Pain Management: Cancer Pain and Pain at the End of Life

PART I: Cancer Pain Management

To many people, the word cancer means pain and death. Sadly, there is much to support that point of view. One study found that 30% of patients experience pain at the time of diagnosis, 30% to 50% experience pain while undergoing therapy, and 70% to 90% experience pain as the cancer advances and overcomes its victims (Portenoy & Lesage, 1999). Yet in 1996 the World Health Organization (WHO) reported that 90% of cancer patients could receive adequate pain relief with the relatively simple drugs that were available at that time (WHO, 1996). Since then, many more pain-relieving interventions have been developed. To achieve the goal of providing adequate pain relief for people with cancer and for those who are dying, caregivers need to know the types and causes of pain and effective strategies to manage pain at the end of life.

Cancer pain is more than a physical symptom. It is a reminder of one’s mortality, a harbinger of death. It may interfere with normal routines, degrade the quality of life, and rob one of rest, creativity, joy, and peace. Cancer pain adds anxiety and stress to its sufferers, their friends, and family. For this reason, professional caregivers:

• Take pain seriously, recognizing that only the person who is suffering knows how it feels.
• Provide information and resources for pain control.
• Communicate with genuineness, accurate empathy, and nonpossessive warmth.
• Encourage sufferers to share their feelings and network with other survivors.
• Respect cultural norms and wishes of sufferers, maximizing their control of pain.
• Encourage release of energy through joy-producing activities.
• Monitor pain medications, effectiveness, and adverse effects.
• Suggest patients keep a pain-relief record, including date, time, pain rating, medication amount, side effects, and comments (Haylock & Curtiss, 1997).

Cancer is treated with both traditional and nontraditional healing measures. Traditional measures include pharmacologic and nonpharmacologic therapies. Pharmacologic remedies include nonopioid analgesics, opioid analgesics, and co-analgesics/adjuvants (drugs that add to the effect of an analgesic, such as a sedative). Unlike postoperative or post-trauma pain, cancer pain may go on for months and years, adding to other sources of pain. As the patient undergoes treatment or the cancer invades other tissue, the intensity of their pain may increase. It is vital for the treating physician to know the name and dosage of all medications being taken by patients, including over-the-counter drugs and herbal supplements.

TYPES AND CAUSES OF CANCER PAIN

Cancer pain is complex, interactive, and ever-changing. It is caused by the cancer itself and the many different measures used to diagnose and treat it.

Pain Due to the Cancer Itself

As cancer cells invade healthy tissue, visceral and somatic pain receptors called nociceptors sense tissue damage and send impulses to the brain, where the person perceives pain. Nociceptor pain may be localized at the cancer site or referred to a remote area. Not only do sensory impulses inform the person of tissue injury, they initiate the release of neuromodulators, which produce localized inflammation and generate even more pain.

As nervous tissue is infiltrated by tumor growth or damaged by its treatment, neuropathic pain results, often persisting long after the initial insult. In some circumstances, secondary pain further complicates the situation. Although secondary pain results from tumor growth, it is not the direct cause of pain. For example, a space-consuming tumor in the brain increases intracranial pressure, which produces severe headaches.

In addition to physical pain, people with cancer and their families experience the psychogenic pain of anticipatory grief, fear, and other negative emotions such as anger and revulsion. In summary, cancer causes nociceptor, neuropathic, secondary, and psychogenic pain.

• Nociceptor pain is pain that is transmitted over intact visceral and somatic nerve fibers from damaged tissue caused by cancerous invasion of bodily tissue, radiation therapy, chemotherapy, and the sticks and jabs of diagnostic procedures. Nociceptor pain may be sharp and stabbing, throbbing and aching, constant or dull.
• Neuropathic pain is pain that is transmitted over damaged nerve fibers due to the abnormal processing of sensory information and is caused by infiltration of nervous tissue by cancer cells, radiation therapy, and chemotherapy. Neuropathic pain is burning, searing, tingling, and migratory.
• Secondary pain is the result of tumor growth but not necessarily the direct result of the invasion of healthy tissue by cancer cells. For example, a space-consuming brain tumor increases intracranial pressure and causes severe headaches.
• Psychogenic pain is caused by the emotional response people have to cancer and death, such as anger, fear, sadness, disgust, shame, guilt, and blame. Negative emotions increase stress and decrease the effect of pain-relieving measures.

