What to Know About Pain Management at the End of Life


The last days and weeks of life should be spent connecting with loved ones, not writhing in pain. But unfortunately, suffering is all too common: More than 60 percent of people report experiencing pain in their last year of life, according to a 2015 study published in the Annals of Internal Medicine. In the last few days of life, that pain can become unendurable. But most of the time, this discomfort can be avoided, or at least eased. Here’s what you need to know about pain management at the end of life, for yourself or for a loved one:

Medications work—if they’re used correctly

The World Health Organization has a cancer pain ladder that many hospice and palliative care professionals use for end-of-life pain management. If the medications are used correctly—meaning they are given consistently every three to six hours, rather than waiting for a patient to complain—they can significantly relieve pain 80 to 90 percent of the time.

  • The first line of treatment for mild pain (generally a score of one to three on a ten-point scale) is either over the counter or prescription strength non-steroidal anti-inflammatory drugs (NSAIDS) or acetaminophen.
  • If this doesn’t work, or the pain is at least a four, the second step is mild opioids like codeine or oxycodone.
  • The third step is stronger opioids such as morphine, fentanyl, and methadone. If the person is having trouble swallowing pills, these drugs can be given via an injection, skin patch, or even as an IV infusion. Besides pain relief, they also induce a feeling of relaxation that can make it easier to breathe and relieve anxiety in general.

Opioid addiction is unlikely

When someone becomes addicted to an opioid, they develop a chemical dependence on a drug and experience withdrawal symptoms when they are no longer taking it. But in end-of-life care, whether in a hospital or nursing home setting or in hospice, the person is closely monitored by both a doctor and a nurse to make sure the pain is well controlled and they’re not running into problems with the medication. And since they are taking these medications around the clock, there is a much lower risk of experiencing withdrawal symptoms.

It is important that doctors and caregivers use these medications correctly. Some research suggests that almost 80 percent of people being treated for cancer-related pain experience dosing-related errors. One big one is not giving them to a patient around the clock on a regularly scheduled interval; another is using a short-acting opioid instead of a longer-acting one. Both can make it more likely that a patient will experience “mini-withdrawal” and have more pain. It’s better to prevent or ease pain before it becomes severe; severe pain is harder to manage.

You also shouldn’t be frightened at the idea of adding even more opioids on to treat breakthrough pain, which is pain that can flare up for anywhere from a few minutes to a few hours. A doctor can prescribe a short-acting or “immediate-release” opioid. Treating breakthrough pain can mean offering an extra dose of opioid as a “rescue dose,” or offering up to 10 percent of the 24-hour total dose.

Most drug-related side effects are manageable

It’s true that opioids can cause side effects, which is one of the main reasons people stop taking them. But many of them—like feeling fuzzy-headed, or experiencing nausea or facial itching—tend to disappear after a few days. If it doesn’t, you can consider trying another opioid.

If the patient is constipated (another common complaint), they can take a daily laxative such as a senna product, Milk of Magnesia, or Miralax. If they can’t swallow, the prescription drug methylnaltrexone (Relistor) can be injected.

There are promising non-drug options out there

Most hospice providers frown on the use of herbal remedies to treat end-of-life pain, as they may interact with other drugs you’re taking. Supplements are also poorly regulated, so it’s hard to know exactly what you’re getting in the bottle. But there is evidence that some complementary therapies may help with pain management. These include:

  • Massage. About sixty percent of hospices offer complementary therapies to patients, with massage being among the most popular. Research has shown that it does significantly reduce pain among cancer patients receiving palliative care, and also helps improve symptoms of anxiety and depression.
  • Animal-assisted therapy. While there haven’t been studies looking specifically at end of life, adults with chronic pain who receive therapy dog visits have significantly lower reports of pain than those who don’t.
  • Acupuncture. A small 2015 study of hospice patients who received weekly acupuncture sessions found that they all reported improvement in pain symptoms, as well as fatigue, nausea, depression, anxiety, and shortness of breath.
  • Music therapy. A review of eleven studies found that music therapy improves pain and physical comfort, with one study finding improvement with just one session.
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