What is Pain Management in Hospice Care?
As hospice nurses, we understand that pain can manifest in many forms – physical, emotional or psychosocial. It is the duty of the hospice nurse to assess and address each aspect of pain. Pain management in hospice care is all about making sure the patient is as comfortable as possible during their stay on hospice – as well as teaching and empowering caregivers with knowledge and tools they will need to manage the pain when the hospice team isn’t there.
Pain management isn’t necessarily always about medications either. Non pharmacological interventions can be just as effective. It is our responsibility to find effective pain management techniques for each individual patient. By doing this, we not only ease the patient’s pain, but we will also reduce the stress of the caregivers, which will allow them to focus on providing the best care possible to their loved ones.
Pain Assessment in Hospice Nursing
Upon admission, the first step for the admitting nurse is setting up a plan of care to ensure the best quality of life and care possible during the patient’s hospice journey. Pain management is one of the most integral parts of the plan of care.
Unfortunately, not all of our hospice patient’s will be able to verbally describe the level, location, or type of pain they are experiencing. Some patients may be completely nonverbal. It is important for the hospice nurse, admitting, as well as visiting, to be sure to continuously assess for pain. Verbal and Nonverbal.
Verbal pain Assessment
This form of assessment is easier. The patient will most likely allow the nurse to know the important details surrounding their type of pain. Important facts to take note of during the assessment include:
- Location of Pain – Knowing where the pain is located on the body will give the nurse a good idea of what caused the pain, as well as how to manage and treat the pain.
- Pain Scale – If the patient is able to verbalize the intensity of pain on a scale from 0-10, this will help the hospice nurse decide the best pain management plan.
- Type of Pain – It is also important for the hospice nurse to ask what type of pain the patient is experiencing. Whether it is a burning, aching, sharp, dull pain, these will be helpful details in the pain assessment process for the nurse to decide the best possible action.
All of this information is crucial to report back to the hospice doctor, and he will in turn provide new orders or advisements to ensure an effective plan for pain management.
Non-Verbal Assessment
Treating non-verbal patients will be a bit more complicated, but far from impossible. With proper assessment skills, and the help of the attentive caregiver, we, as hospice nurses, can manage their pain effectively as well.
Non-Verbal Signs of Pain
- Facial Grimacing – Facial grimacing is described as an involuntary expression where the face contorts. This often indicates pain or discomfort. It is a key non-verbal signs that hospice nurses look for when assessing pain.
- Moaning or crying – A patient experiencing pain may be moaning or crying, or perhaps even crying out for help when they are experiencing a moderate to severe level of pain. In my hospice career, it has happened many times where non-verbal patients would cry for help when the pain was severe. It is our duty as nurses to assess and report these findings to the hospice team and doctor.
- Guarding or Shielding – It is common for when a patient experiences pain in a centralized location, that they will guard that part of their body any way they can to prevent it from being touched or moved.
- Restlessness – A hospice patient may constantly move or reposition themselves. They may be unable to sit still and constantly fidget. These signs of restlessness may also be an indicator for pain.
- Change in mood – When a hospice patient becomes agitated, irritable, or having signs of anxiety – these are possible signs of pain as well.
- Changes in breathing – Rapid, shallow breaths or even irregular breathing patterns are a major signs of nonverbal pain.
- Change in mood – When a hospice patient becomes agitated, irritable, or having signs of anxiety – these are possible signs of pain as well.
- Changes in breathing – Rapid, shallow breaths or even irregular breathing patterns are major signs of nonverbal pain.
With these key findings, you will be able to assess your hospice patient’s pain level.
Non pharmacological pain management techniques
Although the hospice team provides the patient with the necessary pain medication to manage their pain when needed, there may be times when pharmacological interventions are not yet needed. Here is a list of examples of when we, as hospice nurses, can manage pain without the needs of pain medication.
Physical Pain
Pain related to chronic pain, back pain, or joint pain can be an ongoing issue. There are interventions the hospice nurse can provide and demonstrate to the caregiver so that they can provide ongoing support to the patient.
- Heat Therapy – Applying warm compress or heating pads to the affected areas can help sooth the muscles and reduce any stiffness.
- Cold Therapy – Using ice packs can reduce inflammation and numb any sharp pain.
- Massage – A gentle massage can help relax tense muscles and improve circulation.
- Repositioning – Be sure to regularly change the patient’s position to alleviate pressure and improve the patient’s comfort.
Emotional Pain
It is common for hospice patients to experience emotional pain, such as anxiety or depression related to their individual terminal illness. Although the hospice team will put pharmacological interventions in place to combat these symptoms, there are also non pharmacological interventions that the hospice nurse can start with.
- Counseling and support groups – This can provide a safe space for the patient to express their feelings and receive much needed emotional support.
- Relaxation Techniques – Guided imagery and deep breathing exercises are good techniques that may reduce stress and anxiety.
