A hospice environment is a type of setting that provides palliative care for patients with terminal illnesses and their families. Palliative care is an approach that aims to improve the quality of life for patients and families by relieving pain and other distressing symptoms, as well as addressing their physical, emotional, social, and spiritual needs. Pain is one of the most common and challenging symptoms experienced by hospice patients, and it can have a significant impact on their well-being and comfort. Therefore, pain management is a vital component of hospice care that requires a comprehensive and multidisciplinary approach.
Types and Causes of Pain
Pain is a subjective experience that varies from person to person. It can be classified into different types based on its origin and characteristics. Some common types of pain in hospice patients are:
- Nociceptive pain: This is caused by tissue damage or inflammation and is usually described as sharp, throbbing, or aching. It can be somatic (affecting bones, muscles, skin, or joints) or visceral (affecting internal organs).
- Neuropathic pain: This is caused by nerve damage or dysfunction and is usually described as burning, tingling, shooting, or electric. It can be peripheral (affecting nerves outside the brain and spinal cord) or central (affecting nerves within the brain and spinal cord).
- Psychogenic pain: This is influenced by psychological factors, such as stress, anxiety, depression, or grief. It can be associated with any type of pain or occur independently.
The causes of pain in hospice patients can vary depending on their underlying condition and other factors. Some common causes are:
- Cancer: Cancer can cause pain by invading or compressing tissues, nerves, bones, or organs. It can also cause pain by releasing chemicals that trigger inflammation or by spreading to other parts of the body (metastasis).
- Non-cancer diseases: Many non-cancer diseases can also cause pain in hospice patients, such as heart failure, chronic obstructive pulmonary disease (COPD), kidney failure, liver failure, diabetes, arthritis, or infections.
- Treatment-related effects: Some treatments for terminal illnesses can also cause pain or worsen existing pain, such as surgery, chemotherapy, radiation therapy, or medications.
Assessment and Treatment of Pain
The first step in managing pain is to assess its severity, location, frequency, duration, quality, and impact on function and quality of life. The patient’s self-report is the most reliable source of information about their pain. However, some patients may have difficulty expressing their pain due to cognitive impairment, communication barriers, cultural differences, or fear of addiction or side effects. In these cases, the hospice team may use other methods to assess pain, such as observing behavioral cues (e.g., facial expressions, body movements), using validated tools (e.g., numerical rating scales), or asking family members or caregivers.
The second step in managing pain is to choose the appropriate treatment based on the type and cause of pain and the patient’s preferences and goals. The treatment plan should be individualized and reviewed regularly to ensure its effectiveness and safety. The treatment options for pain management in hospice environment include:
- Medications: Medications are the mainstay of pain management in hospice environment. They can be classified into different categories based on their mechanism of action and potency. Some common categories are:
- Non-opioids: These include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen; acetaminophen; and corticosteroids. They are effective for mild to moderate nociceptive pain and can also reduce inflammation and fever.
- Opioids: These include morphine; hydromorphone; oxycodone; fentanyl; methadone; and others. They are effective for moderate to severe nociceptive or neuropathic pain and can also reduce anxiety and dyspnea. They work by binding to opioid receptors in the brain and spinal cord and blocking the transmission of pain signals.
- Adjuvants: These include antidepressants; anticonvulsants; antispasmodics; local anesthetics; bisphosphonates; and others. They are used to enhance the effect of opioids or non-opioids or to treat specific types of pain or symptoms.
Medications can be administered through various routes, such as oral, sublingual, transdermal, rectal, intravenous, subcutaneous, or intrathecal. The choice of route depends on the patient’s condition, preference, and availability. The dose and frequency of medications should be adjusted according to the patient’s response and tolerance. The hospice team should monitor the patient for any adverse effects or complications of medications, such as constipation, nausea, sedation, confusion, respiratory depression, or addiction.
- Non-pharmacological interventions: These include physical, psychological, social, and spiritual modalities that can complement or supplement medications. They can help reduce pain by enhancing coping skills, relaxation, distraction, or meaning. Some examples are:
- Physical interventions: These include massage; acupuncture; heat or cold therapy; transcutaneous electrical nerve stimulation (TENS); exercise; or positioning.
- Psychological interventions: These include cognitive-behavioral therapy (CBT); hypnosis; biofeedback; mindfulness; or counseling.
- Social interventions: These include family or caregiver support; social work; volunteer services; or community resources.
- Spiritual interventions: These include prayer; meditation; music; art; or chaplaincy.
The hospice team should assess the patient’s needs and preferences for non-pharmacological interventions and provide them with appropriate referrals or resources. The hospice team should also educate the patient and their family or caregivers about the benefits and limitations of these interventions and how to use them safely and effectively.
Conclusion
Pain management is a vital component of hospice care that can improve the quality of life for patients with terminal illnesses and their families. Pain management requires a comprehensive and multidisciplinary approach that addresses the physical, emotional, and spiritual aspects of pain. Pain management involves regular assessment and treatment of pain using medications and non-pharmacological interventions that are tailored to the patient’s condition and goals. Pain management also requires ongoing communication and collaboration among the hospice team, the patient, and their family or caregivers to ensure optimal pain relief and comfort.
References
1: https://www.
2: https://elsevier.health/en-US/
3: https://www.aafp.org/pubs/afp/
4: https://prnhospice.com/blog/
5: https://samaritannj.org/