The Journal of Continuing Education in Nursing

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Learning Pain Assessment and Management: A Goal of the End-of-Life Nursing Education Consortium

Deborah Witt Sherman, PhD, APRN, ANP, BC-PCM, FAAN; Marianne LaPorte Matzo, PhD, APRN, GNP, BC, FAAN; Judith A Paice, PhD, RN, FAAN; Maureen McLaughlin, RN, PhD; Rose Virani, RNC, MHA, RN, OCN

Abstract

ABSTRACT

Background: Relief of pain for patients requires that palliative care practitioners have knowledge and skill in both pain assessment and the use of pharmacologic and complementary therapies.

Method: Pain assessment and management and the teaching strategies suggested within the End-of-Life Nursing Education Consortium curriculum are presented.

Results: By addressing the pain experienced by patients with life-limiting illnesses and those at the end of life, the quality of care can be greatly improved. As a multidimensional phenomenon that relates to physical, emotional, and spiritual well-being, the relief of pain enhances the quality of life of patients and lessens the stress experienced by family caregivers.

Conclusion: The relief of pain and suffering is consistent with the philosophy and goals of nursing as a profession and is a nursing responsibility.

Abstract

ABSTRACT

Background: Relief of pain for patients requires that palliative care practitioners have knowledge and skill in both pain assessment and the use of pharmacologic and complementary therapies.

Method: Pain assessment and management and the teaching strategies suggested within the End-of-Life Nursing Education Consortium curriculum are presented.

Results: By addressing the pain experienced by patients with life-limiting illnesses and those at the end of life, the quality of care can be greatly improved. As a multidimensional phenomenon that relates to physical, emotional, and spiritual well-being, the relief of pain enhances the quality of life of patients and lessens the stress experienced by family caregivers.

Conclusion: The relief of pain and suffering is consistent with the philosophy and goals of nursing as a profession and is a nursing responsibility.

Approximately two-thirds of individuals with malignant disease and one-third of individuals who are being treated for cancer experience pain (American Pain Society, 1999). In a study of 50 patients with advanced acquired immunodeficiency syndrome (AIDS), pain intensity was reported as severe, with headache, abdominal pain, chest pain, and neuropathies as the most frequent pain complaints (Berger, Portenoy, & Weissman, 1998). The results of the SUPPORT study (SUPPORT Principal Investigators, 1995) also indicated the incidence of moderate to severe pain in nearly 50% of patients at the end of life.

Such statistics indicate the need for improved pain assessment and management and have led to the consideration of pain as the fifth vital sign. Pain assessment and management are also being evaluated in terms of the Joint Commission on Accreditation of Healthcare Organizations accreditation of hospitals and other healthcare facilities. Given that inadequate pain relief increases psychological distress and potentially decreases immunocompetency, decreases mobility, and increases the work of breathing and myocardial oxygen requirements (Paice & Fine, 2001), and that pain relief is a health care right of all individuals, healthcare professionals must learn to effectively assess and treat pain. Pain management is also extremely important in promoting the quality of life of patients with chronic, incurable, and progressive illness, as well as promoting the quality of life of their family caregivers.

Palliative care education, such as the End-of-Life Nursing Education Consortium (ELNEC) curriculum. provides relevant content regarding pain assessment and management (Table 1). The themes of the ELNEC curriculum (Table 2) emphasize the importance of considering pain assessment and treatment within the context of caring for the patient and family as the unit of care, the role of the nurse as advocate, the importance of cultural considerations, and recognition of the value of an interdisciplinary team of professionals in effectively managing the multidimensional aspects of pain.

Nursing knowledge and skills related to pain assessment and management are essential in correcting deficiencies related to end-of-life care in America and empowering nurses to advocate for the relief of pain and suffering. To this end, the American Association of Colleges of Nursing joined forces with the City of Hope National Medical Center to begin a national educational initiative, entitled the "End-ofLife Nursing Education Consortium" (ELNEC) (www.aacn.nche.edu/elnec). Funded by nearly $3 million from the Robert Wood Johnson Foundation, the ELNEC was launched in February 2000 as a consortium of many organizations represented through the ELNEC Advisory Board to ensure a collective professional approach to improve end-of-life care. Developed through the work of project consultants and with extensive input from the Advisory Board and expert reviewers, the ELNEC curriculum is a "Train the Trainers" course. The expectation is that those trained in the ELNEC curriculum will be vital to the dissemination of knowledge related to end-of-life care. As of January 2004, 591 nursing faculty and 716 continuing education faculty had received ELNEC training during a total of 14 courses.

