The importance of pain management during palliative care nursing essay

Abstract

Palliative care for end of life patients has many aspects, but management of moderate to severe pain is perhaps of the most concern for patients, family members and care providers. In order to provide comprehensive pain control, pain and related symptoms must be accurately assessed by nurses, and pharmacologic and non-pharmacologic measures must be appropriately implemented. Health care professionals must also be aware of potential barriers to pain treatment and how to address such barriers in order to provide the most individualized and effective care possible. The Importance of Pain Management during Palliative CarePain is a subjective and unique experience that varies not only from person to person but according to cause and circumstance as well. Pain can stem from damage to skin, muscles, organs and bones; it can have emotional and psychological triggers. It is natural to expect that because pain can have a wide variety of origins and interpretations, the treatment of pain needs to be as individual as the experience. This is of particular importance during end of life care. Providing palliative care (comfort measure to ease pain, relieve undesirable symptoms and provide emotional support) has immeasurable benefits for the dying and their loved ones. It is important to acknowledge the merits of pain management during palliative care, as well as the potential barriers to providing adequate pain relief, in order for medical professionals to provide the best and most individualized care for their patients. The World Health Organization lists the following as just some of the aspects of palliative care: it provides relief from pain and other stressful symptoms; it supports dying as a normal process; it integrates the psychological and spiritual aspects of care; it provides patients a way to live as actively as possible until death; it offers support for family members to help with coping during the patient’s illness and through their own bereavement process (World Health Organization, 2013). There are many facets to providing comprehensive palliative care, and effectively relieving pain can be one of the most important and challenging for health professionals. According to Creedon and O’Regan (2010), ” Pain occurs in up to 75% of patients with advanced cancer, and 65% of patients dying from other causes (Faull et al, 2005). Managing complex pain at the end of life is therefore an essential aspect of palliative care” (p. 260). Pain experienced by patients with terminal illness is not usually minor in nature; it can be intense and unbearable. Over 33% of cancer patients experience some kind of pain at a moderate or severe level (Reeves, 2008). ” Pain is a significant source of anxiety and distress, and perhaps the most debilitating symptom that is feared the most by cancer patients at the end of life, and requiring expert palliative care (Creedon & O’Regan, 2010, p. 257).” Not only do many end of life patients experience moderate to severe pain, but they can experience fluctuations in their pain and breakthrough pain as well. Burton and Zeppetella (2011) describe breakthrough pain as, ” a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger despite relative stable and adequately controlled background pain” (p. 14). The onset of breakthrough pain is quick, it is severe, and can last 60 minutes or longer (Burton & Zeppetella, 2011). This pain can occur spontaneously or in direct relation to the patient’s diagnosis, and can cause additional anxiety and despair. The occurrence of breakthrough pain is common for cancer patients, and requires additional assessment and interventions, including increased doses of existing medications or even additional medications, for alleviation. A thorough and accurate pain assessment is vital to determine the cause of pain (or breakthrough pain) and whether that pain is directly related to the patient’s illness. Some pain can result from the disease itself, such as actual tissue, muscle, organ or bone damage; it can be a result of nerve pain from inflammation, or even pain from constipation that is a side effect of prescribed opioid analgesics. It is also important to assess the patient’s level of pain and what level of pain they can tolerate throughout the day, while still maintaining a reasonable ability to perform activities of daily living. There are many pain assessment tools available to determine pain level, and they differ according to the ability of the patient to communicate. These tools, in addition to a discussing with the patient the various aspects of their pain (aggravating and alleviating factors, specific pain descriptors, the patient’s emotional state, etc.) allow for analysis of effectiveness of current interventions and the implementation of interventions that may provide additional relief. After pain has been properly assessed it needs to be treated. According to Reeves (2008), ” Opioids may control some of the cancer pain, but additional adjuvant medications may have a synergistic effect that results in improved pain management. Antidepressants, anticonvulsants, and corticosteroids are examples of medications that may be helpful with specific pain syndromes” (p. 417). It is quite important to prevent pain from getting too severe before treatment, or it may be difficult to alleviate. With predictable pain, such as chronic cancer pain, analgesics are the most effective when given 24 hours a day (around the clock) to control pain; this type of schedule also maintains therapeutic blood levels of the analgesics (Reeves, 2008). Although pharmacologic pain interventions are quite effective, it is useful for healthcare workers to know that non-pharmacologic measures can provide added pain relief as well. There are many simple measures every member of a health care team or family caretakers can take to provide comfort to an ill patient. One effective way to relieve pain is to change a patient’s position, perhaps by sitting up or changing sides, placing pillows under knees, arms or ankles, or relieve stiffness through gentle range of motion exercises. Some patients might want a change of scenery, or to make their current environment less bright or noisy. Gentle massage, recordings of soothing noises or guided imagery might help to provide distraction from pain and promote relaxation. Comfort measures may increase one’s pain tolerance which allows the patient to experience less pain, and such measures should be documented in the patient’s record so others on the health care team can utilize them (Reeves, 2008). Providing care through use of pharmacologic and non-pharmacologic methods is helpful, but health care workers must also be aware of potential barriers to effective treatment if they want to achieve comprehensive palliative care. Barriers to treatment can stem from the patient or their care providers. Some doctors and nurses can be de-sensitized to patients’ pain experiences due to seeing pain from a professional perspective on a daily basis. They can also have cultural biases or misconceptions about pain and therefore not treat the pain as aggressively or promptly as they might need to for adequate relief. According to Middleton-Green (2008), ” Healthcare professionals’ beliefs about pain have been shown to affect their attitudes to pain management (Patiraki-Kourbani et al 2004). Nurses may find it difficult to deal with unmanaged pain and this can evoke feelings of inadequacy and powerlessness (Patiraki-Kourbani et al 2004)” (p. 44). It is especially important that nurses perform a self assessment regarding personal beliefs concerning pain in order to provide unprejudiced and professional care. One’s life experiences can influence how they evaluate the way pain is interpreted, so self awareness is essential (Middleton-Green, 2008). Patients can also introduce barriers to their own pain management. Some lack an understanding on the subject of how various pain medications work, and they fear common misconceptions regarding side effects, medication tolerance and dependence. Patients may need education about opiate use, and assurance that they will not develop an addiction because the medication is actually used by their pain receptors (Bass, 2011). Some patients have psychosocial reasons for not reporting or seeking treatment to relieve pain. According to Bass (2011), ” They may think it means they are dying, there may be fear of addiction or concerns about side effects, belief that the pain is inevitable (stoicism), or that the pain represents disease progression. There may also be fear of injection/tablet taking” (p. 67). Many of these fears can be addressed and comforted. Education can help ease anxiety regarding addiction; alternative routes of medication administration can be examined if a patient fears needles or can’t swallow pills; psychotherapy might be helpful for those who need to gain acceptance concerning their condition. As healthcare professionals, nurses need to be able to anticipate some of these concerns from their patients and seek out ways to solve such problems early on in the palliative care process. Pain management comprises a complex, important portion of palliative care. The majority of patients receiving palliative care have some level of moderate to severe pain that needs to be addressed in order for comfort to be achieved. Pain causes distress and anxiety for patients, family members and other caregivers, making it a vital aspect of care. In order for health care professionals to offer comprehensive pain relief, they must accurately assess a patient’s pain, provide pharmacologic and non-pharmacologic measures to combat pain, educate patients on any medication concerns, and perform a self-assessment regarding their own pain-related beliefs. It is through these actions that nurses will bring their patients reprieve from immense discomfort and pain, help to ease anxiety and fear, help to bring about acceptance of the disease process, and promote the ideal nurse patient relationship.