Clinical aspects of palliative care

Objectives
1. Define the guiding principles of palliative care
2. Describe pain management in palliative care
3. Explain pain assessment in palliative care
a. Guiding principles
Access to care

• Palliative care is a right of every adult and child therefore, it

should be included in the Kenya Essential Package for Health
(KEPH).
• Patients and their families shall access holistic palliative care
which aims at meeting their physical, psychosocial and
spiritual needs within their cultural context.
• Palliative care patients shall be referred to appropriate levels
of health care service delivery.
Multidisciplinary team approach

• Palliative care shall be provided by a multidisciplinary team.

• Where an interdisciplinary team is not available, a core team
shall be oriented on palliative care to ensure that all patient
needs are met.
• Members of the team shall communicate and network the
care of the patient and family through regular meetings to
discuss case studies in order to share experiences,
understand problems and identify appropriate solutions.
 Service Delivery Model

• Institutions, guided by the WHO Palliative Care Program

Principles, shall choose a suitable model depending on their
setting and resource availability without compromising quality of
services.
• The model shall be:
a. Developed as a comprehensive and public health approach.
b. Integrated within existing health care delivery systems in
both public and private sector for scale up of the continuum
of care for chronic, life-threatening illnesses.
c. Tailored to the specific cultural and social context.
 Ethical and Legal Aspects of Care
• The goal of palliative care is to improve the quality of life of patients and
family, thus care and support shall be provided for their benefit.
• The patient’s goals, preferences and choices shall be respected according to
the laws of Kenya, and shall form the basis for the plan of care.
• Rights and ethical consideration for the patient shall be observed as
outlined in Kenya National Palliative Care Training Curriculum for HIV&AIDS,
Cancer and other life threatening illnesses.
• When a child’s wishes differ from those of the adult decision-maker,
appropriate professional staff members shall be made available to assist the
child.
 b. Provision Of
Palliative Care Services
1. Palliative care plan

• A patient requiring palliative care should have a detailed

holistic assessment.
• A care plan should be developed by the palliative care
provider in collaboration with the patient and family.
• They must be in order of priority.
• State five nursing diagnosis for a palliative patient.
Assignment: Draw a nursing care plan for end of life care.
Assessment Nursing diagnosis objective Interventions rationale

Neglectful Compromised family The patient will be Assess level of Anxiety level needs
relationships with coping related to able to express anxiety present in to be dealt with
other family inadequate more realistic family before problem
members information understanding and solving can begin.
Inability to complete characterized by expectations of care Individuals may be
caregiving tasks; inability to complete givers. so preoccupied with
altered caregiver care giver tasks… own reactions to
health status situation that they
are unable to
respond to
another’s needs

Establish rapport assist patient and

and acknowledge caregivers to accept
difficulty of the what is happening
situation for the and be willing to
family. share problems with
staff.
2. Pain management
Roby

i. 25 Y.O. Male
ii. One-day post-op abdominal surgery
iii. You enter his room. He is lying quietly in bed,
grimaces as he turns in bed
iv. BP: 120/80; HR = 80; RR = 18bpm
v. Rates his pain at 8/10
i. You administered morphine 2 mg IV 2 hours ago
ii. After injection, you assess his pain Q 30 minutes.
iii. Results: pain intensity 6-8 out of 10.
iv. No respiratory depression, no sedation, no side
effects from morphine.
v. He has identified 2 out of 10 as an acceptable
level of pain relief.
vi. The order: Morphine 1 - 3 mg every hour as
necessary for pain relief.
What will you do?
a) Administer no morphine at this time
b) Administer morphine 1 mg IV now
c) Administer morphine 2 mg IV now
d) Administer morphine 3 mg IV now
Andy

i. 25 Y.O. Male
ii. One day post op abdominal surgery
iii. You enter his room and find him smiling, joking,
and talking with a visitor.
iv. BP: 120/80mmHg; HR = 80b/m; RR = 18bpm
v. Rates his pain at 8/10
i. You gave morphine 2 mg IV 2 hours ago
ii. After injection, you assess his pain Q 30 minutes.
iii.Results: pain intensity 6-8 out of 10
iv. No respiratory depression, no sedation, no side effects from
morphine
v. He has identified 2 out of 10 as an acceptable level of pain
relief
vi. The order: Morphine 1 - 3 mg every hour as necessary for pain
relief.
What will you do?
a) Administer no morphine at this time
b) Administer morphine 1 mg IV now
c) Administer morphine 2 mg IV now
d) Administer morphine 3 mg IV now
What can you say about these two
men?