ELNEC framing involves a didactic and experiential learning experience in end-of-life care for nurse educators from undergraduate nursing programs and continuing education programs from across the country. The ELNEC curriculum provides essential content regarding end-of-life care, effective teaching strategies, and helpful resources for nurse educators and continuing education providers to competently teach end-of-life care and successfully integrate end-of-life content into existing nursing curricula. During this 3day training program, nine modules related to end-oflife care are presented (Table 3).

The purpose of this article is to present the key content and teaching strategies related to pain assessment and management, with a focus on pain at the end of life. The key messages are that: (1) comprehensive pain assessment is essential to adequate pain relief; (2) there are many barriers that impede pain assessment and treatment; (3) nurses should work collaboratively with interdisciplinary colleagues in optimum use of drug and nondrug interventions; and (4) treatment of pain at the end of life also includes attention to suffering. At the completion of this module, participants are able to identify barriers to adequate pain relief at the end of life, list the components of a comprehensive pain assessment, and describe pharmacologic and nonpharmacologic therapies used to relieve pain.

DEVELOPING COMPETENCY IN PAIN ASSESSMENT

In developing competencies regarding pain assessment and management, nurses need to enhance their knowledge and skills, and recognize personal and societal perspectives. Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (International Association for the Study of Pain, 1979, p. 249). Because pain has not only sensory and physical components, but also emotional, cognitive, behavioral, and cultural components, discussion of the multidimensional aspects of pain is important. Most important, nurses and other healthcare professionals need to understand that pain is whatever the person says it is, and experienced whenever he or she is experiencing it (McCaffery & Pasero, 1999). As such, pain is understood as a subjective experience, which requires asking the person if he or she is having pain and questioning about the intensity of the pain.

If a patient is unable to communicate about pain, then behavioral manifestations, such as rocking, moaning, grimacing, social withdrawal, insomnia, or changes in appetite, may be objective indicators of pain. Asking family members if they consider the person to be manifesting pain is also of value in determining whether the person is experiencing pain. However, family members and healthcare professionals often underestimate or overestimate the experience of pain when compared to the patient's self-report.

Barriers to Pain Relief

Improvement in pain management is only possible when there is recognition of the barriers to pain assessment and pain relief, specifically those presented by patients, healthcare professionals, and the healthcare system. Patient barriers include reluctance to report pain, concern that reporting pain will distract the practitioner from treating the underlying disease, fear that the pain means worsening disease, a desire to be viewed as a "good patient," fears regarding addiction, concerns about the side effects of pain medications, costs, and reluctance to take pain medications (Ersek, 1999). Patient and family education is necessary to emphasize every patient's right to pain control and the importance of reporting pain, as well as to dispel myths regarding pain management.

Healthcare professionals, including nurses, often have inadequate knowledge related to pain assessment and management and may be equally concerned as patients regarding addiction, tolerance to opioids, adverse effects, and the regulation of controlled substances. With regard to barriers within the healthcare system, low priority has been previously given to pain management, and there have been problems of availability and access to healthcare professionals with expertise, as well as issues regarding affordability and access to pain medications. Restrictive regulation of controlled substances and inadequate reimbursement are additional system barriers to care (Jacox et al., 1994; McCaffery & Pasero, 1999).

Pain Assessment

Pain History. Table 4 describes the use of the acronym OLDCART for assessing pain in patients. In the assessment of pain, nurses must realize that patients may refer to pain using other terms such as discomfort, hurt, ache, or "pain all over," which refers to total pain, including physical and emotional dimensions. Assessment also includes identifying the location of pain, realizing that many patients have multiple pain sites or referred pain. The intensity of pain should also be assessed on a scale of O to 10, where 0 is no pain and 10 is the worst pain imaginable (Paice & Fine, 2001). Nurses need to be familiar with different pain assessment tools such as the 0 to 10 scale described or a pain visual analogue scale, where the patient identifies the degree of pain he or she is having by marking a point on the line, which is anchored on either side with the descriptors of "no pain" and the "worst possible pain." The FACES scale may also be used to correlate the facial expression selected by the patient with the degree of pain he or she is experiencing (Fig. 1). The FACES scale is used with children and those with cognitive impairment.

