Pain in Palliative Care: Assessment Flashcards
Alberta Pharmacists’
Palliative Care
Competency
Framework
September 2020
https://www.covenanthea
lth.ca/media/125313/202
00923_albertapharmacists
palliativecarecompetencyf
ramework_final.pdf
Provides
expectations of
competencies
required of all
pharmacists in the
province
◦ U of A, RxA, ACP
◦ Pharmacist experts
What is Palliative Care?
NSCLC patients
◦ PC vs SOC
PC arm
◦ Improved QOL
◦ Improved mood
◦ Longer survival
11.6 vs 8.9 months (2.7
months)
Follow-up studies
confirmed results
Palliative care is a philosophy of care that
aims to relieve suffering and improve quality
of living and dying in those patients diagnosed
with a progressive incurable illness. This
includes addressing their physical,
psychological, social and spiritual needs. It
involves optimizing living as fully as possible in
the time remaining, while preparing for dying.
Symptom control at any stage of a life-limiting
illness
what kinds of symptoms
◦ Pain (Nociceptive and neuropathic)
◦ Dyspnea, delirium, confusion, agitation, depression,
anxiety, seizures, fatigue, insomnia.
◦ Constipation, diarrhea, nausea, vomiting, cachexia,
anorexia, decreased function, motility issues/obstruction
◦ Blood clots, bleeding, infections, pruritis, wounds.
◦ Ascites/effusions, electrolyte imbalances, edema.
◦ Psycho-social/spiritual issues
Most pharmacists will care for palliative patients
◦ Community/acute care/continuing care/hospice
Early palliative care
Feasible, cost effective, & efficacious
◦ Patients benefit from
Improved symptom control
Better supported decision making
Reduces unnecessary/over-aggressive treatments at EOL
Improved QOL
Multi-disciplinary team
◦ Appropriate when integrated with disease modifying
treatments (integrated palliative care)
Incorporated into ASCO Guidelines
When should we offer Palliative Care?
Who Requires Palliative Care?
Ask surprise question:
“Would I be surprised if the patient died in the next
12 months?”
If no, then consider PC.
◦ Is PC appropriate for this patient?
If yes, PC may be an option if symptomatic
◦ Some patients in program for many years
Cancer patients
◦ Adult & pediatric
Non-cancer Patients
◦ Renal (ESDR)
◦ Pulmonary (COPD, PF)
◦ Neurology (PD, MS, ALS)
◦ GI: (end-stage liver disease)
◦ Infectious diseases (AIDS)
◦ Geriatrics (Alzheimer’s)
◦ Pediatrics (MD)
Perceptions of Palliative Care
Palliative care
◦ Symptom management at
any stage of a life-limiting
illness
◦ Includes end-of-life care
Misconceptions
◦ Palliative care = death
imminent
HCP’s
Public
Must be C level of care
More education required.
Palliative care is 99% communication
GOALS OF CARE R1 R2 R3 M1 M2 C1 C2
Chest Compressions
Intubation
Resuscitation
ICU
Site Transfer
Surgery
Life sustaining treatments
Symptom control
see slide 21
Palliative Care and GOC
Misconception
◦ You must be C level
Consult service: all
(R1-C2)
TPCU: M1 –C2
Hospice C1-C2
◦ C2: = EOL care
Pain in the Palliative Population
Pain is a common & often devastating
complication of progressive, incurable illness
◦ Advanced cancer, AIDS, end stage lung and heart
disease, motor neuron disease (MND).
85% patients with advanced cancer
experience pain
◦ 67% of these rate their pain as moderate-severe
Cancer, AIDS, & MND patients may
experience neuropathic pain
Pain results in
functional impairment
Failure to manage
pain effectively results
in needless suffering
and poor quality of
life
85% of pain
syndromes can be
controlled
Causes of Pain in Palliative Patients
Terminal Illness
◦ Cancer
Pre-existing pain
conditions
◦ Fibromyalgia
◦ Chronic pain
Previous trauma
◦ Arthritis
◦ Diabetic neuropathy
◦ Migraine
◦ Sciatica
Causes of Cancer Pain: Disease
◦ Direct
Invasion of tissues, organs, bone
Nociceptive: somatic or visceral pain
Invasion of nerves causes neuropathic pain
Central and peripheral nerves
Paraneoplastic phenomena
Altered nerve conduction
◦Indirect
Caused by constipation, obstruction, fractures
Causes of Cancer Pain: Treatment
Chemotherapy
◦ Neuropathies
Radiation
◦ Burns
◦ Pain flare
Surgical
complications
◦ Infections
◦ Wounds
◦ Phantom pain
Barriers to Good Pain Control
Family/patient concerns
◦ Opioids
Addictions /side effects
Lose efficacy over time
◦ Stoicism
◦ Complaining will annoy their caregivers
◦ Financial concerns
◦ Cognitive impairment
◦ Lack of compliance
Heath-care professionals
◦ Skills required
◦ Fears of addiction
◦ Fears of reprimand
◦ Failure to recognize multidimensionality of pain
◦ Underestimating extent of pain
Total Pain
“Total pain” is a term coined by Dame Cicely
Saunders to describe a situation where the pain
experience originates from a number of sources
including physical, social, psychological, and/or
spiritual domains.”