1. Behaviors
2. Subjective nature of pain
3. Coping with pain
 Discussion of Case Scenarios

1. Except for behaviors – both cases were

identical.
2. Subjective nature of pain – must accept
patients’ reports.
3. There are multiple ways of coping with pain
– laughter and distraction are common (i.e.
Andy)
• Even if we believe a patient is not experiencing pain,
we have NO right to impose our beliefs on them.
• Better to be “duped” than provide inadequate pain
relief and nursing care to a palliative patient.
• Both Andy and Roby should receive 3 mg IV now (Its
clear the previous dose was not sufficient, thus it
needs to be increased).
1. Define pain 2 marks
 Pain

• Whatever the person experiencing the pain says it

is, existing wherever the person says it does
(McCaffery).
• Pain is a subjective experience of an unpleasant
sensory and emotional experience associated
with actual or potential tissue damage, or
described in terms of such damage.
• Total pain is a concept commonly used in
palliative care and encompasses physical,
psychological, social, and spiritual aspects of
pain.
• It’s one of the major reasons for seeking
health care.
• Nurses have a central role in pain assessment
and management.
 Nursing roles in pain management
1. Assessing pain and communicating this information to other health care
providers.
2. Ensuring the initiation of adequate pain relief measures.
3. Evaluating the effectiveness of these interventions.
4. Administering pain meds and non-pharmacological pain interventions
5. Advocating for patients to ensure their pain is addressed and managed.
6. Providing comfort to patients such as position changes to ease the pain.
7. Administering pain meds and non-pharmacological pain interventions
8. Educating patients about pain management techniques.
• ADD At least 5 roles
 Dimensions of Pain
Affective (emotions,
suffering)
Physiologic Behavioral (behavioral
(transmission of responses)
nociceptive stimuli)
PAIN
Cognitive (beliefs,
Sensory (pain
attitudes, evaluations,
perception) goals)
Mechanisms of Pain Perception
Medications Interrupt this Pathway

1. Transduction (e.g., NSAIDS, local

anesthetics).
2. Transmission (e.g., opioids).
3. Perception (e.g., opioids, adjuvants,
NSAIDS).
4. Modulation (e.g., tricyclic anti-depressants).
Classification of Pain

I. Acute pain
II. Chronic pain
State five differences between
acute and chronic pain 5
marks
 Acute pain
Sudden onset
< 3 months or as long as it takes for normal healing to
occur
Mild-to-severe pain
Generally can identify a precipitating event or illness
(e.g., surgery).
Course of pain ↓ over time and goes away as recovery
occurs.
Includes postoperative pain, labor pain, pain from trauma
• Treatment includes analgesics for symptom control and
treatment of the underlying cause.
• Manifestations reflect sympathetic nervous system
activation
• ↑ heart rate
• ↑ respiratory rate
• ↑ blood pressure
• Goal is elimination of the pain.
 Chronic Pain
Onset may be gradual or sudden
> 3 month duration; may start as acute injury or event
but continues past the normal recovery time.
Cause of pain may not be known.
Typically pain does not go away; characterized by
periods of waxing and waning.
Mostly behavioral manifestations
↓ physical movement/activity
Fatigue
Withdrawal from others and social interactions
• Can be disabling and is often accompanied by
anxiety and depression.
• Treatment goals
• Pain control to the extent possible.
• Focus on enhancing function and quality of life.
• Explain pain assessment using PQRST
 Assessment of Pain: PQRST

P = Provoking/Palliating factors
• What precipitates/provokes the pain?
• What makes it worse?
• What makes it better (palliates)?
Q = Quality
• What does it feel like?
• Ask open-end questions.
• How would you describe the pain?
• Can you describe how it feels?
R = Region/radiation
• Where is the pain?
• Does it travel or radiate around your body?
• Is the pain in one place?
S = Severity and site
• VAS (Visual analogue scale)
• Numerical scale (scale of 1-10)
• Descriptive scale – how bad is the pain? (no
pain, mild, moderate, severe, very severe, worst
possible)
• FACES pain rating scale - for children, non-
verbal, language barriers.
Visual analogue scale
 Wong-Baker FACES scale

• Use in children who can talk (usually 3 years and older)

• Explain to the child that each face is for a person who feels happy because
he has no pain, or a little sad because he has a little pain, or very sad
because he has a lot of pain.
• Ask the child to pick one face that best describes his or her current pain
intensity.
• Record the number of the pain level that the child reports to make
treatment decisions, follow-up, and compare between examinations.

