Why pain management matters in palliative care
A serious, progressive illness – such as advanced cancer, severe heart or lung disease, or a neurological diagnosis – is often accompanied by chronic pain. Studies suggest that around 60 to 80 per cent of people with advanced cancer experience pain requiring treatment at some point.
Palliative pain management has a clear aim: to preserve quality of life as far as possible, ease suffering, and allow the person affected to live the remaining time as self-determined as possible. Comprehensive palliative pain care is not merely a medical measure, but part of holistic support that includes physical, emotional, social and spiritual aspects.
Pain is not just pain: accurate assessment as the basis
Effective pain relief in cancer and other serious illnesses begins with careful pain assessment. Clinicians distinguish several types of pain:
- Nociceptive pain: caused by irritation of pain receptors, for example through bone metastases or inflammation.
- Neuropathic pain: caused by damaged nerves and often described as burning, stabbing or tingling.
- Visceral pain: arising from internal organs and usually described as dull or cramp-like.
- Mixed forms: several types of pain often occur at the same time.
Accurate classification is crucial because it guides the choice of medication and procedures. Structured assessments – such as the numeric pain scale from 0 to 10 – and a pain diary can be helpful.
The WHO step ladder as a foundation
The World Health Organization (WHO) developed an established stepwise scheme that still forms the basis of palliative pain treatment today:
Step 1: Non-opioid analgesics
For mild pain, substances such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen or diclofenac) are used. They relieve pain and partly reduce inflammation.
Step 2: Weak opioids
If step 1 medication is insufficient, weaker opioids such as tramadol or tilidine are added.
Step 3: Strong opioids
For moderate to severe pain, strong opioids such as morphine, hydromorphone, oxycodone or fentanyl are used. They can be administered orally, as a patch, subcutaneously or intravenously.
In addition, so-called co-analgesics are used at all steps – medicines originally developed for other indications but effective in specific types of pain:
- Antidepressants (e.g. amitriptyline, duloxetine) for neuropathic pain
- Anticonvulsants (e.g. gabapentin, pregabalin) for nerve pain
- Corticosteroids for pain caused by inflammation or swelling
- Bisphosphonates for bone pain caused by metastases
Modern routes of administration
When tablets can no longer be swallowed – for example in the dying phase or in conditions affecting the mouth and throat – alternative routes are available:
- Transdermal patches release substances such as fentanyl or buprenorphine evenly through the skin.
- Subcutaneous pumps allow continuous administration of pain medication and other substances.
- Patient-controlled analgesia (PCA) allows patients to request an additional dose themselves during pain peaks.
- Spinal techniques (epidural or intrathecal pain management) can be considered for very severe pain that cannot otherwise be controlled.
Addressing common concerns about opioids
Many patients and relatives have concerns about strong painkillers. Common questions involve risk of addiction, respiratory depression or a perceived shortening of life. From a medical perspective:
- When correctly dosed in palliative situations, the risk of psychological dependence is low.
- According to current scientific evidence, appropriate opioid therapy is not expected to shorten life.
- Side effects such as constipation, nausea or tiredness can usually be managed well alongside the treatment.
Open information and close medical supervision help to reduce fears.
Non-medicinal approaches complement therapy
Palliative pain management involves far more than medication. Various approaches can contribute to pain relief:
- Physiotherapy and lymphatic drainage: for muscular tension and oedema
- Heat and cold applications: to loosen tissue or dampen pain
- TENS (transcutaneous electrical nerve stimulation): may help in certain types of pain
- Breathing and relaxation techniques: help reduce perception of pain and tension
- Music, art or aromatherapy: can positively influence well-being and mood
- Psycho-oncological and psychotherapeutic support: helps in coping with anxiety, grief and existential questions
Interventional procedures such as nerve blocks or palliative radiotherapy – for example for painful bone metastases – can also bring noticeable relief in suitable cases.
The role of the multi-professional team
Modern palliative care is teamwork. Typically involved are:
- General practitioners and specialists
- Nursing staff trained in palliative care
- Physiotherapy and occupational therapy
- Psychological and spiritual support
- Social work
- Relatives and volunteer hospice companions
In Austria, mobile palliative teams, palliative care units, hospices and day hospices are available. Depending on personal wishes and circumstances, care can be provided at home, in a nursing home or as an inpatient.
What relatives can do
Relatives play a central role. They can:
- attentively notice and document expressions of pain
- support the regular taking of medication
- ensure a calm, pleasant environment
- offer emotional closeness and conversation
- seek support from palliative teams or hospice services at an early stage
It is also important that relatives look after themselves and make use of respite services.
Conclusion
Modern palliative care offers a broad range of effective options to relieve pain at the end of life. A carefully tailored combination of medication, complementary approaches and human attention can help ensure that the final phase of life is experienced with dignity and as much quality of life as possible. Those who seek conversation with the treating team early on create the best conditions for individually appropriate support.
This article does not replace medical advice.