Assessment of pain

It is important to remember that pain is a symptom and not a diagnosis.  The key to successful treatment is accurate diagnosis.  This can be achieved by good history taking.

S                Site
O               Onset
C               Character
R               Radiation
A               Associated features
T                Timing
E                Exacerbating and relieving factors
S                Severity

Causes of pain in palliative care

• Effect of underlying pathology e.g. lung cancer
• Result of treatment e.g. neuropathy from chemotherapy
• Unrelated e.g. DVT/pressure sores

Treatment of pain in palliative care

The principles of pain relief in palliative care are:

• By the clock (regular)
• By the mouth
• By the ladder (use the analgesia ladder)

1. Non-opioid e.g. paracetamol
2. Mild opioid e.g. Codeine and adjuvant e.g. ibuprofen
3. Strong opioid e.g morphine

Factors to consider when prescribing analgesia:

• Renal/liver function
• Route of administration
• Severity of pain
• Current analgesia
• Other symptoms e.g. nausea/vomiting

Morphine or Diamorphine (depending on local guidelines) are the mainstay of analgesia for severe pain in palliative patients.  Initial treatment should involve a short acting opioid e.g. oramorph or Subcutaneous morphine/diamorphine if the oral route is unavailable.  Once the amount to control pain in 24 hrs is known, this amount can be converted to slow release morphine e.g. Zomorph/MST via oral route or Morphine/Diamoprhine via a syringe driver.   A syringe driver/pump is a continuous infusion device where the medication (or combination of medications) are released over 24hrs.

Opiates e.g. codeine/morphine commonly cause nausea and constipation.  Therefore it is good practice to prescribe an antiemetic and laxative when prescribing these medications.

Breakthro​ugh anaglesia

Breakthrough analgesia is used to treat the pain suffered despite regular analgesia.  Every patient prescribed regular analgesia should have “back-up” PRN medications written on their prescription chart if they have further pain.  This is normally the next step on the analgesic ladder.  E.g. if the patient is on regular paracetamol, it is good practice to prescribe PRN codeine or ibuprofen (if stable renal function).  If the patient is on morphine/diamorphine, 1/6 of the total daily dose should be prescribed for breakthrough pain 2-4 hourly on the PRN section of the drug chart.  This should be reviewed every 24hours and the amount of breakthrough analgesia added to the regular prescription.

References

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Assessment of shortness of breath

• Onset e.g. sudden/gradual
• Timing e.g. constant/intermittent
• Exacerbating/relieving factors e.g. when lying flat or walking
• Associated features e.g cough or chest pain
• Severity i.e. impact on day to day life
• Underlying diagnosis e.g. lung cancer

Causes of shortness of breath in palliative care:

• Effect of cancer e.g. lung cancer
• Pulmonary effusion e.g. malignant effusion
• Restriction e.g. superior vena cava obstruction or ascites
• Pulmonary embolus (High risk due to underlying malignancy and associated immobility)
• Anaemia
• Pneumonia
• Pain
• Anxiety

It is also important to remember that any cause of shortness of breath in a non-palliative patient can also occur here.

Manag​ement of shortness of breath in palliative care

• Treat underlying cause e.g. drain an effusion
• Lifestyle changes
• Symptomatic treatment- pharmacological and non-pharmacological
• Rehabilitation

Phamacological treatment

Nebulisers- bronchodilators e.g. salbutamol if reversible airways obstruction or sailine to aid expectoration
Opioids e.g. oramorph 2.5mg PRN 4hourly
Benzodiazepines esp in anxiety e.g. lorazepam
If á secretions- glycopyrronium or hyosceine hydrobromide (dry up secretions)

Non-pharmacological treatment

• Explanation and reassurance
• Oxygen
• Physiotherapy and positioning e.g. sitting down and leaning forward
• Coping mechanisms e.g. minimising activity
• Fans
• Psychotherapy for anxiety
• Alternative therapies and relaxation techniques

References

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Nausea = sensation of the desire to vomit
Vomiting = action of expelling GI contents via mouth (usually an involuntary reflex)

Causes of nausea ​and vomiting in palliative patients

• Cancer e.g. brain metastasis or bowel obstruction
• Disease complications e.g. Hypercalcaemia
• Debility e.g. infection, constipation
• Treatment e.g. chemotherapy
• Concurrent e.g. Gastroenteritis

Manag​ement of vomiting

• Treat underlying cause if possible e.g. infection
• Determine which neurotransmitter receptors are involved
• Chose and antiemetic for the specific neuroreceptor
• Choose the relevant route of administration
• Reassess to identify any additional triggers

Decide whether any of triggers can be reversed

When the cause of symptoms is known, the antiemetic should be chosen depending on its receptor affinity.  E.g. metoclopramide for treatment of drug side effects.

Antiemetic drugs work by binding to specific receptor sites in the chemoreceptor trigger zone (CTZ) or vomiting centre (VC) in the brainstem.  At each site, there are several receptors; the more strongly the drug binds to the receptor, the more potent its antiemetic activity.
Levomepromazine is generally the second line medication used in nausea in palliative care.  It has a broad mechanism of action has good symptomatic relief but many side effects including its action as a sedative.  It can be given by the oral and subcutaneous route.

Non-pharmacological treatments

• Relaxation techniques
• Calm treatment
• Hypnotherapy
• Small meals/snacks
• Cover odorous wounds
• Avoid strong smells e.g. cooking
• Sea bands/acupressure

References

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