The degree of pain experienced by an individual depends on the site of a cancerous lesion and the extent of its growth. Caregivers can expect cancer pain syndromes (clusters of symptoms) to produce the following typical pain:

CANCER PAIN SYNDROMES

Syndrome	Typical Pain
Peripheral nerve syndromes	Constant, burning pain with dysesthesia in area of sensory loss; radiating, often unilateral
Cranial neuropathies	Severe head pain with cranial nerve dysfunction; metastasis to skull base and leptomeningeal tissues
Vertebra of spine	Constant dull, aching pain; may be relieved by standing up or by lying down in a certain position
Bone: metastatic or primary	Aching, deep, intense pain, usually worse at night; pain may be referred to other areas of the body, associated muscle spasm and stabbing pain may occur
Viscera	Pain in related area, such as pancreatic pain, which is relentless, boring, mid-epigastric, radiating through to the mid-back
Plexopathies
Cervical plexus	Aching and diffuse in shoulder girdle and radiating
Brachial plexus (Pancoast’s syndrome)	Heaviness and tightness in upper arm, radiating
Lumbosacral plexus	Aching, pressure-like, may be referred to abdomen, buttocks, lower back, or legs

Pain Due to Diagnostic Procedures

Diagnostic procedures can cause considerable discomfort and outright pain. They may be performed on a regular, preventive basis, such as colonoscopies and mammograms, or on the occasion of a suspicious symptom of cancer. To determine the presence of a cancerous lesion, a biopsy must be obtained and the cells examined under the microscope.

For example, a man notices blood in his stool and reports it to his physician, who schedules a colonoscopy. During the colonoscopy, a suspicious polyp is found and removed, and its cells are examined to determine if they are cancerous. In another situation, a woman notices a lump in her breast and reports it to her physician, who schedules a biopsy, either by needle or surgical excision. Cells from the lump are examined to determine their status.

A multitude of other procedures are performed to obtain specimens for examination. All such measures create physical pain as well as emotional pain, as follows:

PAIN ASSOCIATED WITH DIAGNOSTIC PROCEDURES

Procedure	Typical Pain
Biopsy: skin, breast, bone	Sharp pain from needle sticks for local anesthesia
Biopsy: gastrointestinal tract via upper GI endoscopy, sigmoidoscopy, colonoscopy; laparoscopy	Positional pain; abdominal distention from cathartics and enemas; postoperative incisional pain
Biopsy: lung via bronchoscopy	Positional pain; post-procedural sore throat
Biopsy: kidney, ovaries, and other internal organs via laparoscopy and major surgery	Preoperative fear; postoperative incisional pain; sharp and burning
Blood draws for diagnostic study and assessment of health status	Needle sticks; sharp, piercing pain
Radiological procedures: x-rays, CT scans, MRI, other studies	Uncomfortable, painful positions; hypothermia, fatigue, boredom, fear

Pain Due to the Treatment of Cancer

Although a great deal of research is being conducted to find less invasive ways to treat cancer, at the present time the primary treatments used to rid the body of cancer are chemotherapy, radiation, and surgery. All of these modalities are potentially dangerous, and none of them guarantee success. They destroy healthy cells as well as cancer cells and cause nociceptor, neuropathic, secondary, and psychogenic pain. Sweeder estimated that 20% to 25% of cancer pain is directly related to its treatment (2002). Typical pain of common cancer treatments are listed in the following table.

