19th November 2024

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