For any patient who is receiving hospice care and faces a challenging, chronic, or progressive disease state, the advent of myriad therapeutic interventions can help achieve comfort and pain relief.1  

The existence of unrelieved pain is viewed as a critical factor that can obstruct dignity at the end of life.1 Within the hospice care setting, patients can be placed on specific therapies that are designed with the primary intent of alleviating pain or removing the discomfort that can be associated with a terminal diagnosis. At times, it can prove difficult for family members to watch a loved one in pain and not receiving sufficient medication.2 The existence of a subset of medication classes that are approved for pain management are considered go-to medications when providing comfort care in the hospice care setting. Historically, attention has been given to adequate symptom management at the end of life, with less attention given to the medications that are prescribed to people in hospice.3 The most commonly prescribed drugs include acetaminophen, haloperidol, lorazepam, morphine, and prochlorperazine, and atropine typically found in an emergency kit when a patient is admitted into a hospice facility..3

The presence of pain is recognized as one of the most distressing symptoms that any individual can experience, so it is critical that depending on the type of pain, it is adequately controlled. With pain medicines, measures must be taken to ensure that appropriate doses are given, and the frequency is monitored for any individual who is receiving hospice care. When it comes to pain management, the essential medication class include nonopioid analgesics and opioids.3,4

Adequate pain management is considered a universal requirement in health care.5 Pain control is also recognized as a central component of providing optimal hospice care. Most caregivers, family members, and patients expect that the quality of hospice care provided will include adequately relieving the pain experienced. The understanding that family members and patients have about pain is vital to influencing how patients will react to the pain therapy given.5

The goal of pain management is the help with the reduction of pain to a manageable level considered to be acceptable from a patient’s subjective point of view. The best approach to pain management is one that involves the active participation of the patient to evaluate whether pain is being appropriately managed during treatment.

Pain management is considered more effective if it uses a multidisciplinary approach that encompasses both non-pharmacological and pharmacological interventions. At any given time in an individual’s life, the occurrence of an event has the ability to stimulate nociceptors to send information to the central nervous system to sense pain.6 The combined use of non-pharmacological and pharmacological interventions has been shown to yield more effective pain control, and most patients in hospice benefit from the use of an interdisciplinary approach that is specifically targeted  toward managing their complex problems.7,8 The most commonly recognized pharmacological interventions consist of analgesics, such as narcotics or non-steroidal anti-inflammatory drugs, and non-pharmacologic measures, such as biofeedback, cognitive therapy, and physical therapy.9-11

The initial step that can be taken with pain management is typically focused on the use of short-term pain medication.12 The management of short-term pain control (more than 3 to 4 hours at a time) may be achieved with the use of medications such as Vicodin, Percocet, or Lortab, which consists of a combination of 2 active ingredients developed as either acetaminophen or aspirin, and codeine..12 As time progresses, there may be the need to prescribe much stronger medication. The combination of narcotic medications with other drugs can be used to increase the effectiveness in treating pain in the terminally ill.12 Some of these pain medications can cause kidney problems, stomach bleeding, slow blood clotting, or an upset stomach, so carefully monitoring is necessary to ensure that these adverse effects are immediately identified and treated.13 It can be difficult to evaluate the impact of all the relative strength of the different pain medications, because they all tend to affect people quite differently.14 It is vital for a prescriber to critically evaluate response to drug therapy and modify accordingly based on pain.

The treatment of more severe pain can be achieved through use of narcotics, which are divided into class schedules, with many being in the Schedule II class. The use of narcotics can provide immediate relief or the effects can last for several hours in the form of a sustained release.15 The sustained-release formulations can be used for more chronic pain where the requirements for pain control must be provided on an ongoing basis.16 On the other hand, the immediate-release medications can be used to manage breakthrough pain that can arise at any given moment, sometimes for no reason, and require immediate intervention.17

Within the hospice care setting it is vital to maintain continuity of care as it relates to pain
management.18 Given the subjective nature of pain, adequate treatment can be overlooked at times during the patient care process, but active vigilance on the part of family members, health care professionals, or the patient can help increase the likelihood of achieving positive therapeutic outcomes.
Abimbola Farinde, PharmD, is a pharmacist at Cornerstone Hospital in Houston, Texas, and an adjunct professor at Grand Canyon University’s College of Nursing and Health Care Professionals in Phoenix, Arizona.


References
1.Wilkie DJ, Ezenwa MO. Pain and symptom management in palliative care and at end of life.  Nurs Outlook. 2013;60(6):357-364. doi:10.1016/j.outlook.2012.08.002
2. Kehl KA, Kirchhoff KT, Kramer BJ, Hovland-Scafe C. Challenges facing families at the end of life in three settings. J Soc Work End Life Palliat Care. 2010;5(3&);144-168. doi:10.1080/15524250903555080
3. Sera L, McPherson ML, Holmes HM. Commonly prescribed medications in a population of hospice patients. Am J Hosp Palliat Care. 2014;31(2):126-131. doi:10.1177/1049909113476132.
4. IAHPC list of essential medicines for palliative care. International Association for Hospice and Palliative Care; Houston. Accessed October 5, 2020. http://www.hospicecare.com/resources/pdf-docs/iahpc-essential-meds-en.pdf
5. Glowacki D. Effective pain management and improvements in patients’ outcomes and satisfaction. Crit Care Nurse. 2015;35(3):33-41. doi:10.4037/ccn2015440
6. Leleszi JP, Lewandowski, JG. Pain management in end of life care. J Am Osteopath Assoc. 2005;105(3 Suppl 1):6S-11S.
7. Thomas S. Non-pharmacological dimensions of end of life care. Ann Palliat Med. 2012;1(3):230-231. doi: 10.3978/j.issn.2224-5820.2012.10.03
8. Effective pain management. In: Recognition and Alleviation of Pain in Laboratory Animals. National Research Council (US) Committee on Recognition and Alleviation of Pain in Laboratory Animals. Washington, DC; National Academies Press (US): 2009.
9. Revord J. Noninvasive pain management techniques. Spine-Health. Updated October 12, 2012. Accessed October 6, 2020. athttps://www.spine-health.com/treatment/pain-management/noninvasive-pain-management-techniques
10. Buyukyilmaz F. Non-pharmacological intervention in orthopedic pain: A systematic review. Int J Technol Assess Health Care. 2014;7(3):718-725.
11. Spitz A, Moore AA, Papaleontiou M, Granieri E, Turner BJ, Reid MC. Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatr. 2011;11:35. doi:10.1186/1471-2318-11-35.
12. Pain control: methods and standard of care. Hospice Patients Alliance. Accessed October 6, 2020. https://www.hospicepatients.org/hospic29.html
13. Benyamin R, Trescott AM, Sukdeb D, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105-20.
14. Morgan MM, Christie MJ. Analysis of opioid efficacy, tolerance, addiction and dependence from cell culture to human. Br J Pharmacol. 2011;164(4):1322-1334. doi: 10.1111/j.1476-5381.2011.01335.x
15. Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Inter Med. 2002;17(3): 238-240. doi: 10.1046/j.1525-1497.2002.20109.x
16. Schneider JP. Role of sustained-release opioids in treating chronic pain. PPM. 2007;8(1):1-3.
17.Schneider C, Yale SH, Larson M. Principles of pain management. Clin Med Res. 2003;1(4):337-340. doi: 10.3121/cmr.1.4.337
18. Corrigan JM. Continuity of care: Important but only the first step. Isr J Health Policy. 2012;1(1):22. doi:10.1186/2045-4015-1-22