Hospice Pain Management - Managing Pain in Hospice Care (2023)

Hospice Pain Management - Managing Pain in Hospice Care (1)

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Hospice Pain Management - Managing Pain in Hospice Care (2)Pain management is a primary goal of hospice care. But people often have misconceptions about how hospice care deals with pain and other end-of-life symptoms.

For instance, relatives sometimes worry their loved one will be “doped up” or become addicted to strong pain medications. Or they may fear their family member will suffer severe pain or other symptoms without sufficient relief.

Fortunately, neither scenario is likely, notes Chief Medical Officer Stephen Goldfine, MD at Samaritan Healthcare & Hospice.

“Hospice is about maximizing the patient’s quality of life at each stage of their illness,” he explains.

That means finding the right balance between pain relief and ability to live life. Qualified hospice providers base these decisions on the patient’s needs and preferences.

Pain and other symptoms

Hospice pain management means keeping the patient comfortable and addressing their symptoms, so they have the best possible quality of life.

(Video) Pain Management in Hospice Patients- Hospice Nursing

Hospice Pain Management - Managing Pain in Hospice Care (3)Near the end of life, patients may experience a range of discomforts, including pain, shortness of breath, nausea, anxiety, constipation, swelling, and insomnia, among others. A key goal of hospice care is to reduce these symptoms and increase the patient’s comfort level as much as possible.

Easing these symptoms enhances patients’ well-being, enabling them to make the most of their remaining time. In fact, patients are more likely to receive higher-quality hospice pain management than non-hospice patients with similar health issues, research shows.

Hospice providers treat symptoms in various ways – from the use of certain medications, to psychological and spiritual support, to complementary services such as therapeutic massage. Hospice also provides caregiver training and companionship, which can ease patients’ discomfort.

Evaluating pain

Hospice Pain Management - Managing Pain in Hospice Care (4)The hospice team will assess the patient’s pain during each visit. They will use a pain rating scale, as well as the clinicians’ expertise.

Pain rating scales include numeric measures (the patient rates pain from zero to 10 — from no pain to the worst possible pain); pictures of smiley faces with different expressions (the patient points to the face that best reflects their pain level); and the FLACC scale.

FLACC evaluates pain using five categories of non-verbal indicators: face, legs, activity level, crying, and consolability. For instance, is the patient frowning? Are their legs drawn up? Are they moaning? Can they be soothed? FLACC can be based solely on the hospice team’s observations, making it especially useful for patients who are unable to communicate.

Hospice pain management also evaluates and addresses patients’ emotional and spiritual pain. This type of pain can increase physical pain, and vice versa.

If you live in South Jersey and have questions about hospice pain management
for your loved one, please call Samaritan at (800) 229-8183.

Signs of Pain

Some patients – such as those with dementia – are unable to communicate they’re in pain. Others may try to hide their pain, fearing it will make them seem weak, or not wanting to complain, among other reasons. Thus, it’s important for both family caregivers and hospice providers to watch for any indications of discomfort.

“Few things we do for patients are more fundamental to the quality of life than relieving pain, especially at the end of life.”
American Society for Pain Management Nursing and Hospice and Palliative Nurses Association

Signs of pain can include:

  • Faster breathing rateHospice Pain Management - Managing Pain in Hospice Care (5)
  • Tightly closed eyes or rapid blinking
  • Rise in systolic blood pressure (the first number) from the patient’s normal level
  • Holding arm or leg muscles tightly, or holding a rigid posture
  • Rocking, fidgeting, or pacing
  • Resisting care or guarding part of the body when turning
  • Becoming withdrawn
  • Becoming more aggressive or easily angered
  • Greater confusion
  • Crying, moaning, sighing, or calling out

Medications for hospice pain management

Many hospice patients will need some type of medication to manage their pain or other symptoms. At the same time, hospice doctors and nurses recognize that pain relievers can cause drowsiness and other side effects. Therefore, these providers work to find the lowest dose that will keep the patient comfortable, and that will also enable the person to do the things they find most meaningful – such as interacting with their loved ones.