PAIN CAUSED BY CANCER THERAPY

Therapy	Typical Pain and Complications
Postoperative	Incision pain; sharp and burning
Mastectomy	Tight, constricting, burning in back of arm, axilla, over chest; worse on movement; tingling in distribution of peripheral nerves; loss of sensation
Axillary lymphectomy	Numbness and aching due to edema
Thoracotomy	Referred pain to arm and chest, sensory loss around scar; reflex sympathetic dystrophy may develop
Amputation	Phantom pain in place of missing limb or body part
Radical neck dissection	Tight burning sensation and numbness or prickly sensation in the neck; dysesthesia in area of sensory loss
Oophorectomy	Surgical menopause, hot flashes
Postradiation	Aching pain, similar to postoperative and tumor pain; radiation may cause new neurogenic tumors and soft-tissue fibrosis
Myelopathy	Aching or shooting pain in certain muscles
Necrosis of bone	Aching, prickling; may be localized or referred
Mucositis and stomatitis	Ulcers of the mucus membrane; raw, burning sensation; eating and drinking made painful
Postchemotherapy	Some drugs (vesicants) seriously damage tissue if they leak outside blood vessels (extravasation); most cause nausea and vomiting
Mucositis and stomatitis	Painful ulcers of the mucous membrane in the mouth appear about 10 days after treatment begins, especially from methotrexate, doxorubicin, daunorubicin, bleomycin, etoposide, fluorouracil, and dactinomycin, causing pain on eating or drinking
Aseptic necrosis of the bone	Jaw pain; intermittent calf pain and/or prickling in hands or feet
Painful polyneuropathy	May feel pain in several places at once
Steroid pseudorheumatism	Aching pain in joints
Chemical menopause for estrogen-positive breast cancer	Hot flashes from anti-estrogen drugs such as tamoxifen

EFFECTIVE STRATEGIES TO MANAGE CANCER PAIN

To manage cancer pain, nurses and other caregivers use a process that includes assessing pain, diagnosing it, setting goals to manage the pain, planning appropriate actions, intervening, evaluating the effectiveness of interventions, and communicating with both the sufferer and caregivers.

Assessing Pain

The management of cancer pain is complicated when sufferers:

• Experience chronic pain from other conditions, such as arthritis
• Have a history of substance abuse, especially opioids
• Possess a poor cancer prognosis.

For this reason accurate assessment is vital, especially when a person experiences unusual pain called new pain. Such assessment includes: (1) pain history, (2) observation of nonverbal behaviors, and (3) physical examination.

A pain history is an accounting of the pain just as the sufferer experienced it. A mnemonic tool to help caregivers remember pain history categories is called "OLDCART":

• Onset of pain
• Location (possibly multiple sites)
• Duration (how long it lasts and whether it is constant or intermittent)
• Character (sharp, shooting, dull, aching, cramping, squeezing)
• Aggravating factors such as moving, walking, sitting, turning, chewing,
  breathing, urinating, defecating, swallowing
• Relieving factors (activities or drugs that make pain better or worse)
• Treatment, if any (drug or nondrug interventions) (Bednash & Ferrell, 2002)

Various nonverbal behaviors are exhibited by people who experience pain.

NONVERBAL BEHAVIORS INDICATING PAIN

Facial Expressions	Vocalizations	Body Movement	Social Interaction
Clenched teeth Wrinkled forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth	Crying Moaning Gasping Groaning Grunting	Restlessness Protective body movement Immobility Pacing Rhythmic movement	Silence Withdrawal Reduced attention span Focus on pain relief measures

A physical examination includes inspection (looking closely), palpation (feeling with the hands), percussion (tapping), and auscultation (listening). For example, Jim Pepper complains of deep stabbing pain in the mid-epigastric area of his abdomen that is worse at night. The nurse palpates the area and notes the man’s non-verbal behavior as he gasps and moves to avoid further pain. As the nurse turns to leave the room, Mr. Pepper says, “I bumped into wall last night and hurt my arm.” He winces as he peels his sleeve from a raw weeping wound on his forearm. The nurse examines the area, carefully positions the arm to avoid further injury, and calls for an assistant to stay with the man while she prepares to dress the wound.

