When a person reaches the end of their life, it can be difficult for their loved ones to see them frail and unwell.
The thing families of the dying worry about the most is if their loved one is experiencing pain or suffering.
Complete pain relief is not always realistic, a reduction of pain by 30 to 50 per cent may be considered a good response.
Normally, the goals of pain management need to be balanced between pain relief and the ability to function, physically, emotionally and cognitively.
But as a person approaches end of life and is receiving palliative care, the balance between pain relief and function may change, with less emphasis placed on function.
At this stage the balance may be between the amount of pain relief provided and the ability to stay alert and improve quality of life..
If pain management goals are not being achieved the resident’s doctor should be notified. Changes to the current analgesic therapy may be needed, including stopping medications that are not thought to be adequately relieving pain.
It is important to recognise that adequate pain management requires more than medications.
The management of pain is generally more effective when a multimodal and multidisciplinary approach is applied, combining non-pharmacotherapies with medications.
There are a number of non-pharmacotherapies that are suitable for use in residents in aged care facilities, such as mild heat, mild cold packs, mild vibration, massage, mobilising exercises, passive relaxation.
However, the selection of treatments need to account for the resident’s cognitive and communicative abilities.
The process of pain management, during this difficult time, can be challenging to understand, and there are preconceived ideas that people may not be aware of.
Medications used to manage pain should be selected based on the type of pain the resident is experiencing, for example is the pain nociceptive, neuropathic, inflammatory? Is it acute or chronic? What is the severity of their pain? The medication with the highest likelihood of relieving pain with lowest likelihood of causing side effects should be considered first.
Medication selection should also take into consideration the impact of old age and frailty. For example, what is the impact of age-related renal impairment or impaired cognition?
In order to improve pain relief and minimise side effects, consideration can be given to combining analgesics with different modes of action.
Timing of analgesic dosing is clinically important. Chronic pain requires around-the-clock dosing, preferably with long-acting analgesics.
Opioids can continue to provide effective pain relief over a long time period. Tolerance to the analgesic actions of strong opioids is rarely clinically relevant.
The need for higher doses to manage pain is often due to disease progression. If tolerance does develop, opioid rotation may improve pain management.
Opioids can cause respiratory depression, but tolerance to this effect occurs relatively rapidly. Clinically important respiratory depression is a rare event especially when the initial opioid dose is low and the dosage is adjusted carefully.
Careful use of opioids in this setting includes consideration of other risk factors or respiratory depression and making the appropriate adjustments.
There are actually a number of different routes in which pain medication can be administered.
Oral administration is generally first-line as it is non-invasive. Oral medications can be used when people have no difficulty swallowing.
Transdermal delivery is another first-line delivery mechanism, this is where medication is absorbed through the skin via adhesive patches. It is useful for people taking a number of oral medications, to reduce pill load.
It is also used when people are having difficulty swallowing or if they are having problems absorbing orally administered opioids or if they are experiencing side effects such as vomiting.
Similarly it eases administration amongst people with dementia who may spit out their oral medications.
Other options for people with swallowing issues and who may not be able to tolerate patches include liquids, sublingual formulations and suppositories.
Subcutaneous opioids are also used at end of life situations, these are usually needles under the skin, and are generally not recommended for use in people with chronic pain.
However in a palliative setting, subcutaneous administration is preferred over other parenteral routes such as intravenous or intramuscular injections, as it is less invasive, and has a lower risk of infection.
Opioid analgesics are the cornerstone of pain management at the end of life, including those with cancer pain.
In the palliative care setting, opioids may be required at any stage of an illness, based on the severity of pain.
The modified World Health Organization’s analgesic ladder suggests that weak opioids should be skipped in preference for initiating opioid therapy with low doses of a strong opioid.
Unlike non‐cancer pain, the use of parenteral opioids is considered appropriate for patients with cancer pain or in palliative care under the advise of a medical practitioner.
For situations when a patient may have difficulty swallowing medications, high doses are needed or rapid pain relief is required, or there is a depressed conscious state, opioids in the form of a drip may be better suited.