These are the most common hospice pain management medications:

(Video) Palliative Care and Pain Management

Hospice Pain Management - Managing Pain in Hospice Care (6)Acetaminophen. Known by the brand name Tylenol, this is the most-prescribed hospice medication. It reduces fever and mild to moderate pain.

Bisacodyl. This drug treats constipation, an uncomfortable condition that’s common among patients as they take pain medication and/or eat and drink less over time. Brand names of this laxative include Carter’s Little Pills, Correctol, Dulcolax, Feen-A-Mint, and Fleet Bisacodyl.

Dexamethasone. This steroid can relieve pain, reduce swelling, increase appetite and relieve nausea, among other uses. Brand names include Decadron, Dexamethasone Intensol, and Dexpak Taperpak.

Lorazepam. The second most-prescribed hospice medication, lorazepam reduces anxiety, agitation, shortness of breath, and insomnia. Brand names include Ativan or Lorazepam Intensol.

Haloperidol. Known by the brand name Haldol, this drug helps reduce agitation, nausea, and delusions.

Oxygen. While not technically a medication, this clear, odorless gas can be used as one. Supplemental oxygen – also called 02 – encourages healing, reduces shortness of breath, and decreases air hunger – the sensation of not being able to get enough air.


Take a more in-depth look at common hospice medications.Read more now >>

Morphine and other opioids. These medications relieve moderate to severe pain and shortness of breath. Morphine is the preferred hospice medication for pain management for cancer-related pain.

Misconceptions about opioids in hospice pain management

Hospice Pain Management - Managing Pain in Hospice Care (7)In addition to morphine, other opioids that control hospice patients’ pain include oxycodone (Oxycontin), methadone (Dolophine), and hydromorphone (Dilaudid).

Some families express concern about opioids, including fears about addiction. However, people on hospice are diagnosed with six months or less to live, which is not enough time to develop an addiction. Therefore, priority should be placed on providing the most effective means of pain relief.

Another common worry is that using opioids will hasten the patient’s death. In fact, studies show the opposite: that patients on hospice generally live longer once their symptoms are managed, compared to those who do not receive effective hospice pain management. They key to starting an opioid is to start low and go slow.

These medications are very safe when given for symptom control, and increased slowly as needed for pain relief. Hospice pain management protocols require close monitoring of the patient’s need for the drug, proper dosage, and secure storage of the medication if the patient is living at home.

(Video) Pain Management in Palliative Care

Changes in the patient’s breathing pattern or greater pain are typically caused by their advancing illness, rather than by the medication.

Moreover, starting hospice care as soon as possible after the patient’s terminal diagnosis enables quicker management of pain and other symptoms – allowing the patient to enjoy a better quality of life for a longer period of time.

If you live in South Jersey and have questions about hospice pain management
for your loved one, please call Samaritan at (800) 229-8183.

Emotional and spiritual support for hospice pain management

Hospice Pain Management - Managing Pain in Hospice Care (8)Hospice can provide psychological and spiritual support for patients experiencing any type of physical or emotional pain. The hospice’s social worker and/or chaplain will visit the patient to help address these needs through supportive listening, conversation, and counseling.

In addition, hospice can also address emotional distress — such as anxiety and agitation — with certain medications, such as Ativan (lorazepam) or Valium (diazepam). (See “Medications for hospice pain management” above).

Family members and friends should avoid adding to the patient’s stress and anxiety, by not arguing with or near the patient.

Complementary therapies for hospice pain management

Complementary therapies in hospice can include massage, music, pet, and aroma therapy. These therapies are often used alongside medication and other traditional treatments, thus the name “complementary.”

Massage Therapy. A trained massage therapist uses gentle, therapeutic touch to provide relaxation and comfort. Many patients show improvements in emotional distress, nausea, anxiety, and pain.

Hospice Pain Management - Managing Pain in Hospice Care (9)For instance, massage therapy can reduce swelling by encouraging drainage of lymph fluids. It can ease soreness and stiffness by increasing blood flow to affected joints and muscles.

Massage also lowers blood pressure and eases your heart rate. It reduces unhealthy levels of stress hormones, and releases “feel good” hormones that temporarily lessen the impact of other aches. This therapeutic touch increases circulation, which can help patients feel less cold and more alert.

