Key points
- Pain is a common symptom in palliative care patients and should be approached using the WHO analgesic ladder. Pain scales may help pain assessment
- IR opioids can be started and titrated to benefit, or in severe pain MR opioids can be commenced
- The choice of opioid depends on factors including renal and liver function and absorption issues
- Side-effects are common with opioids, and laxatives are usually co-prescribed
- Clinicians should be alert to the symptoms of toxicity, including wind-up toxicity
- Dexamethasone can be used for a variety of symptoms including breathlessness, nausea, lack of appetite , hiccups, raised intracranial pressure, spinal cord compression, bowel obstruction, bone pain, nerve pain, liver capsule pain and pain caused by inflammation
Dr Rebecca Smithson is a GP in palliative care at the Margaret Kerr Unit in the Scottish Borders
Q: Many GPs do not use pain scales as routine but they seem to be popular with palliative care teams. What is their value?
A: Pain in palliative care patients should be assessed in the same way as pain in any other patient, for example using the SOCRATES mnemonic (site, onset, character, radiation, associations, time, exacerbating and relieving factors, severity). Pain scales add extra valuable information, for instance, when assessing the effect of analgesia.
The simplest scale is to ask the patient to score their pain out of 10, where 0 is no pain and 10 is the worst pain they could imagine. Using a pain scale before analgesia, and repeating it after a suitable interval helps guide us on the effectiveness of the analgesia.
Sometimes it can seem as if an intervention has not worked because the patient is still in pain. But if, for example, a pain score was 8 before an intervention and 5 afterwards, the intervention has been partially effective.
Pain scales can also be of value when assessing patients who are non-verbal, or who have cognitive impairment. Specific pain scoring tools exist for patients with cognitive impairment, such as the Abbey Pain Tool.
Click here to read the full article and download your certificate logging 2 CPD hours towards revalidation