Diagnosing Pain

The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. A more complete nursing diagnosis adds “related to” the medical diagnosis and “manifested by” the symptoms experienced by the patient. Cancer patients often have both acute and chronic pain. In the example given above, John Pepper suffers from “acute pain related to an abrasion of the left forearm, manifested by bleeding, stinging, and burning pain.” Also, he suffers from: “chronic pain related to pancreatic cancer manifested by deep, stabbing pain in his epigastrium.”

Goal Setting and Planning Interventions

Goal setting and planning interventions involves the identification of attainable objectives and reasonable priorities. Because every person is different, healthcare providers discuss various alternatives with patients, and together they set priorities. For example, in consultation with an oncologist and surgeon, a man with a cancerous obstruction of the colon, cirrhosis of the liver, and emphysema decides to undergo a resection of the obstructed colon and pain management rather than the more drastic surgery of a permanent colostomy.

Interventions for the Management of Cancer Pain

PHARMACOLOGIC INTERVENTIONS

Three groups of drugs are used to treat cancer pain: nonopioid analgesics, opioid analgesics, and co-analgesics or adjuvants.

Nonopioid Analgesics

Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammation. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.

With the exception of acetaminophen (Tylenol), most nonopioids are potent anti-inflammatory agents. They are especially effective when the primary cause of pain is inflammation, as occurs in bone cancer. When tissue is damaged, a series of biochemical events lead to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes—cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2)—play an important part in this biochemical process. Drugs that inhibit their action, especially COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified. The following table lists some common nonopioid analgesics.

COMMON NONOPIOID ANALGESICS

Drug	Adult Dose	Considerations
Acetaminophen (Tylenol)	650–975 mg q 4 hr	Used for headaches, osteoarthritis; lacks peripheral anti-inflammatory activity of NSAIDs
Aspirin	650–975 mg q 4 hr	Used for headaches, osteoarthritis, general pain; antipyretic; inhibits platelet aggregation, causing bleeding
Ibuprofen (Motrin)	400 mg q 4–6 hr	Used for osteoarthritis; antipyretic; multiple brand names; available as liquid
Indomethacin (Indocin)	150–200 mg/day	Used for gout; anti-inflammatory; anti-rheumatic
Naproxen (Naprosyn)	500 mg initial dose, then 250 mg q 6–8 hr	Used for gout, headaches; anti-inflammatory; anti-rheumatic; available in liquid preparation

Opioid Analgesics

Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names, typically denoted by Greek letters such as mu (μ), kappa (κ), and sigma (σ). Many of the characteristics of particular opioids relate to the receptor to which they bind. For example, morphine binds to μ receptors and follow μ receptor control.

Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control—an “agonist effect.” Full agonists include such drugs as morphine (Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl (Duragesic patch, Fentanyl oralets), oxycodone hydrochloride (OxyContin), and hydromorphine (Dilaudid).

Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin) and butorphanol tartrate (Stadol). An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.

The primary action of opioids (narcotics) is to alleviate moderate to severe pain. Many of the unwanted side effects of this class of drugs are related to their actions on other than the central nervous system (CNS), causing such effects as constipation and respiratory depression. The following table lists some common opioid side effects and preventative measures.

OPIOID ADVERSE EFFECTS AND PREVENTIVE MEASURES

Body System	Adverse Side Effects	Preventative Measures
Cardiovascular	Hypotension, palpitations, flushing	Monitor blood pressure and heart rate
CNS	Sedation, disorientation, euphoria, dysphoria, light-headedness, lower seizure threshold, tremors	Inform client that tolerance may develop over 3–5 days; administer stimulants as needed
Gastrointestinal	Constipation, nausea, vomiting	Offer anti-emetic; change analgesic; increase fluid and fiber intake; increase exercise; administer laxatives
Genitourinary	Urinary retention	Catheterize as needed; administer opioid antagonist
Integumentary	Itching, rash, wheal formation	Apply cool packs or lotion; administer antihistamine
Respiratory	Respiratory depression; aggravation of asthma	Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)

Some medications combine nonopioid with opioid analgesics in one tablet to offer two different levels of pain relief—acting both on peripheral nerve endings at the injury site and at the level of the central nervous system. Acetaminophen with codeine is such a medication.