40
T = Timing and treatment history/temporal factors
• When did it begin?
• How often do you get it?
• How long does it last?
• When does it occur?
• Does it come and go?
• Is it constant?
• Are you or have you been on treatment for the pain?
• Does it help?
Describe the measures you will use in assessing pain in
Cognitively Impaired/Non-verbal Adults 10 marks.
 Assessing Pain in Cognitively Impaired/Non-
verbal Adults
• Self-report whenever possible:
Often can use numerical scales if taught
0 - 5 scale may be easier
Faces scale - 6 different facial images
• Alternatives to self-report (from most to least useful)
• Pathologic conditions or procedures known to cause
discomfort
• Behaviours
• Facial expressions (frown, grimace, contract muscles around mouth/eyes)
 • Physical movements (restless, fidget,
resists movement, guarding,
combativeness, hostile behaviour).
• Vocalizations (moan, groan, crying).
• Proxy pain rating (family, friends, clinician) - only a
guess.
• Physiological Measures (e.g., HR, RR, BP- elevated) -
least helpful.
 Treatment of pain
All pain treatment is guided by the same underlying
principles
1. The patient must always be believed.
2. Every patient deserves adequate pain management.
3. Set goals for comfort and function
- e.g., what pain rating would allow patient to do post-op
recovery activities?
- Generally ratings > 3-4 interferes with function
4. Prevent occurrence and recurrence
- Predictable pain - give analgesic before
- Pain around the clock (ATC) – analgesics
ATC (wake patient for analgesic before the
pain wakes them).
5. All therapies must be evaluated to ensure
they are meeting patient’s goals.
• Effective pain control is central to palliative
care.
• Use both pharmacological and non
pharmacological measures.
• Providers should be able to control physical
pain according to WHO analgesic ladder.
i. Pharmacological Measures

• The WHO analgesic ladder is the fundamental

approach to all types of pain including nociceptive and
neuropathic pain.
• It should be used as the standard approach to pain
management.
• Pain control drugs should be administered regularly –
by the clock, by the ladder, per oral and for the
individual patient.
Drug therapy
I. Non-opioids
II. Opioids
III. Adjuvents
Each works on pain in different ways (interrupt
pathways in different points/ways).
Different types can be combined for maximal pain
relief.
• See WHO Analgesic Ladder for management of
pain (p. 142)
• See Equi-analgesic chart (McCaffery)
a. Non - Opioids
Acetaminophen and NSAIDS
• General purpose analgesics
• Acute and chronic pain
• Especially for mild Multiple Sclerosis pain
• Also used in combination with adjuvants and
opioids for moderate to severe pain
• Have a ceiling effect - no more pain relief will be
obtained beyond a certain dose.
• Acetaminophen (i.e., Tylenol)
• Analgesic acts on the CNS
• Safest non-opioid for most patients, especially elderly.

• Does not increase bleeding time or cause ulcers.

• May cause hepatotoxicity (do not use in chronic liver
disease or alcoholism).
• Maximum daily dose: 4000 mg
• Also an anti-pyretic
• Neither an anti-inflammatory nor anti-platelet
• NSAIDS
• ASA/Aspirin, Ibuprofin/Motrin/Advil, Celebrex, Vioxx
• Relieve pain at site of injury and act on CNS.
• Block prostaglandin production at site of injury.
• When NSAID doesn’t work: increase dose or try
another type.
• NSAIDS are also
• anti-inflammatory
• anti-pyretics
• anti-platelet (prevent clotting)
*State the side effects of NSAIDs*
• NSAIDS
• Common side effects
• Heartburn, GI ulceration, GI bleeding
• Risk of ulcers increases with increased dose
• Increased bleeding time
• Use cautiously in elderly - prone to GI
problems, platelet dysfunction, renal
problems
b. Opiods