Massage therapy may include gentle stroking, kneading, and light pressure on the hands, feet, legs, or arms, with or without massage oil or lotion. Massage can be provided while the patient is in a hospital bed, wheelchair, recliner, or upright chair. Each visit is tailored to the patient’s needs.


Looking for more information about complementary therapies?
Read about these natural methods for enhancing quality of life.

(Video) Palliative Care – Symptom Management: By Robin Love M.D.

Family members can attend massage therapy sessions, where they can learn how to apply the techniques.

“Massage can be a wonderful way for family members to connect with their loved one,” says Dr. Goldfine at Samaritan. “It can provide peace and comfort toward the end of life.”Read more about massage therapy >>

Music Therapy. Trained music therapists work with patients to help reduce pain, anxiety, and other discomforts. Therapists provide Hospice Pain Management - Managing Pain in Hospice Care (10)individualized treatments that can include creating music, singing, moving, and listening.

In fact, music therapy can address a wide range of physical, emotional, spiritual, and social needs. This enjoyable treatment spurs positive memories and conversations, focusing the patient’s attention away from their worries and discomforts.

Goals of music therapy depend on the patient’s and family’s needs, such as reducing pain or restlessness, as well as creating fulfilling and meaningful memories with loved ones. Read more about music therapy >>

Pet therapy. Trained volunteers visit patients and families with certified pet-therapy dogs. Petting and interacting with an animal prompts Hospice Pain Management - Managing Pain in Hospice Care (11)our bodies to release “feel good” hormones, and distracts people from their illness. This helps reduce pain and stress, and improves overall comfort.

Pet therapy can also lower blood pressure, improve heart rate, and reduce loneliness. It encourages conversation, laughter, and emotional connection between patients and their families. And patients may find joy in reliving memories of their own cherished pets.

Pet therapy visits can range from a couple minutes to a half-hour or more. Each visit can be different, depending on the needs and desires of the patient and family. Read more about pet therapy >>

Aromatherapy. Also known as essential oil therapy, aromatherapy uses fragrant oils from plants to promote comfort and wellness.

Hospice Pain Management - Managing Pain in Hospice Care (12)Aromatherapy can be applied in several ways. Samaritan Hospice uses a method called aerial diffusion, which disperses the fragrance into the room via a sachet or small perfumed bag.

Two of the most commonly used oils are lavender and orange. Lavender is used for restlessness, insomnia, nervousness, and depression. It is also used for digestive issues, including upset stomach, nausea, loss of appetite, and intestinal gas (flatulence). Orange oil is used to relieve spasms and depression, stimulate digestion, and help stop blood from clotting. Read more about aromatherapy >>

If you live in South Jersey and have questions about hospice pain management
for your loved one, please call Samaritan at (800) 229-8183.


How is pain managed in end of life care? ›

simple painkillers for mild pain – like paracetamol, aspirin and ibuprofen. weak opioids for moderate pain – like codeine and tramadol. strong opioids for severe pain – like morphine, oxycodone, buprenorphine and fentanyl.

Which is a goal for the management of pain in hospice care? ›

Pain and symptom management is one of the primary goals of hospice care – keeping the patient comfortable and managing symptoms to ensure they have the highest quality of life for as long as they live.

How do you deal with persistent pain? ›

Tips on coping with chronic pain
  1. Manage your stress. Emotional and physical pain are closely related, and persistent pain can lead to increased levels of stress. ...
  2. Talk to yourself constructively. Positive thinking is a powerful tool. ...
  3. Become active and engaged. ...
  4. Find support. ...
  5. Consult a professional.

What are the stages of pain management? ›

Its three steps are: Step 1 Non-opioid plus optional adjuvant analgesics for mild pain; Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to moderate pain; Step 3 Strong opioid plus non-opioid and adjuvant analgesics for moderate to severe pain.

What interventions can be used to manage pain? ›

Key pain management strategies include:
  • pain medicines.
  • physical therapies (such as heat or cold packs, massage, hydrotherapy and exercise)
  • psychological therapies (such as cognitive behavioural therapy, relaxation techniques and meditation)
  • mind and body techniques (such as acupuncture)
  • community support groups.

