Pain in Palliative Care: Assessment

Question 1

Alberta Pharmacists’
Palliative Care
Competency
Framework
September 2020
https://www.covenanthea
lth.ca/media/125313/202
00923_albertapharmacists
palliativecarecompetencyf
ramework_final.pdf

Answer 1

Provides
expectations of
competencies
required of all
pharmacists in the
province
◦ U of A, RxA, ACP
◦ Pharmacist experts

Question 2

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

Answer 2

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.

Question 3

Symptom control at any stage of a life-limiting
illness

what kinds of symptoms

Answer 3

◦ 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

Question 4

 Early palliative care

Answer 4

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

Question 5

When should we offer Palliative Care?
Who Requires Palliative Care?

Answer 5

 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)

Question 6

Perceptions of Palliative Care

Answer 6

 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

Question 7

GOALS OF CARE R1 R2 R3 M1 M2 C1 C2

Answer 7

Chest Compressions
Intubation
Resuscitation
ICU
Site Transfer

Surgery
Life sustaining treatments
Symptom control

see slide 21

Question 8

Palliative Care and GOC

Answer 8

 Misconception
◦ You must be C level
 Consult service: all
(R1-C2)
 TPCU: M1 –C2
 Hospice C1-C2
◦ C2: = EOL care

Question 9

Pain in the Palliative Population

Answer 9

 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

Question 10

Causes of Pain in Palliative Patients

Answer 10

 Terminal Illness
◦ Cancer
 Pre-existing pain
conditions
◦ Fibromyalgia
◦ Chronic pain
 Previous trauma
◦ Arthritis
◦ Diabetic neuropathy
◦ Migraine
◦ Sciatica

Question 11

Causes of Cancer Pain: Disease

Answer 11

◦ 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

Question 12

Causes of Cancer Pain: Treatment

Answer 12

 Chemotherapy
◦ Neuropathies
 Radiation
◦ Burns
◦ Pain flare
 Surgical
complications
◦ Infections
◦ Wounds
◦ Phantom pain

Question 13

Barriers to Good Pain Control

Answer 13

 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

Question 14

Total Pain

Answer 14

“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

Question 15

Assessments in Palliative Care

Answer 15

 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

Question 16

PPS

Answer 16

ambulation
activity lcl and evidence of disease
self-care
intake
LOC

Question 17

ESAS-r

Answer 17

 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

Question 18

CAGE (addictions)

Answer 18

 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

Question 19

Cognition
Folstein’s Mini-Mental State Exam (1975)

Answer 19

◦ 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

Question 20

Edmonton Classification System
for Cancer Pain (ECS-CP)

Answer 20

 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

Question 21

ECS-CP: Examples

Answer 21

 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

Question 22

Dignity Question

Answer 22

 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.