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 |
|
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 |
|
|
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 |
|
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