____________________________________________ Assessment and Management of Pain at the End of Life
Encouraging patients to be honest about pain and other symptoms is also vital. Clinicians should ensure that patients understand that pain is multidimensional and emphasize the importance of talking to a member of the healthcare team about possible causes of pain, such as emotional or spiritual distress. The healthcare team and patient should explore psy- chosocial and cultural factors that may affect self-reporting of pain, such as concern about the cost of medication. Clinicians’ attitudes, beliefs, and experiences also influence pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [1; 8; 11; 13; 14; 15]. A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [11; 13; 15; 16]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [11; 13]. Cultural and demographic factors may also contribute to lack of effective pain management. Expression of pain and the use of pain medication differ across cultures. For example, His- panic and Filipino patients have been shown to be reluctant to report pain because of fear of side effects or addiction [17]. Even when effective opioids have been prescribed, access may be difficult, as inadequate supplies of opioids are more likely in pharmacies in primarily nonwhite neighborhoods [18]. Communication with patients regarding level of pain is a vital aspect of caring for patients in the end of life. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. ETIOLOGY The prevalence of pain at the end of life has been reported to range from 8% to 96%, occurring at higher rates among people with cancer than among adults with other life-limiting diseases [19; 20]. Pain can be caused by a multitude of factors and is usually multidimensional, with pain frequently being exacerbated by other physical symptoms and by psychosocial factors, such as anxiety or depression [8]. ASSESSMENT Pain should be assessed routinely, and frequent assessment has become the standard of care [8]. Pain is a subjective experience, and as such, the patient’s self-report of pain is the most reliable indicator. Research has shown that pain is underestimated by healthcare professionals and overestimated by family mem- bers [8; 21]. Therefore, it is essential to obtain a pain history directly from the patient, when possible, as a first step toward determining the cause of the pain and selecting appropriate treatment strategies.
INTRODUCTION Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understanding of effective pain management is well-documented [1]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [1; 2; 3; 4; 5; 6; 7; 8; 9; 10].
ISSUES IN EFFECTIVE PAIN MANAGEMENT
The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain relief [11]. This reluctance is related to a variety of attitudes and beliefs [1; 11]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medications • Fear that increasing pain means that the disease is getting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcom- ing these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversa- tions about pain management, especially regarding the use of opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [12]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fiction. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low [1]. It is also helpful to note the difference between addiction and physical dependence. There are several other ways clinicians can allay patients’ fears about pain medication: • Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe. • Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely and that some side effects will abate over time. • Explain that pain and severity of disease are not neces- sarily related.
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MDNJ1525
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