Sourcebook : 3.1 Preventing, assessing, and treating pain

You should know current practices, emulate "best" practices, and strive for "optimal" practices.

Most dying patients, in most settings, most of the time, are in pain or suffer other symptoms. In making baseline measures, many Breakthrough Series teams were surprised to find just how poorly their programs were doing; yet this poor finding challenged groups to do better.

The current state of pain management in most institutions in the country is far from ideal. In contrast, best practices enable clinicians to assess and alleviate most pain and other symptoms. When best practices are used, patients and families come to expect relief from suffering, not agony. By aiming for best and optimum practices, improvement teams can set goals for their patients, hospital wards or units, and institutions.

• Pain is most often not assessed or monitored.
• Patients routinely receive inadequate treatment (e.g., drugs and dosages).
• Pain is usually treated only after serious symptoms have occurred, rather than as prevention.
• Gaps and delays in treatment are agonizing and commonplace.
• Major symptoms are presumed untreatable, though most can be relieved or reduced (pain, dyspnea, depression, anxiety, nausea, itching, insomnia, and so on).
• No one is held accountable for shortcomings.
• Patients and families expect severe symptoms and are grateful for any relief.
• Patient's behavior is misinterpreted as meaning "no pain," (e.g., sleeping, not writhing, etc.).
• Professionals and patients do not fully understand concepts such as addiction, tolerance, titration of doses and management of opioid side effects.
• Regulatory barriers (i.e., triplicate prescribing laws) create patient fears and affect physician prescribing practices.
• There is serious undertreatment of neuropathic pain and lack of knowledge about adjuvant analgesics.

• Pain and other symptoms are assessed 100 percent of the time.
• World Health Organization (WHO), American Pain Society (APS), and Agency for Health Care Research and Quality (AHRQ) guidelines for cancer pain are followed.
• There is a low rate of orders for breakthrough pain (repeated need for breakthrough symptoms triggers increased regular doses of pain medications).
• A rescue dose is always available.
• When pain is continuous, all opioids are on a regular dosing schedule.
• Patients and families control timing of dosing for breakthrough pain
• Sufficient pain medication is provided during medical procedures and transfers between units and facilities.
• Severe symptoms (e.g., on a 0-to-10 scale, pain greater than 3 requires intervention, and greater than 6 is an emergency) receive emergency response.
• Clinician performance is routinely reviewed and shortcomings are addressed.
• Predictable side effects are attended to and managed.
• Patients and families receive education about pain management.

• Pain, depression, dyspnea, and anxiety are assessed on a specified schedule (admission, change in status, and periodically) 100 percent of the time.
• All appropriate modalities are used, often on time-limited trials, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDS), adjuvant analgesics, physical therapy (applications of heat and cold), massage therapy, behavioral techniques, hypnosis, steroids, neuroablative procedures, stimulants, and so on.
• Severe symptoms are treated as an emergency.
• Skilled consultants are readily available to patients in all settings (including ICU, hospital, nursing home, and home).
• Settings are created in which patients and loved ones expect competence, control, and comfort.
• During transfers between units or sites, patients are never left in pain.
• There are routine care reviews and feedback opportunities for quality improvement, public education and accreditation.

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