Cancer patients suffer from a whole spectrum of diseases, and other related issues, including but not limited to the disease itself, immune suppression, pain syndrome, social stigma, financial implications, depression and anxiety.

The Pain Syndrome is particularly challenging, not only for the patient but for the care givers and the physicians as well. This issue should be managed by the experts in the field of Pain Management, who employ a multipronged strategy to provide best results for their patients. Various steps for palliative care management include:

I. Recognizing the Problem

Pain is a very prominent and distressful symptom in patients presenting at the end of life. In the cancer population, its prevalence is over 75% for those with advanced disease. Recognition of the problem is the initial step for effective management.

II. Identify Goals with Patients

The effective relief of pain in a palliative patient depends mainly on a comprehensive assessment to identify the different physical, psychological, social, and spiritual aspects that are specific to each patient. A detailed discussion with patients and their care providers is recommended for terminally ill patients. The discussion should include goals, benefits, side effects as well as limitations of pain management strategies.

III. Step-by-Step Approach to Pain Assessment

After the goals of care have been agreed, a step by step approach to assess the pain is the next step for pain management. The assessment should include a combination of the elements reported by the patient and/or his caregivers regarding his pain experience, as well as a physical exam, and laboratory or imaging studies appropriate to the patient’s condition.

An important aspect of this assessment remains the information obtained from the patient and/or the caregivers regarding the patient’s pain syndrome. The care givers can/should be trained in making an assessment using both verbal and non-verbal cues in addition to other physical signs so that the most appropriate treatment plan can be initiated by the Pain Physicians.

IV. Pain Management

This involves a multidisciplinary approach, including drugs, acupuncture, physiotherapy, psychological support, pain procedures and surgical intervention when appropriate. The patients are commonly prescribed opioids in incremental doses, as the disease progresses. The opioids can be administered as tablets, syrup, patches, and intramuscular or intravenous injections. Morphine tablets and fentanyl patches are the mainstay of medical management in patients with moderate to severe pain. The injectable route is used at a later stage, as the disease progresses.

V. Side Effect Recognition and Management

These patients are on several drugs, and side effects are not uncommon. A physician monitoring program with trained personnel on board is useful in early recognition of these unwanted side effects. These include simple side effects like constipation, rashes and ulcers to more serious ones like infections secondary to immunosuppression, allergic reactions and respiratory depression. The simple side effects may be managed at home; however a hospital admission may be warranted for the serious side effects. The importance of trained personnel in these situations cannot be overemphasized.

Paradoxical hyperalgesia is an important condition that should not be missed in these patients. In this condition, patients experience more pain with increasing dose of opioids. To prevent this, opioid rotation is useful, whereby various opioids are administered on a rotational basis.

To summarise, the palliative patients can be managed effectively at home with the help of trained personnel, who work under the guidance and supervision of Pain Physician.

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