It is also extremely important to assess the quality of pain, which often correlates with nociceptive pain (somatic or visceral) or neuropathic pain. Somatic pain is pain due to the injury of the skin, muscles, bone, ligaments, or tendons and is described as aching or throbbing, such as pain from a laceration or broken bone. Visceral pain is organ pain and is often described as squeezing or cramping in quality, such as pancreatic or abdominal pain. Neuropathic pain, which is generally due to damage of the peripheral or central nervous system, may be described as burning, tingling, electrical, or shooting. Examples of neuropathic pain are diabetic neuropathy or post-herpetic neuropathy (Jacox et al, 1994; McCaffery & Pasero, 1999).

Assessment continues with questions regarding the pattern of pain, such as the description of the "baseline" pain and additional pain that is of rapid onset and greater intensity, known as breakthrough pain (Paice & Fine, 2001). Patients should also be asked about factors that aggravate the pain and those that alleviate it. These factors may provide information regarding the etiology of pain, as do the terms used by patients to describe the quality of pain. In addition, it is helpful to learn what medications have been obtained by prescription or over-the-counter means to alleviate the pain and the degree of their success. Understanding what the pain means to the patient, particularly within his or her cultural or spiritual context, and how pain affects his or her functional status and quality of life are also important components of a comprehensive pain assessment (McCaffery & Pasero, 1999).

Physical Examination. Nurses can gain valuable information based not only on a comprehensive pain history, but also on physical examination. This often assists in identifying the etiology of pain. The nurse should observe for nonverbal cues that may suggest pain, including fatigue, grimaces, moans, or irritability. Observations should also include changes in bony structures or sites of skin breakdown. Palpation of the sites of tenderness is important, as well as auscultation of breath and bowel sounds to determine pain possibly related to pneumonia or bowel obstruction. Nurses should also percuss an area of possible fluid accumulation. A neurological examination provides information regarding sensory deficits, muscle strength, or changes in reflexes that may relate to pain and its etiology.

Reassessment. It is criticai to reassess pain regularly, particularly if there are any changes in pain and following the administration of pain medication. In addition to asking about pain severity, questions can be asked regarding how long the pain was relieved.

Pain Syndromes. Another aspect of pain assessment is the identification of pain syndromes. Such syndromes may be related to the disease or its treatment. For example, a nociceptive pain syndrome may involve pain from bone metastases or pain from oral mucosa infections and visceral pain syndromes due to tumors occupying the liver, such as hepatic capsular distension. Neuropathic pain syndromes may also occur in patients with human immunodeficiency virus (HIV) /AIDS, such as peripheral neuropathy related to antiretroviral therapy, or in patients with cancer who may have lower extremity neuropathic pain due to spinal cord compression or pain associated with treatment, such as pain associated with radiation fibrosis.

At-Risk Populations. Nurses must also recognize the unique needs of special populations, such as children, the elderly, cognitively impaired patients, nonEnglish-speaking patients, and patients with a history of substance abuse. These groups are often at risk for poor pain assessment and management (Ferrell & Borneman, 1999; McCaffery & Pasero, 1999).

DEVELOPING COMPETENCY IN PAIN MANAGEMENT

Principles of Pain Management

In addition to performing a comprehensive pain assessment, nurses must learn the principles of pain management (Table 5). The World Health Organization (1990) developed a three-step analgesic ladder to guide the initial selection of analgesics (Fig. 2). Nonopioids with or without adjuvants are recommended for mild pain, which is defined as approximately 1 to 3 on a 0- to 10-point pain scale. If the patient is in moderate pain (4 to 6 on the pain scale), opioids are used with the nonopioids or adjuvants continued if needed. If pain is severe (7 to 10 on the pain scale), higher doses of the opioid are given with or without the nonopioids or adjuvants (World Health Organization, 1990). If patients present in moderate or severe pain, opioids may be given immediately intravenously and titrated for pain relief. The principle is to titrate medications upward until pain is relieved and to anticipate, prevent, or treat side effects. All patients receiving opioids should also be placed on a bowel regimen to prevent constipation, except patients with preexisting diarrhea (McCaffery & Pasero, 1999).

