PALLIATIVE CARE IS…
• A team that can help your patients and families manage
the pain, symptoms, and stress of serious ill...
CONCEPTUALIZING
PAIN
Kyle P. Edmonds, MD
Assistant Clinical Professor
Doris A. Howell, MD, Palliative Care Service
UC San ...
OBJECTIVES
• Pain may be nociceptive, neuropathic or both and
the history tells you which.
• A standardized approach to th...
PAIN
“Pain is whatever
the person says it is…”
- Margo McCaffery
MECHANISM OF PAIN- DESCARTES
BASIC STEPS: PAIN PROCESSING
• Transduction
• Transmission
• Perception
• Modulation
NOCICEPTOR
• Nerve cell
• Activation
• Thermal
• Chemical
• Mechanical
• Transmits signal
PAIN TRANSDUCTION
• Response to noxious
stimuli
• Carried by A-delta and
C-fibers
TRANSMISSION: 3 STAGES
• Stimulus to cord
• Cord to brain stem
• Brain stem to higher
cortex
•Sensation
•Somatosensory
cortex
•Emotional response
•Frontal cortex
•Limbic system
TRANSMISSION
PERCEPTION
• Experience
• Conscious
• Multidimensional
• Interaction of
transmission /
transduction
“TOTAL PAIN”
Pain
Disease
Mgmt
Physical
Psych
SocialSpiritual
Practical
EOL
Worries
MODULATION
• Changing
• Inhibiting
• Spinal cord level
PAIN PROCESSING
• Transduction
• Transmission
• Modulation
• Perception
CLASSIFICATION OF PAIN
• Physiologic
• Nociceptive
• Neuropathic
• Mixed
• Temporal
• Acute
• Chronic
NOCICEPTIVE PAIN
• Somatic
• Skin
• Soft tissue
• Bone
• Visceral
NEUROPATHIC PAIN
• Damaged or dysfunctional
nerves
• Central
• Peripheral
MIXED PAIN
• Experiencing
• nociceptive and
• neuropathic
CLASSIFICATION OF PAIN
• Physiologic
• Nociceptive
• Neuropathic
• Mixed
• Temporal
• Acute
• Chronic
TEMPORAL CLASSIFICATION:
ACUTE
• Sudden or recent onset
• Identifiable cause
• Short duration
• Sympathetic response
TEMPORAL CLASSIFICATION:
CHRONIC
• Persistent
• No obvious cause
• Functional impairment
• No sympathetic response
INTERVAL SUMMARY
Understanding the pathophysiology
leads to improved assessment and targeted
management that will improve ...
PAIN ASSESSMENT
1. Location
2. Description (type)
3. Change over time
4. Severity (0 – 10)
5. Effect of treatments
• Benef...
• Constant
• Breakthrough
• Intermittent
acute
3. CHANGE OVER TIME
PAIN ASSESSMENT TOOLS
• Self Report
• NRS (adult)
• Behavioral Pain Scales
• Checklist of Non-Verbal Pain Indicators (CNPI...
INTERVAL SUMMARY
Assessment of pain requires a thoughtful
history and physical. This step helps you to
tailor & target you...
FEEDBACK? QUESTIONS?
• New Opioid Naïve Pain Orders Set
• What’s working?
• Not working?
• More pages? Less?
• Easier? Har...
PlasmaConcentration
0 Time
Absorption
Excretion
First Order Kinetics
When biological effect
follows plasma concentration
MILD PAIN / MULTIMODAL PAIN
• Mild Pain: pain score 1-4
• UCSD guidelines are to avoid use of opioids for mild
pain
• Mult...
PlasmaConcentration
0 Time
Principle:
Scheduled Dosing  Steady State
Pain control
Unwanted
effects
MODERATE / SEVERE PAIN
ORDERS
• Moderate (VAS=5-7) & Severe (VAS=7-10)
• Behavioral Scale/APP set to moderate dose
• Nurse...
• Breakthrough
• Intermittent
acute
PAIN CHANGE OVER TIME
PlasmaConcentration
0 Time
IV
PO / PR
60min
Time to Maximum
Concentration ( t Cmax )10min
RESCUE OPTIONS
• Rescue is EITHER PO or IV
• No more than 3 (oral or IV) in 24 hrs.
• Used with EITHER moderate or severe ...
