Severely disabled and institutionalized people present challenges for health care providers in assessing pain and response to treatment, in preventing and managing side effects, and in confronting difficulties in informed consent. Nursing homes and assisted living settings face many challenges in managing pain for frail elderly patients and those with dementia. Some facilities may not have licensed personnel available at all times and thus may require unusual arrangements for opioid storage and administration. Many facilities have residents who cannot report pain or advocate for relief.
Assessing pain in demented patients or in those who cannot communicate can be difficult; few of these patients with chronic pain cry out, moan, sweat profusely, or have rapid heartbeats. Most just reduce activity and withdraw from others. The only way to relieve their pain is to have an attentive and consistent caregiver who notices that the person is in pain and then observes the patient's response to treatment.
Some professional and lay caregivers are reluctant to give opioids to demented patients. In some instances, caregivers fear inducing delirium. Others say that by experiencing some pain, the patient remains more alert.
How might nursing homes assess their pain management performance? Simple measures might be:
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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 [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].