Another principle in the use of analgesics is to begin with an immediate-release formulation with the use of breakthrough doses as needed. When the patient has had pain relief for 24 to 48 hours, the 24hour dose of the opioid can be calculated and converted to a long-acting formulation. Sustained-release formulations are helpful in treating continuous pain syndromes. A breakthrough or rescue dose of an immediate-release preparation of opioid should also be available for incident pain (e.g., movement induced), idiopathic pain in which the etiology is unknown, or when there is end-of-dose failure from increased pain prior to the next dose of analgesic. The breakthrough or rescue dose is calculated at a rate of 5% to 15% of the total 24-hour dose and can be repeated in 1 hour for an oral administration, in 30 minutes for a subcutaneous administration, and within 15 minutes for intravenous administration. A breakthrough dose can also be calculated as 50% to 100% of the hourly rate for parenteral infusions (subcutaneous, intramuscular, or intravenous).

To provide effective pain management, it is important to use equianalgesic charts to convert from one route of opioid to another, such as intravenous to oral, as well as to convert from one opioid to another, such as from morphine to hydromorphone (Table 6). In addition, it is important to learn how to titrate opioids to analgesia, such as increasing the baseline dose by 25% to 50% for mild to moderate pain or increasing the baseline dose by 50% to 100% for moderate to severe pain. This can be calculated on the total 24hour dose divided by the frequency of the dose or based on the hourly dose. Opioid rotation is of value when one opioid is ineffective after upward titration of the dose or if it produces adverse effects (Paice & Fine, 2001). For example, if morphine produces ineffective relief, it is advisable to switch to hydromorphone or oxycodone if appropriate (American Pain Society, 1999; McCaffery & Pasero, 1999).

Pharmacologic Therapies

Nonopioids. Nurses need to have knowledge regarding nonopioids and opioids. Nonopioids, including acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) have a ceiling effect in which additional dosage may have no further beneficial effect. Acetaminophen has both analgesic and antipyretic actions, but greater than 4 g/day may result in hepatotoxicity (Shiodt, Rochling, Casey, & Lee, 1997). NSAIDs, including aspirin, Ibuprofen, and naproxen, inhibit the production of prostaglandins by blocking cyclooxygenase. A new class of NSAIDs, known as COX-2 inhibitors, allow the function of COX-I, which protects the gastric lining, renal function, and blood clotting, while inhibiting COX-2, which has inflammatory effects. COX-2 inhibitors are celecoxib and rofecoxib. NSAIDs are effective in relieving pain from inflammatory conditions and bone pain. However, NSAIDs that are not COX-2 selective may inhibit platelet aggregation with a resultant risk of bleeding, as well as producing significant gastric toxicity and renal dysfunction, especially when patients are dehydrated (Garcia, 1997; Miyoshi, 2001).

Opioids. The benefits of opioids in treating moderate to severe pain are emphasized, as well as the action of opioids in blocking the release of neurotransmitters, which are involved in the processing of pain. The use of immediate-release opioids, such as oxycodone, morphine sulfate, and hydromorphone, as well as long-acting opioids, such as oxycodone hydrochloride timereleased, morphine sulfate long-acting, or the transdermal fentanyl patch, which lasts from 48 to 72 hours, is reviewed. Nurses also learn about the adverse effects of meperidine such as its toxic metabolite, known as normeperidine, which causes central nervous system toxicity (including the risk for seizures, confusion, or myoclonus). Similar to meperidine, propoxyphene also has a toxic metabolite and is discouraged as inappropriate in end-of-life care (American Pain Society, 1999).