PRINCIPLE:
ACUTE PAIN  PRN MED
• Treat rapidly & safely
• Short-acting dosed at
point of maximum effect
(Cmax)
PlasmaConcentration
0 Time
Cmax
Acute Pain Principle
PO / PR
≈ 1 hr
Cmax
• Constant
• Breakthrough
PAIN CHANGE OVER TIME
PRINCIPLE:
CONTINUOUS PAIN  SCHEDULED
MED
• To achieve steady-state
• Schedule non-opioid
• Opioid use guided by data
• P...
CONTINUOUS PAIN PRINCIPLE
PlasmaConcentration
0
Dosing every half-life ( t ½ )
Oral morphine = 4 hours
164 8 12
Time ( hours )
20 24
50%
75%
87.5%
9...
PlasmaConcentration
0 Time
Steady state after 5 half-lives
≈ 20 hours
Pain control
Unwanted
effects
PlasmaConcentration
0
Time to Drip ( or Long-acting )
Steady State
164 8 12
Time ( hours )
20 24
50%
75%
87.5%
93.75%
97%
...
PlasmaConcentration
…20 Time
Steady State ~ 20 hours
Concentration
needed to
control pain
Concentration
where side-effects...
PlasmaConcentration
0 Time
STAGES OF RESPIRATORY
DEPRESSION
Sedation
Bradypnea
Death
Awake &
in Pain
PASERO OPIOID SEDATION
SCALE (POSS)
• S = Asleep, easy to arouse
• 1 = Awake & Alert
• 2 = Slightly drowsy, easily aroused...
SUMMARY
• Pain may be nociceptive, neuropathic or both and
the history tells you which.
• A standardized approach to the a...
PALLIATIVE CARE IS…
• A team that can help your patients and families manage
the pain, symptoms, and stress of serious ill...
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Conceptualizing pain

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Building a conceptual understanding of pain in the palliative care population with emphasis on physiology, pathophysiology, assessment and management. Provides principles of management as guided by basic pharmacologic principles incluing first-order kinetics.

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  • Pain is a frequent problem whether associated with advanced illness or other acute or chronic conditions,Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ. Understanding the experience of pain in terminally ill patients. Lancet. 2001;357(9265):1311-1315. PMID: 11343734.50% of 988 terminally ill patients reported pain. Of those patients experiencing moderate or severe pain,29% wanted more therapy, 61% wanted therapy to remain the same, 9% wanted less therapy or to stop their pain treatment altogether. Of these, 34% feared addiction, 31% were adverse to physical side effects (eg constipation), 33% averse to mental side effects (eg confusion) and 30% averse to additional pills or injections. Although the majority of patients had cancer, there was no association between disease and level of pain. We will briefly review the basic concepts important to understanding the physiology of pain This starts to build the common language we need when assessing and managing painWho in this room has experienced pain? Would you be willing to share you experience?
  • This is how the International Association for the Study of Pain has defined pain… recognizes that it is not only a sensory but also emotional experience Pain is the physical symptom that patients and families fear most Which is why I think the next definition is very useful. . .