Two Categories
• Morphine like (mu agonists) - largest group**
• =Agonist-antagonists
Opioids: Mu agonists

• Examples: morphine, demerol, darvon,

oxycodone, heroine, codein
• Bind to/activates mu opiod receptor sites in
spinal cord, preventing transmission of pain
impulses.
• Best for acute and cancer pain treatment.
• No ceiling on dose (increasing the dose increases
effect; no maximum dose); can increase dose until
desired effect obtained or side effects are
unacceptable/unmanageable.
• Relieves all types of pain.
• Routes: oral, IM (not recommended b/c unreliable
absorption and pain), IV, rectal, topical.
• Side effects:
•N&V
• Constipation (most common - prevent with laxatives)
• Itching
• Drowsiness
• Respiratory depression (generally not a problem if dosing is
correct)
• Monitor respiratory status
• Most at risk are opioid naive
• Naloxone (narcan) to revers effects of narcotics
• Sedation/drowsiness (safety precautions very important)
• precedes respiratory depression, so can serve as a warning
c. Adjuvant Analgesic Therapy

• Primary use is not pain relief (e.g., anticonvulsants,

antidepressants).
• Useful for some painful conditions.
• Mostly used for neuropathic pain.
• Mechanisms of action and side effects vary across
different medications.
 Combining analgesics

• Combining analgesics from > 1 group sometimes

improves pain relief.
• To attack more than one pain mechanism.
• Reduce side effects by using lower doses of each
analgesic.
• Can combine acetaminophen with NSAIDS
• Do not combine NSAIDS with each other (increases risk
of side effects).
• Combine opioids with non-opioids (e.g.
tylenol with codeine)
• All mu agonists work in same way, therefore
do not combine, instead increase the dose.
• Combine adjuvant(s) with opioid and non-
opioids (especially for neuropathic pain).
Pharmacologic and Nonpharmacologic
Therapies for Pain
 ii. Non Pharmacological therapy
• This is the management of pain without
medications.
• Can reduce the dose of an analgesic required to
control pain thereby minimizing side effects of drug
therapy.
• Some strategies are believed to alter ascending
nociceptive input or stimulate descending pain
modulation mechanisms .
• They work by altering thoughts, focusing
concentration to better manage and reduce pain.
• Methods of non-pharmacological pain
management should include:
• Education of the patient and family / carer on the
condition to provide insight and support.
State five non-pharmacological methods of pain management
• Physical pain relief strategies
• Acupuncture
• Application of heat / cold
• Exercise
• Massage/lotion therapy
• Positioning
• Occupational therapy
• Physiotherapy
• Percutaneous electrical nerve stimulation (PENS)
• Transcutaneous electrical nerve stimulation (TENS)
• Vibration
• Cognitive therapies
• Distraction
• Hypnosis
• Imagery
• Relaxation
• Psychosocial therapy/care
- Companionship
- Music
- Art
- Aromatherapy
- Drama
- Group therapy
• Spiritual care
• Meditation on the word of God
• Prayer
• Religious counseling
 iii. Surgical therapies
• Performed for severe pain that is unresponsive to all
other therapies.
• Nerve blocks
• Used to reduce pain by interrupting transmission of
nociceptive input.
• Neural blockade with local anesthetics is sometimes
used for peri-operative pain.
• For intractable chronic pain when conservative
therapies fail.
iv. Placebos

• Any medication that produces an effect because

of its implicit/explicit intent and not because of
its physical or chemical properties (e.g., sugar
pills, saline injections).
• What does it mean when relief is obtained from
placebos?
• Are placebos ethical?
 Self reflection questions
1. How do you assess and manage pain and other symptoms in your palliative care
practice? Reflect on the effectiveness of your current approaches and any areas
for improvement.
2. How do you address the psychosocial and spiritual needs of patients and families
in palliative care? Reflect on a specific approach or intervention that you have
found particularly effective.
3. How do you ensure that advance care planning is incorporated into the care of
your palliative care patients? Reflect on a time when advance care planning had a
significant impact on patient care.
4. Reflect on a challenging ethical dilemma you have encountered in your palliative
care practice. How did you approach the dilemma, and what were the outcomes?
5. How do you ensure that your clinical practice in palliative care is evidence-based?
Reflect on how you stay updated with the latest research and incorporate it into
your practice.
• Write five nursing diagnoses on pain
5 marks