Nurses are informed that many patients may say they are allergic to opioids when what they describe are often the common side effects rather than an allergic reaction, which is rare. The only absolute contraindication to the use of opioids is a history of hypersensitivity reaction, such as wheezing or edema. Respiratory depression is also a rare, though feared, side effect. The greatest prevalence of respiratory depression occurs with opioid naive patients. Reversal of respiratory depression, through administration of naloxone, is appropriate only when the patient is unarousable, has a respiratory rate of less than 8 breaths per minute, and has an oxygen saturation of less than 90%. In this case, 0.4 mg of naloxone in 10 mL of sterile water or saline is administered as 0.1 to 0.2 mg over 1 to 2 minutes. In addition to the development of tolerance to respiratory depression, tolerance to nausea, vomiting, and sedation also develop over days. Nausea may be treated with antiemetics and sedation treated with psychostimulants, such as methylphenidate. Pruritus (itching) and urinary retention are also more common with spinal delivery of opioids. The use of mixed agonist-antagonists (e.g., butorphanol tartrate, pentazocine hydrochloride, and nalbuphine hydrochloride) are not recommended given their ceiling effect and the high rate of psychotomimetic effects, namely hallucinations and disorientation (Portenoy, 1998; McCaffery & Pasero, 1999).

Given concerns regarding addiction by both patients and healthcare professionals, it is important to educate nurses regarding addiction, tolerance, and physical dependence. Addiction rarely occurs when opioids are used for pain management. Addiction is a primary, chronic, genetic, and psychosocial disease characterized by compulsive use, use despite harm, and loss of control. Tolerance is recognized as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time (American Academy of Pain Medicine, 2001). In many cases, the need for an increased dosage of opioid is the result of worsening disease, rather than loss of analgesic effect. Tolerance does not equal addiction. Physiological dependence is recognized as a state of adaptation that is manifested by the abrupt withdrawal of opioids or rapid dose escalation. Nurses need to understand that physical withdrawal is a normal physiologic response rather than evidence of addiction (Paice & Fine, 2001).

Adjuvant Analgesics. In many situations, the use of adjuvant medications may reduce the need for opioids or may be more effective in the case of neuropathic pain, which is often less responsive to opioid therapy. Tricyclic antidepressants, such as amitriptyline and nortriptyline, are useful in the treatment of neuropathic pain, although they should be administered at bedtime because of their sedative effect. Tricyclic antidepressants have anticholinergic effects, such as constipation and dry mouth, but desipramine may be better tolerated than the others. Cardiac arrythmias, conduction abnormalities, and narrow-angle glaucoma are relative contraindications to tricyclic antidepressants (Portenoy, 1998).

Another category of adjuvant analgesia is anticonvulsants, which are particularly effective in the treatment of neuropathic pain. Older anticonvulsants, such as carbamazepine, block sodium channels, which inhibits the conduction of pain. Gabapentin, a relatively new anticonvulsant, may also have Nmethyl-D-aspartate antagonist activity. The analgesic dose of gabapentin ranges from 900 to 3,600 mg /day in divided doses (Benedetti et al., 2000).

Local anesthetics are also valuable adjuvant therapy. Similar to anticonvulsants, local anesthetics inhibit the movement of sodium across the membrane of the sensory nerve. Local anesthetics can be administered intravenously or as spinal or epidural anesthetics. Local anesthetics are also available topically in the form of EMLA cream, which is applied to intact skin to alleviate pain.

Corticosteroids have benefits in terms of pain management, as well as increasing mood and appetite and lessening fatigue. Corticosteroids inhibit prostaglandin synthesis and reduce edema in tissues, thereby benefiting patients with visceral pain, neuropathic pain, and bone pain. Dexamethasone is the most preferred because it produces the least amount of mineralocorticoid effect. The dose of dexamethasone may be 16 to 24 mg/day (Portenoy, 1998).

At times, patients need relief from pain associated with spasm. In this situation, baclofen is an effective adjuvant therapy that is often dosed at 5 mg orally three times a day and can be titrated upward to 60 to 80 mg/day. Another beneficial adjuvant is capsaicin, which is derived from chili peppers and is believed to deplete substance P, which is released from the nerve endings of pain neurons. Capsaicin causes pain when it is first adrrunistered due to the release of substance P, and then reduces pain. It is effective in the treatment of post-mastectomy pain, post-therapeutic neuropathy, or post-surgical neuropathic syndrome. Nurses must remind patients and caregivers to wash their hands after application to prevent burning of the hands and inadvertently rubbing their eyes and creating eye pain (McCaffery & Pasero, 1999).