  • Descartes:  “I feel pain, therefore, I am”This diagram represents the early concept of pain transmission A single nerve carries the impulse from the point of injury to the brain
  • New receptors, pathways, and hypotheses are being investigated everyday     We will not go into this diagram in any depth, but you can see that multiple connections,  neurotransmitters and pathways are represented Pain is much more than the early philosophers thoughtIt is important for all clinicians caring for the patient to have a basic understanding of pain and be able to talk to each other using the correct clinical language Let’s begin by defining some terms…
  • Let’s start with defining a nociceptorUse hand and fingers to represent a nerve cell A nociceptor is a nerve that has developed to carry the pain signalSo imagine that I am one giant nociceptor . . . What am I doing when there is not an incoming pain stimulus . . . (resting quietly, scanning the environment) What happens when the person I (the nerve cell)belong to touches a hot stove? (nerve is stimulated by heat- a thermal stimulus)Discussion….(feel pain, withdraw hand, put in cold water, etc)So you have just defined the process of nociception . . . (the pain nerve cell being “turned on” and communicating with the rest of the body “pain”)Nociceptive pain involves direct stimulation of nociceptors that detect mechanical, chemical, and thermal stimuli and mediate nociceptive pain Nociceptors transmit this information along normal pathways to be perceived in the brainFormal definition- primary afferent neurons that exist throughout the body and have the intrinsic ability to respond selectively to specific noxious stimuli (Pasero, McCaffery, Pain Assessment and Pharmacologic Management. 2011; page 1)Guide to Pain Management in Low-Resource Settings.   Eds Kopf, A & Patel, NB.  IASP, 2010, chap 3 Physiology of Pain p 13Nociceptors are unspecialized, free, unmyelinated nerve endings that convert (transduce) a variety of stimuli into nerve impulses, which the brain interprets to produce the sensation of pain.  l
  • Nociception is the neural processing of noxious stimuliActivation of receptors in peripheral pain pathwaysTransmission of information about noxious stimuli to the brainSo, ULTIMATE DEFINTION: PAIN is the perception of nociception which occurs in the brain and includes 4 basic steps
  • This reflects “normal” pain, a healthy nervous system doing what it is designed to doLet’s walk through each step, one at a time…
  • Noxious events activate primary (afferent) neurons that exist throughout the body A painful stimuli causes the nerve to be “turned on”
  • Now our signal is climbing from the skin to the spinal cord and on to the processing and perception centers in the brain.Primary afferents continue the impulse via A-delta and C fibers from the periphery to the spinal cordAfferent information passes through dorsal root ganglia to the spinal cord where it synapses in the dorsal horn and connects to the “second order” neuronThe stimulus is continued from the spinal cord via multiple ascending pathways to the brainstem and higher cortical levels Transmission is the process by which impulses are sent to the dorsal horn of the spinal cord, and then along the sensory tracts to the brainThe primary afferent neurons are active senders and receivers of chemical and electrical signals Their axons terminate in the dorsal horn of the spinal cord where they have connections with many spinal neuronsIn turn, spinal neurons have inputs from many primary afferents
  • This is the point in the process when we consciously know that we are in painExplains our individual response to a painful stimuliWhy we may respond differently to the same, repeated painful experienceRequires activation of higher brain structures, thalamus, limbic systemIncludes processes that influence movement, emotions and drivers related to pain
  • As the pain is translated and travels to the brain, multiple factors interact with the signal.This is where the pathophysiology meshes with the model of Total Pain Inhibitory mechanismLocal and descending processes occur in multiple sites from the periphery to the cortex, most importantly in the spinal cordInvolves the release of numerous neurochemicals endogenous opioids, serotonin, norepinephrine
  • Dr. Saunders gives us the concept of Total Pain- which is the summation of all these domains: Physical symptoms, Emotional & psychological problems, Spiritual or existential distress and Social concerns.This recognizes that we are more than a physical body, and that other factors influence the sensation of painThe basic concepts we will discuss today provides a pathophysiologic basis which supports this model
  • To review, these are the 4 steps we have just discussedWe will add to these steps the physiologic and temporal classifications of painNow let’s move outside the body of our patient and look at the way that we, as clinicians, think about pain.
  • We, as a group, like to put things in boxes – to classify them. [CLICK] Let’s begin by looking at the different physiologic types of painWhen we think about pain from a physiologic standpoint, we think about it being nociceptive, neuropathic or mixedNociceptive painfollows the 4 basic steps we have just learned aboutThis is a healthy, intact nervous system doing what it is designed to doWe continue to develop an understanding of this type of pain and how the body reacts to painful stimuliNeuropathic pain does not follow the steps we have just learned aboutReflects a damaged or traumatized nervous systemWe do not know as much about neuropathic pain as we know about nociceptive painWe have to understand whether our patients have either nociceptive or neuropathic pain, or a combination of the two…referred to as “mixed” pain