Drug Tolerance and Dependence

Drug tolerance is a physiologic condition in which humans require larger and larger doses of a drug to provide the same effect as the original dose. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may help overcome tolerance. However, drug tolerance is not the only reason drugs become ineffective. They may be less effective because of advancing cancer growth and tissue damage and thus greater pain.

Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. Other such needs include drug-to-drug interaction, drug-to-food interaction, increased physical activity, changes in opioid formulation, and psychological dependence (addiction).

Physical dependence is a physiologic adaptation of tissues to a drug. If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response, including excessive yawning, nausea, vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. By slowly reducing the dose of an opioid analgesic, physical withdrawal symptoms can be reduced or eliminated.

Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for the drug’s nonanalgesic emotional effects. Opioids with an affinity for both μ and σ receptor sites produce euphoria and hallucinations. Thus, these drugs are the most frequently abused narcotics. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues.

Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly “drug-seeking” but “relief-seeking.” Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or inadequate doses spaced too far apart.

Adjuvant Analgesics

Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain but have been found to enhance the effects of analgesics. Caregivers need to remember that these are “helper drugs,” not substitutes for analgesics. Clients in pain still need analgesics. The following table describes some common adjuvant analgesics.

COMMON ADJUVANT (CO-ANALGESIC) DRUGS

Class of Adjuvant Drugs	Indications and Primary Effects
Antidepressants: Tricyclics and serotonin, reuptake inhibitors	Burning, neuropathic pain; improves sleep, enhances mood and analgesic effects
Anti-epileptic drugs	Neuralgic and neuropathic pain (sharp, prickling, shooting pain)
Antispasmodic	Reflex sympathetic dystrophy syndrome
Anxiolytic drugs: Benzodiazepines, buspirone, venlafaxine	Anxiety and sedation
Botulinum toxin	Migraine headache
Lidocaine	Neuralgic pain and diabetic neuropathic pain
Psychostimulants	Offsets sedating side effects and enhances analgesic effects of opioids
Steroids	Inflammatory and chronic pain of cancer, malignant spinal cord compression, headaches, and arthritis

Placebos

A placebo is a “sugar pill,” an inactive substance prescribed as if it were an effective dose of a medication. Research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000). This so-called “placebo effect” has been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and gadgets to people in pain. Because their purpose is to deceive and strip clients of the right to make informed decisions, legitimate medical practice does not use placebos. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is when subjects give prior consent for the possible use of placebos in research studies.

World Health Organization Pain Management Ladder

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended a three-step pain management ladder based on the intensity of pain.

1. Mild pain (intensity 1–3 on the 0–10 standard): Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists, then administer…
2. Mild to moderate pain (intensity 4–6): Use combination medications such as oxycodone and acetaminophen and adjuvants. If pain persists, then administer…
3. Moderate to severe pain (intensity 7–10): Use potent opioids such as morphine, fentanyl, methadone, and adjuvants.

To prevent under-treatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant cancer pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at the lower level (Jackson & Stanford, 2003).

Routes of Administration

Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.

