the total experience of suffering, distress and grief. Although complete relief of pain may not be a realistic goal, pain can usually be minimised by:

  • early identification and intervention; this may also decrease total analgesic requirements in the long term
  • taking a systematic, multidimensional approach to management that simultaneously addresses all sociopsychobiomedical factors affecting pain
  • working with patients and their carers to determine achievable goals as part of a comprehensive and individualised pain management plan
  • collaborating with patients, carers, families, friends and healthcare professionals to achieve the best result
  • combining pharmacological and nonpharmacological strategies that target the cause and type of pain; take a strategic approach and use interventions that are most likely to help the patient.

Many patients with palliative care needs experience multiple types of pain simultaneously and require multimodal analgesia, which combines pharmacological and nonpharmacological strategies with different mechanisms of action. A multimodal approach aims to improve pain management by using additive or synergistic effects of different treatments to reduce analgesic requirements.

These guidelines provide general management advice on pain caused by advanced and progressive disease in the last year of life, and the following specific types of pain commonly experienced by patients with palliative care needs: