The document outlines principles of palliative care and pain management, emphasizing a holistic approach that enhances the quality of life for patients with life-threatening illnesses. It details the various aspects of pain assessment and management, including classification of pain types, and advocates for multidisciplinary team approaches to care. The principles also include patient-centered care, family involvement, ethical considerations, and the importance of a continuum of care in supporting patients and families.

1. Principles of Palliative Care & Pain
assessment control and Management.

2. Study outline:
Introduction
What is palliative care ?
Principles of palliative care .
principles of pain management
Definition Pain
Pain pathway
Classification of pain
Pain assessment
Pain management

3. Quotation from Dame Cicely (RIP 2005)
You matter because you are YOU
You matter up to the last moment of your life
And we will do all that we can to help you
To LIVE until you die”
Set up the first
modern hospice
at St.
Christopher's
Hospice in
London &
emphased
Paliative care -
1967

4. Back ground
Hospice –Is conceptualized care that emphasizes palliative care rather than curative care to
improve quality of life rather than quantity .
In Africa ;- 1979-Zimbabwe: Island hospice
In Uganda ;-1993: Hospice Africa Uganda

5. What is palliative care?
“A holistic approach that improves the quality of life of patients and their families facing the
problems associated with life threatening illness, through the prevention and relief of
suffering by means of early identification and impeccable assessment and treatment of pain
and other problems, physical, psychosocial, and spiritual.” .(WHO-2002)
Palliative care is both a philosophy of care and an organized, highly structured system for
delivering care.
Palliative care includes the entire spectrum of intervention for the relief of symptoms and
the promotion of quality of life.
It provides the relief of unnecessary physical, psychological
and spiritual pain caused by life-limiting illnesses from the point of diagnosis to the end of life
and even bereavement support for family members. (APCA)- empathic in approach.

6. What is hospice care?
Although all patients, regardless of prognosis, may benefit from the services of a
palliative care physician, hospice care is a specific form of palliative care
intended for patients who have an estimated prognosis of 6 months or less to
live.
Hospice care, and benefits can be continued beyond the original 6 months of
estimated survival if physicians certify that life expectancy remains limited to 6
months or less.

7. Indications of palliative care:
(a) patients with conditions that are progressive and life-limiting, especially if characterized
by burdensome symptoms, functional decline, and progressive cognitive deficits;
(b) assistance in clarification or reorientation of patient/ family goals of care;
(c) assistance in resolution of ethical dilemmas;
(d) situations in which a patient/surrogate declines further invasive or curative treatments
with stated preference for comfort measures only;
(e) patients who are expected to die imminently or shortly after hospital discharge; and
(f) provision of bereavement support for patient care staff, particularly after loss of a
colleague under care.

8. When to start palliative care
•Its about improving the quality of life not quantity –
every day left must be lived with dignity
•from when life threatening illness or life limiting
illness has been diagnosed
According to Shega joseph hospice eligibility
criteria,USA
The illness is terminal (a prognosis of ≤ 6 months)
and the patient and/or family has elected palliative
care.
The patient has a declining functional status as
determined by either:
◦ Palliative Performance Scale (PPS) rating of ≤ 50%-60%
◦ Dependence in 3 of 6 Activities of Daily Living (ADLs)
The patient has alteration in nutritional status,
e.g., > 10% loss of body weight over last 4-6
months
The patient has an observable and
documented deterioration in overall clinical
condition in the past 4-6 months, as
manifested by at least one of the following:
◦ ≥ 3 hospitalizations or ED visits
◦ Decrease in tolerance to physical activity
◦ Decrease in cognitive ability
Other comorbid conditions

10. Fundamental elements of palliative care.
The fundamental elements of palliative care consist of:
• pain and non pain symptom management,
•communication among patients, their families, and care providers, and
•continuity of care across health systems and through the trajectory of illness.
•Additional features of system-based palliative care are team based planning that includes
•patient and family;
•close attention to spiritual matters; and
•psychosocial support for patients, their families, and care providers, including bereavement
support.

11. Principles of palliative care include:
•Holistic approach
•Patient centred care
•Teamwork and partnership,
•Involve and support family
•Appropriate ethical considerations
•Continuum of care.