ANALGESIC DRUG ADMINISTRATION

Route	Indications	Contraindications
Oral (per os = PO)	Preferred route due to lower cost and convenience; may be prepared as powders, tablets, capsules, liquids, or lozenges	Gastrointestinal irritation; inability to swallow; need for more potent analgesic
Rectal (R)	Inability to take oral drugs; can be self-administered; longer duration than oral	Anal or rectal lesions, diarrhea, thrombocytopenia
Intramuscular (IM)	Acute, short-term pain relief	Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly
Intravenous (IV) bolus	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; gives only brief pain relief when prolonged relief is needed
Continuous intravenous (IV) infusion	Gives constant opioid blood level when other methods are ineffective	Requires infusion pumps with alarms and close monitoring
Patient-controlled analgesia (PCA)	Allows predetermined IV bolus of analgesic when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous (SC) opioid infusion	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; potential site irritation
Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular	Intractable pain when client cannot tolerate systemic opioids by other routes	Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Regional nerve blocks	Continuous or single dose analgesic for acute and chronic pain; used for trauma, burns, and labor	Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Topical (cream-laden anesthetic)	Analgesic for needle sticks, venipuncture, dermatitis, and insect stings	Must be applied 30–60 min in advance of need
Transdermal skin patch	Continuous dose of opioid; allows home use	Absorption is accelerated when body temperature is over 102°F; costly
Nasal sprays	Alternative to IV, IM, and oral opioid administration; rapid onset of action	Nasal exudates or mucosal swelling may prevent consistent absorption

NONPHARMACOLOGIC INTERVENTIONS

Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately, there are many nondrug interventions to reduce pain, especially when used in conjunction with effective drugs. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of nursing practice. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater sense of control, and are considered holistic nursing practice.

Physical Interventions

Comfort measures such as clean and smooth sheets, soft and supportive pillows, warm blankets, and a soothing environment have been used by caregivers throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical well-being of patients.

Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is bodily movement to health, an entire profession has developed specializing in physical therapy. However, caregivers need not wait for a specialist to offer these important pain-relieving interventions.

Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic nursing care, backrubs offer an important noninvasive way to relieve pain and provide comfort.

Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decreases blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are an important means of providing comfort.

Cognitive-Behavioral Interventions

Relaxation exercises are effective ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, yoga, and other such interventions may relieve pain. One such exercise involves controlled breathing. A coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. The coach suggests the subject locate an area of muscle tension, contract the muscles in that area, and then relax them. As the subject relaxes, pain perception and anxiety diminish.

Guided imagery is similar to relaxation exercises in that a coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.

Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. Distraction alone does not work for cancer pain and chronic, long-term pain.

Complementary and Alternative Medicine (CAM)

An increasing number of people in the United States are also turning to theories and practices outside the realm of conventional Western medicine to relieve pain. In 1991, the federal government established the Office of Alternative Medicine. In 1998, the agency became the National Center for Complementary and Alternative Medicine (NCCAM), making the center one of 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services. NCCAM defines CAM as “a group of diverse medical and healthcare systems, practices, and products that are not currently part of conventional medicine” (NCCAM, 2009a).

The mission of NCCAM is to explore “complementary and alternative healing practices in the context of rigorous science…and [to] disseminate authoritative information to the public and professionals” (NCCAM, 2007). In this context, “complementary” describes practices used in conjunction with or to supplement conventional medical treatments, and “alternative” means those that are used independently or in place of conventional medicine. Practitioners of such techniques and practices often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit.

The major categories of complementary and alternative medicine are:

• Biologic (herbal mixtures; macrobiotic diets; orthomolecular, such as megadoses of vitamins, magnesium, melatonin, etc.)
• Energy fields (acupuncture, therapeutic touch, pulse fields, Reiki, etc.)
• Manipulative and body-based (chiropractic, lymphatic drainage, reflexology, aromatherapy, deep-muscle massage, shiatsu, etc.)
• Mind-body (biofeedback, hypnosis, art therapy, prayer, etc.) (Diluzio & Spillane, 2002)

Biologic. Plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When prepared in a purified form, the dose is more precise than it can be from a plant. Some common active chemicals originally derived from plants are: digitaloid found in the foxglove plant (digitalis), saponins found in sarsaparilla (irritant laxatives), alkaloids found in nightshades (atropine), and alkaloids found in the opium poppy (morphine) (McGuigan & Krug, 1942).