How do you handle a patient in pain management? ›

Simple Ways to Better Communicate with a Patient in Pain
  1. When entering the room of patients in pain, always tell them that you are there to help comfort them and to do your best to relieve their pain.
  2. Remain calm and show empathy.
  3. Express concerns for the patient's feelings.
  4. Use “I” statements.

What are the 4 goals of hospice care? ›

What are the goals of hospice care?
  • Caring for the whole person, not just the disease.
  • Addressing your physical, emotional, social, and spiritual needs.
  • Focusing on you and your family.
  • Providing the best possible quality of life for whatever time remains.

How much pain is too much pain? ›

Severe Pain.

When it intensifies to level 8, pain makes even holding a conversation extremely difficult and your physical activity is severely impaired. Pain is said to be at level 9 when it is excruciating, prevents you speaking and may even make you moan or cry out. Level 10 pain is unbearable.

Why pain medication is not working? ›

Hormonal issues, poor metabolism, poor sleep, high blood pressure, or stomach conditions could change the effect of your medications. It is important to inform all of your doctors about any other conditions you may have to help avoid these problems.

What is the golden rule of pain management? ›

The key to pain management is to treat your patient the way you'd want to be treated.

What level is considered severe pain? ›

There are many different kinds of pain scales, but a common one is a numerical scale from 0 to 10. Here, 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain.

What is the gold standard of pain management? ›

A Numerical Rating Scale (NRS) ranging from 0 to 10 (0, no pain; 10, maximum pain), which is based on a patient's self-report, is the gold standard for pain evaluation in patients who can communicate their pain intensity.

What is the 2 step method to pain management? ›

Patients generally start on Step 1 of the ladder (paracetamol). As pain increases or is not well controlled on this, they progress to Step 2 which involves a stronger pain killer (weak opioid such as codeine).

What is the most effective pain management? ›

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are most effective for mild to moderate pain that's accompanied by swelling and inflammation. These drugs are commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps.

What is the most common form of pain management? ›

The most commonly used medications can be divided into the following categories: NSAIDs and acetaminophen: Many different types of NSAIDs are available, and some of them (such as ibuprofen) are available OTC. NSAIDs can be very effective for acute muscular, bone, and arthritic pain.

How do you comfort client in pain? ›

Have them close their eyes, create a pleasant scene, focus on that image, and describe it aloud. Remember to be gentle with your clients and speak in a calm and soothing voice. Distraction is another good method to 'distract' the client from their pain.

What is the role of a nurse in managing pain? ›

The licensed nurse is responsible and accountable to work toward effectively managing the patient's pain through assessment, intervention and patient advocacy. and non-pharmacological interven- tions to control the patient's identified pain.

What is usually not included in hospice care? ›

Hospice, however, doesn't cover room and board fees at senior communities. Instead of providing endless surgeries and treatments, hospice focuses exclusively on the comfort of the patient. The palliative portion of the care may offer an array of pain medications while not treating the cause of the terminal illness.

What are the 3 stages of hospice care? ›

The early stage, the middle stage, and the final stage are the three stages of death. Various alterations in responsiveness and functionality characterize them. It's crucial to remember, though, that the timing of each stage, as well as the symptoms encountered, might differ from person to person.

What are 3 types of care provided by hospice? ›

Hospice offers four levels of care, as defined by Medicare, to meet the varying needs of patients and their families. The four levels of hospice include routine home care, continuous home care, general inpatient care, and respite care.

What is a 7 on the pain scale? ›

7 – Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep. 8 – Intense pain. Physical activity is severely limited.

What should I not tell a pain management doctor? ›

Don'ts: Things Pain Patients Wish Doctors Would Avoid
  • Don't label patients. ...
  • Don't tell patients the pain is 'in our heads. ...
  • Don't tell us to just 'live with the pain.

What's another word for extreme pain? ›

OTHER WORDS FOR excruciating

1 unbearable, insufferable, unendurable, agonizing, racking.

