How to assess a patient in pain towards the end of life: Information for clinicians

This information is sourced from PANGScottish Palliative Care GuidelinesThe WHO, Dr Tony Duffy and Dr Ros Taylor:

The choice of analgesia should be based on the cause (see table below) and a risk/benefit assessment, taking into consideration side effects, co-morbid conditions and other medications.

An overview of recommended treatments for common types of physical pain at the end of life

Type of pain Typical symptoms  Red flags Initial treatment options Specialist treatment options
Bone Usually well localised, might be worse on weight bearing and often tender to touch Symptoms/signs of spinal cord compression Paracetamol, NSAIDs, titration of strong opioid.

Consider scans for rapidly changing pain.

Radiotherapy and bisphosphonates can often help.

See bone pain for fuller guidance

Neuropathic

Burning, shooting, tingling or lightening in nature.

Altered sensation. Pain may follow a dermatomal distribution

Symptoms/signs of spinal cord compression

Neuropathic agents are first line (Gabapentin, Pregabalin, Oxcarbazepine,Tricyclic Antidepressants).

Paracetamol, weak opioids and NSAIDs may also help

Steroids for urgent control of severe nerve pain.

See neuropathic pain for fuller guidance

Chest pain Depends on cause. Consider pleural, cardiac, oesophageal, or bone pain from ribs/recent fall Consider pulmonary emboli/myocardial infarction According to cause According to cause
Infections and abscesses Swinging fever, worsening pain, possibly swelling and related skin changes Signs of sepsis Blood tests and often empirical treatment with antibiotics if infection is suspected IV antibiotics, imaging and surgical drainage if appropriate
Mouth pain Localised or generalised sore lining of the mouth Remember that sore mouths affect eating, drinking, hydration, nutrition and well-being Treat identified infection (e.g Candida or HSV) and give adequare pain control and mouth care 

If chronic facial pain, oral tumours, bleeding and difficulty swallowing seek specialist advice.

See oral problems for fuller guidance

Skin Depends on cause. See radiotherapy skin reactions if relevant Signs of sepsis See radiotherapy skin reactions if relevant  
Abdominal

Depends on cause- does the patient have cancer?

Liver metastases cause a dull ache and tenderness in the right side of the abdomen. 

Peritoneal metastases, biliary colic and bowel obstruction cause colicky pain. Constipation and dyspepsia are common

Symptoms or signs of bowel obstruction

Treatment depends on cause.

Constipation and dyspepsia are common.

If the patient is known to have cancer see: Assessment of abdominal pain in patients with cancer. 

If no signs of bowel obstruction treatment options include laxatives, or buscopan for colicky pain.

Only give opioids for abdominal pain if the diagnosis is known

If signs of acute or subacute bowel obstruction 
 Headache   Consider increased intracranial pressure especially if nausea ralso a problem   Steroids for increased ICP if confirmed on scan

If the cause of the pain is unknown, use the WHO ladder below as an approach to pain control.

Top Tips

If the cause of the pain is unknown, use the WHO ladder below as an approach to pain control

  • The immobility and cachexia of advanced illness can cause generalised physical pain
  • Use oral long-acting analgesia where possible, except in renal and liver failure where short-acting options are best 
  • Review regularly - ask patient to keep a diary of what helps, and in what dose
  • Ensure regular laxatives are co-prescribed when prescribing opioids
  • All patients should have access to antiemetics when opioids are first prescribed
  • Transdermal opioid patches are best used for stable pain (slow to titrate in acute situation) but helpful if vomiting or not swallowing
  • Patients receiving a NSAID who are at risk of gastrointestinal side effects should be prescribed a proton pump inhibitor.
The WHO pain ladder

If pain isn't controlled move to the next step.

Step One:  Mild pain. Paracetamol 1g qds +/- a non steroidal anti-inflammatory drug (NSAID)

Step Two:  Mild to moderate pain. Consider combination preparations e.g. Co-codamol 30/500 (maximum 8 tablets in 24h or Tramadol - up to 400mg/24h   

Step Three: Moderate to severe pain. Morphine remains the gold standard opioid. Alternative opioids can be considered if dose titration of morphine is limited by side effects. Please see Starting morphine: Information for clinicians

 

Sources

PANG Guidelines Analgesia Prescribing

Published 16th October 2016

Scottish Palliative Care Guidelines - Pain

Published 11th November 2014

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