  • Normal tissue responses to painful stimuli Described as sharp, aching or throbbingFurther subdivided into somatic and visceral painSomatic pain, mediated by the somatic nervous system, subserves skin, bone, and muscle Pain localization is precise and is often described as sharp, aching, or throbbing For example, describe the pain you have when you cut your finger (sharp, well localized, pinpoint with one finger)Visceral pain, mediated by the autonomic nervous system, subserves internal structures such as the visceral cavity It is typically difficultto localize or describe, and sometimes characterized as crampyFor example, describe the pain you have with diarrhea (crampy, deep, use the entire hand to show where pain is, radiates to back)We use the patient’s words and their actions, along with the pathology of the disease to accurately assess the pain
  • Neuropathic pain has been defined as a primary lesion or dysfunction of the nervous system Damaged caused by ischemia, compression, infiltration, metabolic injury, or transection Patients tend to describe neuropathic pain with words like burning, tingling, numbness, shooting, stabbing, or electric-like feelings Dysfunction of the nervous system repetitive nociceptive stimuli can create a condition where spinal cord neurons have increased sensitivity “central facilitation” nerves are undamaged, an abnormal signaling system a given noxious stimulus receives a larger response than normal (hyperalgesia)non-noxious light touch can stimulate pain pathways (allodynia)The N-methyl-D-aspartate (NMDA) receptor is thought to be involved in setting up this abnormal pathway Preliminary evidence suggests that if the initial nociceptive pain impulses are controlled, these neurological changes can be prevented Although neuropathic pain may respond well to opioids, adjuvant analgesics (tricyclic antidepressants, anticonvulsants, antiarrhythmics, etc.) are often required in combination with opioids to achieve adequate relief
  • Which …is what we are most often facing in advanced illnesses….a combination of both nociceptive and neuropathic pain
  • Returning to the ways in which we think about pain, [CLICK] let’s now consider the time course of the sensationacute or chronic
  • Sudden or recent onsetIdentifiablecause: injury, disease, medically causedShort duration usually < 1month Sympathetic responseFight or flight responsescharacteristic behavior: rubbing, moaning, crying, etcMay resolve spontaneouslyUsually responsive to medication therapy
  • Persistent: usually > 3 to 6 months; does not resolve spontaneously May not be an obvious cause for the reported pain May be due to a chronic disease or conditionProlonged Impairment: both physical and psychologicalUsually no sympathetic responseMay not APPEAR to be in pain when looking at themmay exhibit insomnia, anorexia, irritability, depressionChronic pain is often more challenging to manageNow that we have an idea of the pathophysiology, let’s look at a standardized way to assess pain…
  • In this session, we have reviewed the way that nociceptive pain messages are transmitted from the site of injury to the brain and back to the body with a responseWe have learned language to describe pain that is nociceptive, neuropathic and mixed painWe have learned to classify pain based on the time experiencedWe have learned that pain is not only a physical sensation, but a broader idea of “total pain”Our goal remains focused on the patient and the relief of painOur goal is to improve the experience for the patient, caregivers, team
  • 5 elements we want to focus on for a pain assessmentTo many (if not most!), this will feel simplistic. However…All clinicians assess, all clinicians reportAnd we have consistencyAllows for accurate and safe treatment plans to be developedLet’s walk through each of these steps together.
  • Ask how the pain changes over timeThis is important because it helps identify the need for immediate release medication, extended release medication, or a combination of the two Constant pain is experienced throughout the day.There may be some variation in intensity, but the patient is in pain the entire dayBreakthrough pain describes an increase over the level of constant pain It may be due to certain activities (walking, bathing) or occur without any warningIntermittent acute (or incidental) pain describes pain that comes and goes, and fluctuates between being pain free and in pain
  • Multi-modal guidelines: ASA; APS; ASRA; USDept HHS Agency for Healthcare Research & Policy: CurrOpinAnesth 2010; J Orthopedics 2013Scheduled dosing may reduce overall pain enough to reduce dose required or frequency of opioids.
  • Behavioral/APP will be a prn option if building your own orders
  • The half-life is the parameter that guides routine dosingFor opioids (except methadone), the half-life is 4 hours Let’s look at why this matters…
  • For the patient with CONSTANT pain, non-scheduled dosing leads to return of pain prior to effective concentration of next breakthrough doseRequires patient educationVery difficult to achieve in the hospital given the other time demands on the floor nursing staff!![CLICK] with routine dosing, you can see that the steady state (represented by the line at the peak of the curves) results in each scheduled dose becoming effective before the prior dose is removed from the body.Speaking of steady state…
  • This graph demonstrates the plasma concentration increasing with routine dosing based on the half-life100%, or maximum plasma concentration is reached after 5 doses, when consistently given based on half lifeWhen dosed repeatedly, the plasma concentrations approach a steady state after 4 to 5 half-lives. Thus, steady-state plasma concentrations are usually attained within a day4 hr half life x  4 doses  = 16 hr4 hr half life x  5 doses  = 20 hourGiven this, I would like you to think about starting morphine drips. Often times, we will increase drips, we will titrate them up, when people have symptoms out of control.Can anyone think of a problem with this, knowing what we now know??When will that drip reach steady state…reach its maximum effect?
