Managing pain in the last days of life

Pain assessment

All patients in the last days of life should have regular pain evaluations.^{7, 8} However, the assessment of pain in this setting can be challenging as patients become less responsive or begin to experience delirium.^{*1, 3} It can also be difficult to assess pain in patients with limited communication due to cognitive impairment.^{1, 3}

Pain evaluation usually involves determining:^{4, 9}

• The severity of the pain. A tool to measure pain intensity is recommended, e.g. verbal descriptor, numerical scale, Faces Pain Scale. The Abbey Pain Scale can be used to assess pain in patients with limited or no communication.
• The type(s) of pain present (see box about adjuvant or co-analgesics):
  • Somatic, e.g. aching, throbbing, gnawing, localised
  • Visceral, e.g. deep, dull, aching, cramping
  • Neuropathic, e.g. burning, shooting, tingling
  • Bone, e.g. constant, deep
• Whether there is a specific cause that can be treated, e.g. urinary retention, constipation
• Any factors that relieve and exacerbate pain, e.g. body position, movement, temperature, psychological factors, spiritual concerns about the dying process
• The impact of pain on all aspects of the patient’s wellbeing and functioning

Practice Point: Consider other practical ways to identify that patients with limited communication may be experiencing pain, e.g. by recognising facial expressions or non-specific distress behaviours such as restlessness, moaning, muscle tension.^{1, 3, 8} If it is still uncertain whether a patient with limited communication is in pain after an initial assessment, an empiric trial of analgesics may be appropriate.

^*For further information, see: “Managing delirium and psychological symptoms in the last days of life”

Consider both non-pharmacological and pharmacological pain management options

Making the patient comfortable and pain free is the primary goal in the last days of life. Most commonly this is achieved with the use of analgesic medicines (see: “Morphine is usually the first-line pharmacological treatment”), but non-pharmacological strategies (see below) should be used as well if appropriate.^{4, 6, 9}

Ideally, pain management will have been discussed with the patient and their family/whānau prior to the last days of life so that a plan is already in place, i.e. advance care planning, see: www.hqsc.govt.nz/our-work/advance-care-planning/.

Non-pharmacological pain management strategies:^{3, 4, 6, 9}

• Acknowledge and validate the patient’s pain experience, reassure them that every effort will be made to manage their pain
• Minimise exposure to triggers that exacerbate pain, e.g. particular movements or body positions, psychological distress
• Encourage the family/whānau to spend time with the patient which may help to ease their pain
• Regularly reposition the patient (if possible and appropriate). This can be comforting, pressure relieving, and help to reduce stiffness and muscle aches. Provide pressure relieving aids as required.
• Suggest relaxation or distraction techniques depending on the patient’s level of functioning, e.g. listening to music or a podcast, watching television, guided imagery (a technique where the person imagines positive images or scenarios, e.g. favourite holiday destination), reminiscing, mindfulness, meditation or prayer (depending on the patient’s spiritual or cultural beliefs)
• Use a hot or cold pack
• Gentle massage or touch (i.e. by family/whānau)
• Create an ambient environment, e.g. by lowering lights, setting an appropriate room temperature, aromatherapy

Support the use of other techniques and methods for pain relief that the patient or their family/whānau want to try if they are unlikely to cause harm, e.g. traditional techniques (such as Rongoā Māori, Ayurvedic or Chinese herbal medicines), homeopathy, acupressure/acupuncture.

Morphine is usually the first-line pharmacological treatment

Opioids administered subcutaneously are recommended for patients with pain in the last days of life.^{4, 6} Patients already taking opioids orally usually require conversion to a subcutaneous form, i.e. convert oral doses of morphine to subcutaneous doses of morphine (see: “Oral doses should be converted to subcutaneous”).

Morphine is the first-line pharmacological treatment for most patients in the last days of life (Figure 1).^{4, 6} Oxycodone may be considered for patients who are unable to tolerate morphine.⁴ If a patient has significant renal impairment (i.e. eGFR < 30 mL/min/1.73 m²), the active metabolites of morphine or oxycodone can accumulate resulting in opioid toxicity.⁴ Symptoms and signs of opioid toxicity include myoclonic jerks, excessive sedation or confusion, restlessness and hallucinations.^{1, 4}

Fentanyl (subcutaneous) may be appropriate in patients with significant renal impairment (Figure 2);⁴ however, dosing and administration is more complicated than morphine. Therefore, in practice, morphine may still be used in some patients with renal impairment in the last days of life, particularly if doses are not too high. In the last days of life, contraindications for treatment also become less absolute.

Practice Point: Anticipatory prescribing of “as needed” doses of analgesia is also recommended in patients without current pain (Figure 1); if pain arises the “as needed” dose can be administered and then regular dosing initiated.⁶

Figure 1. Anticipatory prescribing for pain algorithm for patients with normal renal function in the last days of life. Adapted from South Island Palliative Care Workstream, 2020.⁶

CSCI = continuous subcutaneous infusion

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Figure 2. Anticipatory prescribing for pain algorithm for patients with impaired renal function in the last days of life. Adapted from South Island Palliative Care Workstream, 2020.⁶

CSCI = continuous subcutaneous infusion

Oral doses should be converted to subcutaneous

Many patients entering into their last days of life will already be established on an analgesic treatment regimen, usually with a long-acting opioid (either oral or transdermal). For patients currently taking an opioid orally, conversion to a subcutaneous dose for 24-hour continuous subcutaneous infusion is recommended in the last days of life (Table 1).^{4, 6} This is often required as the patient’s level of consciousness and alertness is expected to reduce during this period, which makes swallowing no longer possible.^{6, 8} If a patient is currently using transdermal fentanyl, patches can remain in situ and subcutaneous fentanyl (unapproved route) can be prescribed and administered on an “as needed” basis for breakthrough pain (Table 1).^{4, 6}

Practice Point: Fentanyl patches take 72 hours to reach steady state and should not be initiated in patients who are opioid naïve.¹⁰ The lowest dose fentanyl patch (12.5 micrograms per hour) is equivalent to up to 60 mg of oral morphine.¹⁰

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Table 1. Dose conversion and “breakthrough” dose calculations for subcutaneous morphine, oxycodone and fentanyl.⁶

Prescribe “as needed” doses for breakthrough pain

Subcutaneous morphine/oxycodone doses should also be prescribed and administered on an “as needed” basis for breakthrough pain (Table 1).⁶ “Breakthrough” doses are generally one-sixth of the total 24-hour dose and should be prescribed every hour (occasionally every thirty minutes) as needed. A maximum of eight “breakthrough” doses administered within 24 hours are recommended.⁶ If the patient has incident pain, e.g. pain associated with movement such as changing position, dressing changes, administer the “as needed” dose prior to the activity.⁶

If pain persists and/or at least three “breakthrough” doses have been required (other than those needed for incident pain) within 24 hours, increase the dose of the opioid in the continuous subcutaneous infusion by the total additional dose required in the previous 24 hours (excluding doses needed for incident pain).⁶ A new “breakthrough” dose will now need to be calculated.⁶ If pain still persists after a further 24 hours, contact the local hospice or palliative care team.⁶

Laxatives are usually only required if constipation is causing discomfort in the last days of life

Almost all patients taking strong opioids experience persistent constipation and are routinely co-prescribed an oral laxative regimen. In the last days of life, however, constipation may not cause symptoms and the benefit from laxatives during this time may be limited.^{1, 8} Oral laxatives are ceased once swallowing is no longer possible. Suppositories or enemas are rarely required in the last days of life and they should only be considered if constipation is causing significant discomfort to the patient.⁸