- Aromatherapy – Using calming scents like lavender and chamomile can help promote a relaxing environment.
- Journaling – For those able, it is good to encourage the patients to write down their feelings. This can be a great way to release emotional stress.
Spiritual Pain
It’s not uncommon for people coming up on the end of their lives to begin to feel a sense of hopelessness or existential distress. Existential distress at the end of life is a sense of hopelessness, or feeling as if they are a burden upon others. These patients feel a sense of despair that is associated with their inevitable death. There are ways to help the patients, and the caregivers through these difficult times.
- Spiritual Counseling – The Social Chaplain and the MSW on the hospice team are great advisors in these situations, and as the hospice nurse, it is advised that you advocate for them and get the other team members involved.
- Talk About Their Lives – It may help to encourage the patient to reflect on their lives, their achievements, and any meaningful experiences that they may have had.
- Music Therapy – Playing calming or their favorite music may help the patient find peace.
- Art Therapy – If the patient is able to, it would be beneficial to encourage them to start doing an art or craft. This is a great way to get them to express their hardest to talk about feelings and emotions.
Psychosomatic Pain
Psychosomatic pain is a type of pain that is caused by psychological factors. This type of pain commonly manifests by headaches and stomachaches. Thankfully there are ways to help the patient in non pharmacological ways.
- Breathing Exercises – Having the patient practice deep, slow breathing is a good way to calm their nervous system. This will hopefully alleviate their symptoms.
- Yoga or stretching – If the patient is able to, gentle yoga and stretching exercises can help relieve muscle tension and improve the overall well-being of the patient.
- Laughter Therapy – There’s a reason for the old saying “Laughter is the best medicine”. Encouraging activities where the patient may laugh can help release endorphins and reduce the perception of pain. Perhaps putting on their favorite light hearted show, movie, or even stand-up comedian could be a great way to do this.
All of these techniques can be powerful tools in managing pain and offering comfort to your hospice patients. Also teaching these techniques to the caregivers will greatly improve the patient’s quality of life.
Pharmacological Interventions to Combat Pain
When non pharmacological interventions have been used and the patient is still experiencing pain, that is when it is important to talk to the hospice doctor and have a plan of care in place to manage the pain. This should be done upon admission.
It’s important to start at a safe starting point, when introducing pain medication to a patient. Some people may have never taken pain medication. Either because they have never needed to, or the patient simply has never been comfortable taking meds. It is crucial to have a discussion with the patient, as well as the caregiver, that at some point on the patient’s hospice journey, they may need to start taking pain medication.
Doing so proactively can make the conversation go more smoothly when the time comes to start introducing pharmacological interventions to combat the hospice patient’s pain.
Here is a list of the pain medications used in hospice, and their uses.
- Acetaminophen – for mild pain
- Ibuprofen, naproxen – for mild to moderate pain
- Hydrocodone – for moderate to severe pain
- Morphine, Oxycodone, Hydromorphone for severe pain
- Fentanyl – For continuous severe pain
For neuropathic pain, here is a list of meds that the hospice doctor may prescribe:
- Gabapentin
- Pregabalin
- Lidocaine patches for localized neuropathy.
- Tramadol for severe neuropathic pain.
Challenges in Pain Management for Hospic Nurses
Many hospice patients have a complex list of medications, and it is important that there is open communication upon admission so that the hospice doctor knows every medication that the patient is on before starting a proper plan of care for pain management. There are times when a patient has a history of drug abuse, that they may not be fully truthful in what they are taking. It is important to let the patient know that they are in a safe, non judgemental place, so that they can receive the best and safest care possible.
It is also important to have the same level of communication to the family members and hospice caregivers. Many times in my career I have had conversations with family members that involved assuring them that the medications involved in managing the patient’s pain are safe and under supervision of the hospice team, under the guidance of the hospice doctor.
Many families are uncomfortable with providing pain management because they believe that they are killing their loved one. It is very likely that as a hospice nurse, you will need to re-educate the family members multiple times, and re-assure them that the patient will feel better once they take the medication. This scenario will most likely occur when the patient needs pain management at the end of life. Just be patient and supportive of the caregivers and family members during these difficult times.
Empowering Caregivers to Manage Pain
As hospice nurses, our ultimate goal is to provide peace and comfort during one of the most challenging times in the patient’s and the caregiver’s life. This is more than just physical pain, but they can also provide psychological, social, spiritual and emotional comfort to their loved ones. We need to take the time to educate the caregivers on all the tools they have available to manage the pain and discomfort of their loved ones, because they may not know.
Doing so not only reduces the stress of the caregivers, but it also will enhance the quality of care, and ultimately, the life for the patient. If we focus on the individual needs and explore all avenues of pain management, we can truly make a difference in our patients’ lives. Remember that even though our presence is temporary, we will leave a lasting impact on the loved ones lives.
