Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 3.0 Preventing Assessing and Treating Pain

Life's sharpest rapture is the surcease of pain.
- Emma Lazarus

Several recent studies have demonstrated that pain is undertreated. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, or SUPPORT (SUPPORT Principal Investigators, 1995), collected data on 9,105 very sick hospitalized patients and, after identifying problems in their care, tried and failed to correct them. SUPPORT researchers found that more than half of the patients who were awake at all in their final days were in serious pain. In a five-state study (Bernabei et al., 1998) of 13,625 nursing home cancer patients over the age of 65, fully one-quarter of those who reported daily pain received no analgesics. Most of the rest received doses that were inadequate or too weak, and performance worsened as patients were older.

Table 3.1 Use of Analgesics by Nursing Facility Residents with Cancer
Daily Pain GroupNo Pain
Analgesic Use(n = 4003)(n = 9610)
Nonnarcotic only659 (16%)2297 (24%)
Weak opiates (e.g., codeine)1293 (32%) 870 (9%)
Strong opiates (e.g., morphine)1029 (26%)390 (4%)
Any analgesic2984 (74%)3557 (37%)
Reprinted with permission from Bernabei, 1998, p. 1879

Poor pain management is not limited to nursing homes and hospitals. A survey of 3,200 American, British, and Canadian oncologists pointed to serious shortcomings in oncologists' ability to offer optimal pain relief and to recognize depression in their patients. Although 95 percent said they felt competent to manage pain, more than half said that more than 20 percent of their patients die in pain. An analysis of practice patterns found that 25 percent of those surveyed do not routinely provide optimal pain relief. Half said they did not feel competent to manage a dying patient's depression. The survey also found that up to 25 percent of oncologists do not like taking care of dying patients (Emanuel and Emanuel, 1998).

In This Chapter

Good pain management may even extend life - contrary to the widely held belief that aggressive pain management hastens death. In fact, untreated pain can lead to depression, apathy, and the loss of a will to live. The shortcomings in treating patient pain mean that a wide variety of changes will lead to improvements in patient care. This chapter features easy-to-replicate programs from Breakthrough Series groups, instruments for assessing pain and measuring improvement, and good ideas on how to do a better job - by next Tuesday.

This chapter describes many successful changes, as well as ideas that seem worth trying based on what we know about pain management. Subjects include:

Here is a review of current, best, and "even better" practices. The remainder of this chapter focuses on activities that directly affect care and activities that can improve the way an institution or organization improves pain management.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ ].

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