Energy fields. Such healing measures are based on theories about unseen forces in the human body. Acupuncture, for instance, is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When these forces are out of balance, pain and illness result. There are at least 350 acupuncture points by which energy flows are accessible. The theory posits that by stimulating these points with very fine needles, the energy flow can be rebalanced and pain relieved (Mayo Clinic, 2009; NCCAM, 2009b).

Manipulative and body-based. These are healthcare approach that focuses on the relationship between the body’s structure and its functioning. Chiropractic care primarily focuses on back, neck, and headache pain. Reflexology, aroma therapy, and shiatsu may be employed to improve the emotional state of cancer patients. Ongoing research is looking at effects of these approaches, how they work, and conditions for which they may be most helpful (NCCAM, 2009c).

Mind-body. These healing measures include biofeedback, hypnosis, art therapy, and prayer. Though they have been used throughout human history to effect healing and pain relief, only recently have they been subjected to scientific study (Diluzio & Spillane, 2002).

Evaluating the Effectiveness of Interventions

Evaluation is a critical phase of managing cancer pain. It tells the degree to which an intervention did, in fact, reduce pain and, if so, how much and at what cost to the patient.

To find out, we gather data from the best source of information, the client, and to some degree the client’s caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, data is gathered about adverse effects of an intervention, such as an allergic reaction, hypotension, constipation, or respiratory depression.

Communicating and Documenting

Communication about pain and the response of patients to interventions is facilitated by accurate and thorough documentation. This communication needs to be conveyed from caregiver to caregiver and shift to shift. Various tools have been devised to facilitate this communication, including pain flow sheets, running diaries, and bedside computer charting, called “point-of-care.” When communicating information about pain, it is important to describe the time and exact nature of an intervention, including details such as the level of pain before and after intervention, specific analgesic and dose, and adverse effect, such as respiratory depression. The more specific and timely a report, the more effective the evaluation will be.

Because pain is a potent motivator for change, people who suffer are vulnerable to all manner of fake gadgets and magical cures. It is the responsibility of healthcare professionals, especially nurses, to give patients accurate information about medications, devices, physical activities, and psychological strategies in clear, understandable ways. Such teaching empowers those who suffer and demonstrates genuine concern, accurate empathy, nonpossessive warmth, and respect.

PART II: Pain Management at the End of Life

The focus of pain management at the end of life is to provide support and comfort rather than cure for the dying and those they leave behind. To do this, caregivers need to understand the concepts, guidelines, ethical concerns, and legal issues associated with the end of life.

PALLIATIVE CARE AND HOSPICE

Palliative care is the active, total care of clients with a goal of providing comfort rather than cure (WHO, 2000). It addresses pain control, symptom management, and social, emotional, spiritual, and financial concerns of people at the end of life.

In 1968 Cicely Saunders—nurse, social worker, and physician—opened St. Christopher’s Hospice in England to care for people who were dying alone and in pain. She developed the concept of enhancing the quality of life through palliative care rather than curative treatment. In 1970 the philosophy of palliative care for dying patients was brought to the United States. Since that time it has spread throughout the nation, addressing the needs of people whose lives are ending.

Suffering is a highly personal experience that depends on the meaning of an event, such as an illness or loss. One can suffer without physical pain, and one can have physical pain and not necessarily suffer. The founder of the modern hospice movement described suffering as “total pain,” an experience of fear of physical distress and dying, concerns about relationships, changing self-perception, and memory of another person’s suffering (Panke, 2002).

The word quality refers to a measure or a grade of services or products. Quality of life refers to the state or condition of one’s being. If people are physically comfortable and emotionally satisfied, we say their quality of life is good. If they are in pain, under stress, alone, sad, or distressed, as many people are, we say their quality of life is poor. The goal of hospice and palliative care is to enhance the quality of life of dying clients.