  • We work towards the steady state of plasma concentration to provide pain relief[CLICK]We try to avoid too little medication (trough) that leads to increased pain, or too much medication (peak) that leads to unwanted side effects This curve represents optimal dosing with the trough and the peak both staying within the therapeutic rangeLow end of the therapeutic range would be the plasma concentration needed to control painHigh therapeutic range would be the plasma concentration where side effects start to occur
  • Given this, I would like you to think about starting morphine drips. Often times, we will increase drips, we will titrate them up, when people have symptoms out of control.Can anyone think of a problem with this, knowing what we now know??When will that drip reach steady state…reach its maximum effect?
  • Conceptualizing pain

    1. 1. PALLIATIVE CARE IS… • A team that can help your patients and families manage the pain, symptoms, and stress of serious illness. • Available at any age and at any stage in a serious illness and can be provided along with curative treatment. • Expert communication for challenging situations. • Partnering with you for better outcomes by helping your patients tolerate curative treatment.
    2. 2. CONCEPTUALIZING PAIN Kyle P. Edmonds, MD Assistant Clinical Professor Doris A. Howell, MD, Palliative Care Service UC San Diego Health Sciences Adapted from the Palliative Care International Curriculum Series Editor, Frank R. Ferris, MD
    3. 3. OBJECTIVES • Pain may be nociceptive, neuropathic or both and the history tells you which. • A standardized approach to the assessment of pain helps prevent miscommunication. • For constant pain, schedule dose using data. • For breakthrough pain, use PRN dose.
    4. 4. PAIN “Pain is whatever the person says it is…” - Margo McCaffery
    5. 5. MECHANISM OF PAIN- DESCARTES
    6. 6. BASIC STEPS: PAIN PROCESSING • Transduction • Transmission • Perception • Modulation
    7. 7. NOCICEPTOR • Nerve cell • Activation • Thermal • Chemical • Mechanical • Transmits signal
    8. 8. PAIN TRANSDUCTION • Response to noxious stimuli • Carried by A-delta and C-fibers
    9. 9. TRANSMISSION: 3 STAGES • Stimulus to cord • Cord to brain stem • Brain stem to higher cortex
    10. 10. •Sensation •Somatosensory cortex •Emotional response •Frontal cortex •Limbic system TRANSMISSION
    11. 11. PERCEPTION • Experience • Conscious • Multidimensional • Interaction of transmission / transduction
    12. 12. “TOTAL PAIN” Pain Disease Mgmt Physical Psych SocialSpiritual Practical EOL Worries
    13. 13. MODULATION • Changing • Inhibiting • Spinal cord level
    14. 14. PAIN PROCESSING • Transduction • Transmission • Modulation • Perception
    15. 15. CLASSIFICATION OF PAIN • Physiologic • Nociceptive • Neuropathic • Mixed • Temporal • Acute • Chronic
    16. 16. NOCICEPTIVE PAIN • Somatic • Skin • Soft tissue • Bone • Visceral
    17. 17. NEUROPATHIC PAIN • Damaged or dysfunctional nerves • Central • Peripheral
    18. 18. MIXED PAIN • Experiencing • nociceptive and • neuropathic
    19. 19. CLASSIFICATION OF PAIN • Physiologic • Nociceptive • Neuropathic • Mixed • Temporal • Acute • Chronic
    20. 20. TEMPORAL CLASSIFICATION: ACUTE • Sudden or recent onset • Identifiable cause • Short duration • Sympathetic response
    21. 21. TEMPORAL CLASSIFICATION: CHRONIC • Persistent • No obvious cause • Functional impairment • No sympathetic response
    22. 22. INTERVAL SUMMARY Understanding the pathophysiology leads to improved assessment and targeted management that will improve outcomes
    23. 23. PAIN ASSESSMENT 1. Location 2. Description (type) 3. Change over time 4. Severity (0 – 10) 5. Effect of treatments • Benefit (+) • Unwanted effects (-)
    24. 24. • Constant • Breakthrough • Intermittent acute 3. CHANGE OVER TIME
    25. 25. PAIN ASSESSMENT TOOLS • Self Report • NRS (adult) • Behavioral Pain Scales • Checklist of Non-Verbal Pain Indicators (CNPI) – non-critical care units • Critical-Care Pain Observation Tool (CPOT) – ICUs • Assumption that Pain is/will be Present (APP)
    26. 26. INTERVAL SUMMARY Assessment of pain requires a thoughtful history and physical. This step helps you to tailor & target your treatment options.
