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

This information is sourced from Dr Tony Duffy and Dr Ros Taylor:

The choice of analgesia should be based on the cause (see table below) 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 or tingling in nature

Altered sensation. Pain may follow a dermatomal distribution

Symptoms/signs of spinal cord compression

Neuropathic agents are first line (e.g. Tricyclic Antidepressants, Pregabalin, Duloxetine)

Paracetamol, 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 or recent fall

Consider pulmonary emboli or angina

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 (often related to chemotherapy)

Remember that sore mouths affect eating, drinking and well-being

Consider herpes simplex

Treat identified infection (e.g Candida or HSV) and give adequare pain control and mouth care 

Severe facial pain, oral tumours, bleeding or dysphagia seek specialist advice

See oral problems for fuller guidance

Skin

Depends on cause. See radiotherapy skin reactions if relevant

Signs of cellulitis or DVT

See radiotherapy skin reactions if relevant

 

Abdominal

Abdominal pain in cancer is common

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

Peritoneal metastases may cause colicky pain. Constipation and dyspepsia are common

Symptoms or signs of bowel obstruction

Treat any Constipation or dyspepsia 

Assessment of abdominal pain in patients with cancer gives detailed guidance

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

If signs of acute or subacute bowel obstruction may need scanning

 Headache

 

Consider increased intracranial pressure especially if nausea is also a problem

 

Steroids for increased ICP if confirmed on scan

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

Top Tips
  • If the cause of the pain is unknown, use the WHO ladder 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 
  • Ask patient to keep a diary of what helps, and in what dose
  • Ensure regular laxatives are co-prescribed with 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

Recommended Resources

PANG Guidelines Analgesia Prescribing

Published 16th October 2016

Scottish Palliative Care Guidelines - Pain

Published 11th November 2014

WHO - Palliative care

Published 2nd October 2024

Share

Related Services

24 hour Advice Line Michael Sobell Hospice
Close

24 hour Advice Line Michael Sobell Hospice

T. 0203 824 1268

Offers support and advice on palliative care issues to GPs, Care Homes, District Nurses and hospital doctors.

It is also an Advice Line for patients and families who live in Hillingdon and need advice on any aspect of palliative care. 

The Advice Line is answered by hospice nurses in the Inpatient Unit and queries are escalated to the on-call palliative medical team if needed.

Related Articles

1st July 2024

Abdominal pain in patients with cancer: Information for clinicians

21st June 2024

Bone pain: Information for clinicians

4th July 2024

Neuropathic pain: Information for clinicians

Feedback