Pain Control Guidelines

To help caregivers provide better care to individuals in pain and at the end of life, Paice and Fine (2001) suggest the following guidelines:

1. Assess a client’s pain and evaluate its effects on the individual’s quality of life. Titrate analgesics according to goals of care, pain, severity, need for supplemental analgesics, severity of adverse side effects, measurements of functional abilities (such as interaction with others, mobility, and sleep), emotional state, and effects of pain on quality of life.
2. For continuous pain relief, use sustained-release formulations and around-the-clock dosing.
3. Treat breakthrough pain with immediate-release formulations.
4. Monitor the client’s status frequently, especially during dose titration.
5. Anticipate adverse effects and prevent or treat them as necessary.
6. Be aware of possible drug-drug and drug-disease interactions.
7. Reassess pain regularly. Determine what level of pain is acceptable to the client. If pain is not relieved adequately, don’t give up. Consult resources outside your institution, including nursing colleagues and experts in related disciplines.
8. Differentiate pain from other symptoms such as delirium or multi-system failure.
9. Use sedation selectively to relieve intractable pain when other pain-relieving measures have failed and there is a do-not-resuscitate (DNR) prescription.
10. If the client is unable to communicate verbally, consult with caregivers and use nonverbal behaviors to evaluate pain.

Ethical and Legal Issues at the End of Life

Ethical principles guide caregivers at every stage of life, including its end. Ethical and legal issues and end-of-life care are often intertwined (Scanlon, 2003). This is especially true because pain frequently accompanies terminal illnesses.

BASIC ETHICAL PRINCIPLES

Caregivers follow these basic ethical principles (Hamilton, 2009):

• Respect for human life and dignity. Demonstrate respect for the dying person’s beliefs, values, privacy, and physical and psychological needs.
• Beneficence. Give care with gentleness, kindness, and a generosity of spirit.
• Autonomy. Respect the wishes of the individual and encourage family members to do the same.
• Justice. Give equal care to the poor, the rich, the young, the old, the addict, the psychotic, the criminal, the righteous, and the self-righteous.
• Honesty. Speak truthfully, with openness and candor, creating a culture of frankness for the dying person and the family.

ADVANCED DIRECTIVES

It is vital for all healthcare facilities to anticipate potential conflicts and see that advance directives are in place. When they are not, healthcare professionals may believe they are legally required to continue medically provided nutrition and hydration even when a client no longer benefits.

To resolve this conflict, all fifty states and the District of Columbia have enacted statutes to comply with the Client Self Determination Act (Omnibus Budget Reconciliation Act of 1990). The federal law requires that all healthcare institutions receiving Medicare and Medicaid funding must inform clients in writing about their right to accept or refuse medical or surgical treatment before they become incapacitated. Legal forms called advance directives facilitate this law. (Instructions and forms for each state are available without charge at http://www.caringinfo.org/stateaddownload/.)

There are two basic types of advance directives:

• Living will (treatment directive): written document that directs treatment in accord with the client’s wishes.
• Durable power of attorney for healthcare (appointment directive): also called a medical power of attorney for healthcare or healthcare proxy; a written document that designates a spokesperson (agent, proxy, surrogate) to represent the person in decision making (Partnership for Caring, 2009).

Despite legislation, Last Acts found that only 15% to 20% of the general population had an advance directive. They also found that decision making was skewed by circumstances at the moment, and that nurses play a vital role in helping families come to terms with the impending death of a loved one because nurses may be the first to recognize signs of approaching death (2002).

Communication Strategies

Caregivers can use three communication strategies to help terminally ill clients and their families accept the reality of death and make decisions about end-of-life care. They are:

• Use clear, unambiguous words, such as dying and death.
• Do not use words like hope because of the many meanings such words can convey.
• Collaborate with other providers to enforce evidence of failing health and the need to have an advance healthcare directive (Norton and Talerico, 2001).

In sum, pain management at its best provides maximum pain relief and minimal harm to individuals at every stage of life, including its end.