    27. 27. FEEDBACK? QUESTIONS? • New Opioid Naïve Pain Orders Set • What’s working? • Not working? • More pages? Less? • Easier? Harder? • Next steps?
    28. 28. PlasmaConcentration 0 Time Absorption Excretion First Order Kinetics When biological effect follows plasma concentration
    29. 29. MILD PAIN / MULTIMODAL PAIN • Mild Pain: pain score 1-4 • UCSD guidelines are to avoid use of opioids for mild pain • Multi-modal analgesic guidelines • Scheduled vs PRN non-opioid agents
    30. 30. PlasmaConcentration 0 Time Principle: Scheduled Dosing  Steady State Pain control Unwanted effects
    31. 31. MODERATE / SEVERE PAIN ORDERS • Moderate (VAS=5-7) & Severe (VAS=7-10) • Behavioral Scale/APP set to moderate dose • Nurse reassessment around analgesic peak • PO peak 1 hour • IV peak 30 minutes • Rescue dose available at reassessment
    32. 32. • Breakthrough • Intermittent acute PAIN CHANGE OVER TIME
    33. 33. PlasmaConcentration 0 Time IV PO / PR 60min Time to Maximum Concentration ( t Cmax )10min
    34. 34. RESCUE OPTIONS • Rescue is EITHER PO or IV • No more than 3 (oral or IV) in 24 hrs. • Used with EITHER moderate or severe pain after reassessment at the peak of the PRN drug administered.
    35. 35. PRINCIPLE: ACUTE PAIN  PRN MED • Treat rapidly & safely • Short-acting dosed at point of maximum effect (Cmax)
    36. 36. PlasmaConcentration 0 Time Cmax Acute Pain Principle PO / PR ≈ 1 hr Cmax
    37. 37. • Constant • Breakthrough PAIN CHANGE OVER TIME
    38. 38. PRINCIPLE: CONTINUOUS PAIN  SCHEDULED MED • To achieve steady-state • Schedule non-opioid • Opioid use guided by data • PRN usage or • Short-acting meds scheduled on the T½
    39. 39. CONTINUOUS PAIN PRINCIPLE
    40. 40. PlasmaConcentration 0 Dosing every half-life ( t ½ ) Oral morphine = 4 hours 164 8 12 Time ( hours ) 20 24 50% 75% 87.5% 93.75% 97% 100%
    41. 41. PlasmaConcentration 0 Time Steady state after 5 half-lives ≈ 20 hours Pain control Unwanted effects
    42. 42. PlasmaConcentration 0 Time to Drip ( or Long-acting ) Steady State 164 8 12 Time ( hours ) 20 24 50% 75% 87.5% 93.75% 97% 100% Pain Control Change GTT 12+ more hours!
    43. 43. PlasmaConcentration …20 Time Steady State ~ 20 hours Concentration needed to control pain Concentration where side-effects start to occur
    44. 44. PlasmaConcentration 0 Time STAGES OF RESPIRATORY DEPRESSION Sedation Bradypnea Death Awake & in Pain
    45. 45. PASERO OPIOID SEDATION SCALE (POSS) • S = Asleep, easy to arouse • 1 = Awake & Alert • 2 = Slightly drowsy, easily aroused • 3 = Frequently drowsy, arousable, drifts off to sleep during conversation • 4 = Somnolent, minimal or no response to stimulation
    46. 46. SUMMARY • Pain may be nociceptive, neuropathic or both and the history tells you which. • A standardized approach to the assessment of pain helps prevent miscommunication. • For constant pain, schedule dose using data. • For breakthrough pain, use PRN dose.
    47. 47. PALLIATIVE CARE IS… • A team that can help your patients and families manage the pain, symptoms, and stress of serious illness. • Available at any age and at any stage in a serious illness and can be provided along with curative treatment. • Expert communication for challenging situations. • Partnering with you for better outcomes by helping your patients tolerate curative treatment.

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