How long is too long on pain medicine? ›

If you need opioids, it is best to limit your use of opioids to no more than seven days. Using these drugs for more than 30 days can lead to addiction and dependence. You should use the low and slow rule. This means you start with the lowest dose and use as infrequently as possible.

What next if gabapentin does not work? ›

You will need to increase the dose for gabapentin to be effective. Gabapentin does not work for everyone. If you do not feel any improvement in your pain after 6 – 8 weeks, do not suddenly stop taking the tablets but speak to your doctor.

Why do doctors not like pain meds? ›

Opioid medications have long been prescribed to help people manage their chronic pain and live productive lives. However, the rising tide of the opioid crisis has led to concerns that opioids are over-prescribed. This has led some doctors to stop prescribing pain medication to patients who need it.

What pain medication is given at end of life? ›

The most commonly prescribed drugs include acetaminophen, haloperidol, lorazepam, morphine, and prochlorperazine, and atropine typically found in an emergency kit when a patient is admitted into a hospice facility.

What is the difference between palliative care and pain management? ›

Palliative care physicians are specially trained in complex pain management resulting from serious illnesses such as cancer, so they are experts in administering managing opioids and other potent pain medications. Pain management specialists usually treat pain that does not result from complex, serious illness.

Why is it important to include pain relief in end of life care? ›

Pain management is a key part of end of life and palliative care. If pain is well managed, quality of life will be better. The person is likely to sleep better and have more energy during the day. If they feel less pain, they can be more active, which also reduces the risk of complications.

What role do you think pain management plays in end of life care for the elderly? ›

Successfully reducing pain and addressing concerns about breathing can provide needed comfort to someone who is close to dying. Side effects may include confusion, drowsiness, or hallucinations.

What are the 3 end of life drugs? ›

Medicine for pain in palliative care – an appropriate opioid, for example, morphine, diamorphine, oxycodone or alfentanil. Medicine for breathlessness – midazolam or an opioid. Medicine for anxiety – midazolam. Medicine for delirium or agitation – haloperidol, levomepromazine, midazolam or phenobarbital.

Does hospice administer pain medication? ›

Ninety-one percent of the hospice patients were administered pain medication to manage symptoms, compared to 81 percent of control patients.

Why does hospice use oxycodone? ›

Controlled-release oxycodone (OxyContin) is commonly used for pain relief in terminal cancer. This opioid may be considered as a treatment option for patients who prefer oral pain control, but who are unwilling to take oral morphine sulphate or cannot tolerate its side effects.

Why is palliative care better than hospice? ›

Palliative Care vs Hospice Care

Hospice is comfort care without curative intent; the patient no longer has curative options or has chosen not to pursue treatment because the side effects outweigh the benefits. Palliative care is comfort care with or without curative intent.

How do you know when a dying patient is in pain? ›

If your family member or friend is unable to communicate

If the person cannot communicate verbally, you can look for signs that they are in pain. These include: frowning. changes in their mood – for example, being quieter or becoming aggressive.

What are the 5 priorities of end-of-life care? ›

 The five priorities focus on: recognising that someone is dying; communicating sensitively with them and their family; involving them in decisions; supporting them and their family; and creating an individual plan of care that includes adequate nutrition and hydration.

What is the main goal of pain management? ›

The first and most major pain management goal is pain control and relief while taking the lowest dose of medications possible. Meaningful pain relief has been proven to improve functionality and quality of life.

Why is pain management a priority? ›

Pain interferes with many daily activities, and one of the goals of acute pain management is to reduce the affect of pain on patient function and quality of life. The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients following surgery.


1. Palliative care and pain management through Hospice Africa
2. Exploring the Foundation of Pain Management in Hospice Care with Dr. Robert Twycross
(Barbara Morningstar)
3. How to manage pain?
4. Managing Pain in Palliative Care
(Center for Rural Health)
5. Cancer Related Pain Management From a Palliative Care Perspective C. Kelly - 20221012
(UNC Cancer Network)
6. Pain Medication Myths: Addiction and Hastening Death - Palliative Care
(Canadian Virtual Hospice)
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