Routes of Administration. Nurses also need to learn about the various routes of medication administration in the management of pain. The preferred route is an oral preparation in the form of either immediate-release tablets or capsules when the needed baseline dosage has been determined, or long-acting preparations such as morphine sulfate long-acting or oxycodone hydrochloride time-released, which are administered for 8 to 12 hours. Long-acting morphine preparations (e.g., sustained-release morphine and morphine sulfate extended-release capsule) can be administered in 24-hour intervals and can be sprinkled over food if the patient is unable to swallow pills. Liquid preparations are also available, such as the liquid preparation of morphine. A misconception held by healthcare professionals is that oral medications are less effective than parenteral medications. The oral route can provide equivalent analgesia, but the drug dosage must be increased compared to that for intravenous or subcutaneous routes due to first-pass metabolism. As such, 10 mg of intravenous morphine is approximately equal to 30 mg of oral morphine (Benedetti et al., 2000).

The intravenous route is useful when patients cannot swallow or when absorption through the gastrointestinal tract is altered. Subcutaneous infusions can also be given at home at a rate of 5 to 10 mL/hour with 1 to 3 mL as the ideal rate. Intramuscular routes are discouraged because of variability in absorption and the pain of intramuscular injections (McCaffery & Pasero, 1999).

Other routes for pain medication are enteral, although there are many ethical issues regarding the use of feeding tubes at the end of life, or by the rectal or vaginal route, through which long-acting opioid tablets can be placed when a patient is no longer able to swallow. Thrombocytopenia or painful anorectal lesions preclude the use of these routes and absorption is approximately 90% of that achieved by the oral route.

The transdermal route, specifically the use of transdermal fentanyl, is effective if the patient does not have cachexia or fever, which may change the drug absorption. The patch is placed every 48 to 72 hours on non-hairy, non-edematous skin with good capillary flow, such as the chest, upper arms, or shoulders. Given that the peak onset does not occur for approximately 17 hours, immediate-release opioids should be adrninistered during this time period to ensure adequate analgesia. Oral transmucosal fentanyl citrate can be rubbed against the oral mucosa to provide rapid absorption of the drug for breakthrough pain. Fentanyl cannot be used if the patient is opioid naive; instead, the patient must be receiving at least 60 mg of morphine orally or its parenteral equivalent daily, otherwise an anaphylactic-type reaction may occur (Benedetti et al., 2000).

Topical preparations can also be used for pain management, such as the use of capsaicin for neuropathic pain states (e.g., post-herpetic neuropathy). Topical lidocaine and other local anesthetics such as EMLA cream may be helpful for use in brief pain conditions. Topical opioids can also be used but are not to be confused with transdermal delivery. Most opioids (except fentanyl) are hydrophilic or water soluble, which prevents their absorption through fat-soluble tissues. However, new effective formulations of topical opioids are available in the form of dressings impregnated with opioids (McCaffery & Pasero, 1999).

The spinal route is another effective route for the administration of pain medications, including intrathecal or epidural. This route allows the delivery of medications including opioids, local anesthetics, or alpha-adrenergic agonists. This requires specialized knowledge of healthcare professionals and there is a risk of infection. This is useful if the patient is not receiving benefit from medications given systemically or when the patient cannot tolerate adverse systemic opioid effects. It is also helpful for patients with neuropathic pain of the lower extremities that may respond to epidural local anesthetics, alone or in combination with an opioid (Portenoy, 1998).

Nonpharmacologic Therapies

In addition to the pharmacologic management of pain, nonpharmacologic modalities can also be of benefit. Key issues in the selection and use of nonpharmacologic treatments are listed in Table 7. Cognitive-behavioral therapies serve as adjuncts to medications, including the use of guided imagery, relaxation, distraction, cognitive reframing, prayer, counseling, and support groups. Physical measures, such as the use of heat, cold, massage, repositioning, or bracing produces a sense of relaxation and relief of pain (Paice & Fine, 2001). Patients' willingness to use nonpharmacologic approaches to pain management is often contingent on cultural perspectives. Patients are encouraged to report the use of nonpharmacologic interventions or complementary therapies to avoid any drug interactions (McCaffery & Pasero, 1999).