Need to assess all domains
◦ Classify type(s) of pain
◦ Treat appropriately
Assess patient’s expression of pain to optimize
◦ Pharmacological interventions
◦ Non-pharmacological interventions
Failure to recognize contributing factors like
psychological distress may lead to ineffective
management and over-reliance on
pharmacological methods
Cancer pain may change as the disease
progresses
Assessments in Palliative Care
History
Physical exam
Goals of care
PPS (performance)
ESAS-r (symptom)
CAGE (addiction)
MMSE (cognition)
◦ NOT AVAILABLE 8/2022
ECSCP (pain classification)
Medication History
◦ BPMH
◦ Opioid History
◦ Allergy assessment
Lab values
Imaging
Microbiology
Review of systems
PPS
ambulation
activity lcl and evidence of disease
self-care
intake
LOC
ESAS-r
9+ symptoms rated
on numerical rating
scale (0-10)
◦ Pain, tiredness,
drowsiness, nausea,
appetite, shortness of
breath, depression,
anxiety, wellbeing,
other (eg:
constipation)
ESAS-r Graphed
Completed daily
◦ Patient (preferable)
◦ Proxy (family/caregiver)
Each symptom is
plotted daily
Visualize how the
symptoms are
improving/worsening
over time
CAGE (addictions)
Questions
◦ Have you ever felt you should Cut down on your
drinking?
◦ Have people Annoyed you by criticizing your
drinking?
◦ Have you ever felt bad or Guilty about your
drinking?
◦ Have you ever had a drink first thing in the morning
or a drink to get rid of a hangover? (Eye-opener)
Score 0-4/ 4. 2+/4 = + ve CAGE
Cognition
Folstein’s Mini-Mental State Exam (1975)
◦ Cognition screen
◦ Free to use for 30 yrs. Now authors want to
enforce copyright . Looking for alternative
Some groups use other assessments
◦ Confusion Assessment Method (CAM)
◦ Mini-Cog (clock-drawing & memory)
◦ Blessed Orientation Memory Concentration Test
(BOMC)
MOCA (executive function) unable to use
◦ SLUMS is an alternative
Edmonton Classification System
for Cancer Pain (ECS-CP)
Complex and multifactorial
◦ Mechanism of pain (nociceptive/neuropathic)
◦ Presence of incident pain
◦ Psychological distress
◦ Addictive behaviors
◦ Cognitive function
Mechanism of Pain
◦ No = No pain syndrome
◦ Nc = Nociceptive pain
◦ Ne = Neuropathic pain
◦ Nx = Unable to classify
Incident pain
◦ Io = No incident pain
◦ Ii- Incident pain
◦ Ix Unable to classify
Psychological Distress
(PD)
◦ Po = No PD
◦ Pp = PD present
◦ Px =Unable to classify
Addictive Behavior (AB)
◦ Ao = No AB
◦ Aa = AB present
◦ Ax+ unable to classify
Cognitive function`
◦ Co= no problems
◦ Ci = partial impairment
◦ Cu= total impairment
◦ Cx= unable to classify
N__I__P__A__C
ECS-CP: Examples
Nx Ix Px Ax Ci
◦ Unable to assess pain type, or if incident pain,
psychological or addictive components present because of
cognitive impairment. (eg. Patient admitted in delirium)
No
◦ no pain present, non-malignant pain only (eg. arthritis), or
no cancer diagnosis.
Ne Ii Pp Aa Co
◦ Has neuropathic and incident pain. Psychological
component to pain expression and history of addictions.
Nc Ii Po Ao Co
◦ Has nociceptive pain & incident pain, but no other pain
syndromes
Dignity Question
What do I need to know
about you as a person to
give you the best care
possible?
Patient given more time to
answer this
Jack states:
“I just want to die now. I have
no family, and no one will care if
I am gone. I have nothing to live
for.
I just need to make sure the
animals on the farm are OK.
Winter’s coming real soon.
Crops are still in the field.
Not sure what will happen to it
when I’m gone. My kids don’t
care any more, you see…it’s my
own fault really. Didn’t treat
them or their mom right…but
it’s too late now.