12. Principles of palliative care
1)Holistic Approach
Carrying out a comprehensive assessment and
addressing problems holistically.
All 4 aspects that make up the whole person need
to be addressed ie Physical, Spiritual,
Psychological and Social
2) Patient Centred Care .
Patient should be at the centre of care .
Focus on the patient’s wishes, respect and
involve them in any decision making about their
care and treatment options

13. Principles of palliative care
3)Team work and partnerships
multi-disciplinary teams for patients and
families is key .
Team members help to share and support each
other.
No single professional can adequately address
all the issues arising from a life limiting illness.
Constant exposure to patient’s distressing
circumstances can be emotionally draining on
staff members.
Social workers
Clinical team
Spiritual team
Nutritional team
Rehabilitation/Therapist
Administration
Nursing team
Community leaders.
Support staff.

14. Principles of palliative care
4) Family involvement and support .
Family /care giver should always be involved
in the plan for care of the patient
It enables continued social support and a care
to the patients while in care, at home and
community .
5)Appropriate Ethical considerations
- patients Rights should be respects at all time
and medical ethics guide to achieve this :
Beneficence - Do good
Non Maleficence - Do no harm
Autonomy - Patients right to decide
Justice - Fairness

15. Principles of palliative care
6)Continuum of Care
Many Resources and services are involved to provide holistic care for ill persons and family care
givers.
Care can be provided from home to community and from clinics to hospitals and vice versa.
But which stage there should be continuity of care.
Thus continuum of care into which patient and family may enter at any one point.

16. Principles of pain management
Is the most common symptom that brings patient to the doctor.
Management depends on cause ,alleviating ,triggering and potentiating factors and providing
rapid relief whenever possible .
An unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such
damage". (internationational association for study of pain.1979 )
The following note was appended. "Pain is always subjective. Each individual learns the
application of the word through experiences related to injury in early life.

17. Updates in pain

18. Pain pathways
Nociceptors:
A fibres – myelinated, cause a sharp,
stinging pain
C-fibres – unmyelinated, responsible for dull,
aching pains
In chronic pain – continued stimulation causes
changes in the response

21. TYPES OF PAIN
The concept of 'total pain',
 includes not just the physical but also social, emotional and spiritual aspects of suffering.(cicely
saunders ,1960)
TOTAL PAIN
Psychological(fear ,depre
ssed,stress,guilt,etc
Social (job loss,
loss of loved one )
Spiritual (why me,
God is punishing me,?
Physical
(site,onset,radiation,
exacerbators,poor
sleep
PAIN
 ACUTE –
surgical,trauma,a
cute infection
 Chronic –
cancer ,Arthritis,n
europathy

22. Types of pain
Nociceptive-Tissue pain (somatic,visceral)
Activation of nociceptors in superficial
skin,viscera or deeper MSK.
Intact nerve pathways
Somatic-nociceptors in cutaneous and deep
MSK eg skin,msk,vessels,mucosa.
Cancer –bone mets
Non cancer –arthritis,trauma etc
Well
localized,aching,squeezing ,throbbing,gnawing
sensation
Visceral pain –activation of nociceptos in
visceral ie visceral compression ,infiltrating
tumors,myocardial infarction ,PUD.
Poorly localized,deep pressure,crampy,colic

23. TYPES OF PAIN
Neuropathic pain –Nerve pain ie peripheral and central.
From damaged nerves
Varying descriptions ie constant,stinging,pricking
Due to cancer related ,non cancer related eg HIV –HZ,DM,stroke.

24. Pain assessment
Holistic pain assessment is key to pain management
History taking and examination very important.
The following questions based on PQRST approach ie
Where is pain(location) ?
how severe is the pain? (severity)
For how long(duration) ?
What is pain like? (quality /character)
What makes it increase or reduce(aggrivating/relieving)
How often (timing /periodicity )
Does it move any where?(Radiating )

25. Tools used for assessing severity

26. Pain management
WHO,1990 started that freedom from pain is fundamental Human right ,No Person should be allowed
to die in pain
The principles of pain control
Consider Aetiology
Diagnose the cause
Choose the best management plan
Treat under lying cause if possible.

27. Principles of pharmacotherapy in
palliative care
• Believe patient report of symptoms.
• Modify pathologic process when possible and appropriate.
• In terminally ill, avoid medications not directly linked to symptom control.
• Use a multidisciplinary approach.
• Consider nonpharmacologic approaches whenever possible.
• Engage participation of clinical pharmacist in treatment plan.
• Select drugs that can multitask (i.e., use haloperidol for agitated delirium and nausea).
• For pain, use adjuvant medications when possible .
• When using opioids, spare when possible (adjuvant medication, local or regional anesthetics,
surgical interventions, etc.).