Special Populations

Consideration should also be given to the pain management of special populations. For example, both children and older adults are frequently undertreated for pain. There are misguided fears of addiction for both populations and beliefs that children do not feel pain because of their underdeveloped nervous system. For the older adult, given potential changes in absorption, distribution, metabolism, or excretion of medications, it is recommended to start at slightly lower doses, but to titrate aggressively to effectively control pain. Many older adults may eventually require doses in the same range as other adults.

Individuals with a history of or current substance abuse may also not receive effective pain management because of concerns regarding their addiction risk and inadequate pain assessment. An interdisciplinary approach including addiction counselors and other experts in the field is helpful in developing an effective plan of care with realistic goals, setting behavioral limits if necessary, and consideration of comorbid psychiatric conditions. Patients with a history of substance abuse may need higher doses and more aggressive titration of opioids given their degree of tolerance.

Concern for patients who are uninsured or poor must also be considered because the cost of medications may prohibit adherence to prescribed regimens. Prescribing generic formulations, which are less expensive, is appropriate. The possibility of patients enrolling in patient assistance programs offered by pharmaceutical companies, which may provide analgesics at no cost, should also be explored (McCaffery & Pasero, 1999).

End-of-Life Pain

The assessment and management of pain during the last hours of life is also extremely important. At this point, diminishing consciousness may make pain assessment difficult and behavioral cues, such as body posture or grimacing, may be indicative of pain. If the patient is not currently receiving opioids, a therapeutic trial of opioids may be indicated to determine whether the behaviors diminish (Ferrell & Ferrell, 1996). If the patient at the end of life is receiving opioids, upward titration to provide pain relief is warranted and supported by the American Nurses Association Position Statement "Promotion of Comfort and Relief of Pain in Dying Patients" (1995). The statement indicates that "increasing the titration of medication to achieve adequate symptom control, even at the expense of mamtaining life or hastening death secondarily, is ethically justified" (American Nurses Association, 1995). During the last days and hours of life, body systems begin to shut down, including renal and liver failure. As a result, there is the potential accumulation of opioid metabolites, particularly morphine-3 glucuronide and morphine-6 glucuronide, which can produce myoclonus, hallucinations, or a hyperirritable state. Therefore, there may be a reduced need in terms of the dose of opioids or frequency of administration. However, this requires ongoing assessment and reassessment to maintain effective pain management and comfort at the end of life (McCaffery & Pasero, 1999).

In other situations, patients may have intractable pain at the end of life despite aggressive titration of opioid therapy and other therapies. In this case, sedation to a level of unconsciousness may be the only alternative to provide comfort (Wein, 2000). The decision regarding sedation should be considered after all possible etiologies of pain are ruled out and all treatment options have been considered by the patient and family, along with discussion and support by the interdisciplinary team. When sedation is desired, an aggressive increase in existing opioids may be sufficient to relieve pain, and in many instances the use of benzodiazepines, including lorazepam or neuroleptics such as haloperidol, may induce sedation. Midazolam may also be used or propofol may also be given as an intravenous infusion. In addition, the dose of opioids at the end of life should be based on appropriate assessment.

Although nurses may fear that administering opioids may hasten death, the Principle of Double Effect recognizes that the goal is to alleviate pain and suffering, and hastening death, although it may occur, is unintentional. Thus, the nurse should provide pain relief and the fear of sedation or respiratory depression should not limit the use of opioids.

Due to decreased renal or hepatic function, the dose of opioids may be decreased during the final hours of life. Metabolites of morphine, which may accumulate and produce hallucinations, myoclonus, or a hyperirritable state, may need to be changed to another opioid, such as hydromorphone, in the face of renal failure (American Pain Society, 1999). Nurses can do much to alleviate suffering at the end of life, which is important to the memories held by families in the patient's final hours of life.

