Sourcebook : 3.1 Preventing, assessing, and treating pain

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

One need not have read a professional journal lately to know that people are dying in pain. Too many health care providers do not hear or have learned to ignore patients’ pain. Several recent studies have demonstrated that pain is undertreated. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, or SUPPORT, (JAMA, 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, 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 doses or too weak.

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 usually 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, 1998).

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 almost any change 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 module describes how to:

• define pain,
• describe patient and provider rights and responsibilities,
• use patient-self-reports,
• measure pain as a fifth vital sign,
• use clinical practice guidelines,
• make pain management an institutional priority,
• set standards for pain control,
• give health care providers handy resources and offering on-going educational programs,
• review prescribing practices for opioids, and
• improve practices in nursing homes and assisted living facilities.

This text is derived from the book Improving Care for the End of Life : A Sourcebook for Health Care Managers and Clinicians.