28. Principles of pharmacotherapy in
palliative care
• Avoid fixed combination drugs.
• Avoid excessive cost.
• Select agents with minimum side effects.
• Anticipate and prophy lax against side effects.
• For the elderly, the hypo protein emic, the azotemic: “Start low and go slow.”
• Oral route whenever possible and practical.

29. Principles of pharmacotherapy in
palliative care
• No IM injections.
• Scheduled dosing, not prn, for persistent symptoms.
• Stepwise approach. (See the World Health Organization Analgesic Ladder for pain.
• Reassess continuously and titrate to effect.
• Use equianalgesic doses when changing opioids .
• Assess patient/family’s comprehension of management plan.

30. The World Health Organization three-
step ladder for control of pain
Step:1 mild pain (visual analogue scale, 1–3) - Nonopioid ± adjuvant medication
Step 2: moderate pain (visual analogue scale, 4–6) -Opioid for mild to moderate pain and
nonopioid ± an adjuvant
Step 3: severe pain (visual analogue scale, 7–10) -Opioid for moderate to severe pain ±
nonopioid ± an adjuvant

31. Analgesia
5 principles of Rational analgesia usage
If possible always by mouth
At regular interval and titrated against pain
By WHO analgesic ladder
By patient involvement in decision making,
feedback, sideeffects.

32. Cont.
NSAIDS
Inhibit Cox1-normally physiological present
in stomach(PG1),renal
perfusion(PGE2),platelet aggregation(TXA)
and COX2 inducible during inflammation.
Opiod bind to specific opiod receptors ie
mu,kappa,delta nd ORL-1 opiod receptors
Principles of morphine use
Oral better to prevent dependency
Start low titrate depending on patient pain-
2.5mg-5mg (5mg/5ml)4hry
Double dose at night
Review every 24hrs-increses dose by 1/3 -1/2
if pain not relieved by 90%
Renal and liver disease –reduce dose nd
frequency .

33. Contn.
Principles of NSAID use
Protect against gastritis
Avoid in renal impairment
Consider availability
Efficacy
Safety
Cost

36. On use of OPIODS
Opioids compounded with aspirin or acetaminophen are limited to treatment of moderate
persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.
Slow-release preparations of morphine and oxycodone may be given rectally.
Timed-release tablets or patches should never be crushed or cut.
Opioid analgesics are the agents of choice for severe cancer-related pain.
Sedation is a common side effect when initiating opioid therapy.
Tolerance to this usually develops within a few days.
If sedation persists beyond a few days, a stimulant (methylphenidate 2.5–5 mg PO bid) can be given.
Initiate bowel stimulant prophylaxis for constipation when prescribing opioids unless contraindicated

37. Adjuvant treatments
Adjuvant or co analgesic agents are drugs that enhance analgesic efficacy of opioids, treat
concurrent symptoms that exacerbate pain, or provide independent analgesia for specific types
of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain).
Co analgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is
commonly used as an initial agent for neuropathic pain.
No place for meperidine (Demerol), propoxyphene (Darvon, Darvocet, or mixed agonist-
antagonist agents [Stadol, Talwin]) in management of persistent pain.
Always consider alternative approaches (axial analgesia, operative approaches, etc.) when
managing severe persistent pain.

38. Adjunvants
Medications which are usually used for other
indications but in certain circumstances are
effective for relieving pain.
Essential part of the analgesic ladder
Can be used on their own or in addition to
other medications on the ladder.
Can modify disease progression e.g Steroid
Antidepressants e.g. amitriptyline
Anticonvulsants e.g. phenytoin,
carbamazepine
Muscle relaxants (baclofen, diazepam)
Corticosteroids (dexamethasone)
Antispasmodics (buscopan)

40. Adjuvant medications.

41. Reference
https://www.africanpalliativecare.org/awareness/what-is-palliative-care/)
. (https://www.who.int/news-room/fact-sheets/detail/palliative-care) 5th
/august /2020
Palliative care making a difference in rural Uganda, Kenya and Malawi: three rapid evaluation field
studies https://bmcpalliatcare.biomedcentral.com/articles/10.1186/1472-684X-10-8;12th
may 2011.
https://www.painaustralia.org.au/media-document/blog-1/blog-2020/blog-july-2020/the-new-definiti
on-of-pain
.
https://quizlet.com/117919774/pta-102-pain-assessment-flash-cards
Handbook of Palliative Care in Africa. African Palliative Care Association, 2011
https://www.vitas.com/for-healthcare-professionals/hospice-and-palliative-care-eligibility-guidelines/h
ospice-eligibility-guidelines
SCHWAZ PRINCIPLES OF SURGERY 10TH
EDITON.

42. END