TEACHING STRATEGIES RELATED TO SYMPTOM MANAGEMENT

Teaching nurses and other healthcare professionals regarding pain and its management presents several challenges. First, preexisting attitudes and deeply held beliefs regarding pain and the use of opioids must be addressed. Second, pain incorporates physical, emotional, social, and spiritual dimensions, requiring a significant variety of skills when conducting a pain assessment and developing a plan of care. Third, response to medications is highly variable, so pain must be constantly reassessed and doses changed in response. Fourth, because good pain management is interdisciplinary, professionals must possess strong communication skills regarding this symptom.

Changing attitudes regarding pain requires reflection and an honest assessment of our own beliefs. Presenting scenes from movies demonstrating unrelieved pain can generate thoughtful consideration of our perceptions of patients who report pain. Learners can be asked to share their own personal experiences with pain or the experiences of their family and friends, including the response of healthcare professionals. Learners who have had past clinical experiences may share their professional observations. The use of case studies is also an effective teaching strategy to discuss aspects of pain assessment and management (Appendix).

In addition, role playing cases that involve complex pain problems can impart sensitivity to the cultural and psychosocial factors associated with pain. Examples might include the elderly patient with cancer pain who is hearing impaired and diminishes his or her reports of pain despite behavioral cues that suggest severe pain. Another case might be the patient with HIV-associated neuropathy who has a history of substance use. Asking learners to play each role while another learner serves as the professional and then reversing their roles imparts empathy and an awareness for the complexity of this phenomenon.

Another strategy for changing attitudes and beliefs is to invite patients and families to share their experiences. Representatives from the American Cancer Society, the American Chronic Pain Association, the Sickle Cell Society, and other patient groups are often willing to describe their experiences to groups of learners.

To address the complex dimensions of pain, facilitators can videotape learners while conducting a pain assessment (using a fellow learner to serve as the patient). Playing back the videotape allows learners to critically analyze the strengths and weaknesses of the assessment, and what they might change in the future.

The need for frequent dose changes demands that nurses be comfortable with using equianalgesic tables. Worksheets with sample cases provide practice in this arena. Clinical mentoring is extremely useful. Facilitators can arrange time for the learner to spend with the pain service (if one exists) on rounds or in the clinic to observe different analgesics and techniques used. This can be informative, even if the population is not palliative, and can enhance networking.

Finally, pain relief demands interdisciplinary care. Nurses must learn to work within a team. Simulated interdisciplinary team rounds or case conferences, with individuals playing the roles of different professionals, provides insights to the issues faced by the various members of the team. The group may practice strategies for dealing with complex or confrontational interactions.

CONCLUSION

The assessment of pain is now recognized as the fifth vital sign and patients have a right to the relief of pain. Improvement in pain management is possible when there is recognition of the barriers to pain assessment and relief, specifically barriers presented by patients, healthcare professionals, and the healthcare system and strategies developed to overcome such barriers. The education of nurses in pain assessment and management is critical to quality care. Nursing education must address the importance of a comprehensive pain history coupled with a comprehensive physical examination, which assists in identifying the etiology of the pain and in the identification of pain syndromes.

In addition to knowledge regarding the principles of pain management, nurses must further learn about the appropriate use of nonopioids, opioids, and adjuvant therapies, the most effective routes of administration for pain medication, how to titrate and convert opioids, and how to prevent and treat side effects and manage adverse reactions. In addition to the pharmacologic management of pain, nurses can offer complementary therapies, which often address the multidimensional aspects of pain.

In the ELNEC curriculum, learning pain assessment and management involves the cognitive, psychomotor, and affective domains of learning. As such, teaching strategies are used that not only enhance nurses' knowledge and skills regarding pain assessment and management, but also encourage nurses to examine their own related attitudes and beliefs, with the intent of promoting positive attitudes in the use of pain therapies. More information about ELNEC training is available at the following web site: www.aacn. nche.edu/elnec.

With nurses prepared to address pain and other symptoms experienced by patients and families with life-limiting illness and those at the end of life, the quality of care and the quality of life of patients can be greatly improved. It is nurses' responsibility to ensure adequate pain relief through the appropriate administration of pain medications and other therapies and through serving as advocates to ensure that such relief is available.

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10.3928/0022-0124-20040501-07

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