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Last Updated: Wednesday, 20 July, 2005, 19:48 GMT 20:48 UK
Pain control
The following is a guide to pain control and what you should expect as a patient.

Professional responsibility

Ensuring that patient's pain is managed properly is a key part of the professional duties of medical staff. It is written into the General Medical Council's "Good Medical practice" guidance, which describes the principles of good medical practice and standards of competence, care and conduct expected of doctors in all aspects of their professional work. It states that

"In providing care you must: provide the necessary care to alleviate pain and distress whether or not curative treatment is possible;"

:

The Royal College of Nursing advises that nurses will ensure good quality physical, mental and emotional care by:

"alleviating pain and discomfort and recognising that it is appropriate for the individual to define their own levels of tolerance of pain and distress. Particular consideration needs to be given to people who are unable to communicate their feelings. Ways must be found to understand their requirements in such situations"

for more details from the Royal College of Nursing's document "Caring in Partnership: older people and nursing staff working towards the future" follow the link below.

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And guidance from the Standing Nursing and Midwifery Committee states that:

"Management of the older person's pain forms an important part of nursing assessment and care planning, as part of the multi-disciplinary approach during the acute phase of illness."

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Pain management

There are principles which shape best practice in managing pain control. A Working Party Report by the Royal College of Physicians (RCP) states that when dying becomes a factor in a patient's illness, it is important that it is recognised by everyone caring for the patient, and that the goals of management of a dying patient are:

  • To control the patient's symptoms
  • To make the quality of life as god as possible
  • To enable the patient to do what he or she wants to do

According to the same report, approximately two thirds of terminally ill patients experience pain, whatever the underlying diagnosis. Many people fear dying in pain almost more than death itself.

The RCP states that as with all clinical situations, a careful assessment should be made to determine the "likely reason for the pain, and whether there is a cause which can be relieved" . But many terminally ill patients need regular pain medication to achieve pain control. The World Health Organisation has a guide which the RCP recommends when adjusting analgesia (pain relief)

  • Step 1: non-opioid analgesia, e.g. paracetamol
  • Step 2: opioid for mild to moderate pain, e.g. dihydrocodeine
  • Step 3: opioid for moderate to severe pain e.g. morphine.

If the patient's pain is not controlled on Steps 1 or 2, the or she needs to climb to the next step of the ladder

With cancer - pain can be an issue, but recent guidance by the National Council for Palliative Care noted,

"Pain and advanced cancer are not synonymous: 2/3 of patients experience pain, but 1/3 will experience no significant pain throughout the course of their illness."

The same guidance states that the aims of cancer pain management are:

  • To achieve a level of pain control which is acceptable to the individual
  • To assess the pain and evaluate the effectiveness of pain management promptly
  • To be aware of the components of total pain
  • To relieve pain at night and at rest and on movement
  • To provide up to date information on the use of pain relieving drugs to patients and their carers
  • To provide support and encouragement for caregivers of patients with cancer pain

For more details about the work and publications of the National Council for Palliative Care follow the link below.

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The use of morphine - an opioid - is particularly important in managing severe pain in terminally ill patients, and there are principles for its use, which the Royal College of Physicians lays out in its report:

  • Always start with immediate release morphine (morphine IR) so that you can adjust the dose frequently
  • Most patients new to morphine will need a starting dose of 5-10mg every 4 hours, unless they have been on high doses of another opioid such as dihydrocodeine
  • Give morphine IR regularly every 4 hours. A double dose can be given at bedtime so that the patient can sleep undisturbed
  • The same dose of morphine IR should be given in addition, between the regular doses, if the patient is in pain ('rescue' or 'breakthrough' analgesia). Do not alter the regular schedule, even though an extra dose has been given
  • If the pain is not controlled, add up the total morphine taken in the previous 24 hours, and increase the dose by 30-50%
  • Once the pain is controlled, and you know the patient's 24-hour morphine requirement, a modified release preparation can be used.
  • Morphine IR should always be available for rescue analgesia when needed. If certain activities, such as a wound dressing, can be predicted to cause pain, it is sensible to give rescue analgesia before beginning the activity.
  • The predictable side effects of morphine, particularly constipation and nausea, must be treated at the same time.

Different patients may need widely varying doses of morphine. Provided higher doses produce better pain control, and not intolerable side effects, the dose should be increased progressively, with frequent and regular reassessment by the multidisciplinary team, until the pain is adequately controlled.

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Palliative care - a good death?

A lot of work has gone on to try to ensure that patients who have reached the end of their lives or whose illness is not curable, are afforded a decent and dignified death, wherever that may occur.

The National Institute for Health and Clinical Excellence, has defined palliative care as:

"the active holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care area are also applicable earlier in the course of the illness in conjunction with other treatments"

For more information about NICE - the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health visit their website below.

The British Geriatrics Society - which is the professional association of doctors practising geriatric medicine - in its policy document "Standards of Care for Older People" states:

"Older people with terminal illness should expect to receive appropriate medication, nursing care and emotional support to control distressing symptoms. This may be provided by teams including specialist nurses, McMillan nurses, palliative care physicians and counsellors at home, in hospice or hospital settings, in day facilities or nursing homes according to needs and the older person's preference."

And a working party report for the Royal College of Physicians points to the key features of the needs of older people dying in hospital.

"2.30 Older people dying in hospital need to have care provided by nurses and doctors who have received training in palliative care, feel confident and competent in talking about terminal illness with patients and their relatives, and who can provide a consistent approach. Geriatricians and physicians should work closely with palliative care physicians to ensure that there is adequate symptom control and that individual quality of life is preserved in the last stages before death. The environment should allow privacy and dignity for patients and their families. Hospice care is a limited resource but nevertheless should be available to older and younger patients alike."

Extract from: "Management of the older medical patient"

And the charity Age Concern has identified the following principles of a good death. The British Geriatrics Society says that understanding these allows end-of-life care to be planned in an effective manner.

  • 1. To know when death is coming and to understand what can be expected
  • 2. To be able to retain control of what happens
  • 3. To be afforded dignity and privacy
  • 4. To have control over pain relief and other symptoms
  • 5. To have choice and control over where death occurs (i.e. a home or elsewhere)
  • 6. To have access to any spiritual and emotional support required
  • 7. To have access to hospice care in any location, not only in hospital
  • 8. To have control over who is present and who shares the end
  • 9. To be able to issue advance directives which ensure wishes are respected
  • 10. To have time to say goodbye and control over other aspects of timing
  • 11. To be able to leave when it is time to go and not have life prolonged pointlessly


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