Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Implementing Pain Management Guidelines

Karen S. Heller, Ph.D.
Education Development Center, Inc.

[Citation information: Heller KS. Implementing Pain Management Guidelines. Innovations in End-of-Life Care, 1999;1(3), www.edc.org/lastacts]

The relief of pain and other symptoms throughout the trajectory of a terminal illness and enhancing the quality of life for patients and their family members remain major challenges. Although it is well known that undertreatment of pain has adverse clinical and quality of life effects for patients, pain associated with many life-threatening illnesses, most notably cancer pain, remains seriously undertreated.¹ The reasons for this treatment failure are complex and involve the interrelation of multiple barriers involving health care professionals, patients, the public and the health care and legal systems. Among the barriers recently summarized by Foley² are knowledge deficits among clinicians about how to assess and treat cancer pain; widespread fears among clinicians, patients and the public about possible adverse consequences resulting from the prescription of opiates, including concerns about side effects and fears of addiction; legal restrictions on prescribing opiates and clinicians' concerns about legal liability; and in some countries, lack of access to opiates.³ Moreover, effective pain management in clinical settings has been hampered by the absence of documented pain assessments and a lack of clear accountability for relieving pain.⁴ Until very recently, the relief of pain has been given low priority in health care institutions, with few economic resources committed to treating pain and a lack of policies to support the use of validated pain measurement tools in clinical practice.⁵

In recent years there has been growing awareness of the need to provide better pain and symptom management, particularly for cancer patients, throughout the course of their disease. Advances in knowledge about the pathophysiology of cancer pain and the availability of validated pain measurement tools now make it possible to provide adequate pain relief to cancer patients.⁶ There also has been growing recognition worldwide that many aspects of palliative care are applicable earlier in the course of illness in conjunction with anti-cancer treatment. As the Institute of Medicine's Committee on Care at the End of Life observed, "... it is not enough to emphasize control of symptoms once they are well-established. If identified and impeccably managed earlier in the trajectory of illness, many of the symptom problems that afflict dying patients could be either eliminated or more readily managed." ⁷ Early aggressive treatment of pain, before it becomes intractable, is now recognized to be extremely important if adequate control is to be achieved.

During the 1980s and early 1990s in the United States, educational efforts to improve pain management targeted first nurses, and then physicians, with little initial effect, which led many researchers to conclude that professional education alone was insufficient to change practice.⁸ Recent efforts have focused on a combination of professional education and continuous quality improvement efforts, as well as institutionalizing better pain management through such measures as increased documentation of pain assessment and treatment.^{9, 10} National guidelines on the treatment of cancer pain underscore that pain management is not just the responsibility of individual clinicians; institutions are accountable for having structures and processes in place to ensure that patients have access to appropriate pain management. The American Pain Society¹¹, U.S. Agency for Health Care Policy and Research¹² and the Oncology Nursing Society¹³ all have recognized the role institutions play in improving pain management and made recommendations directed at institutional structures and processes. The Joint Commission on the Accreditation of Hospitals has standards for pain management in dying patients and recently proposed institutional standards for pain management overall (January 1999) which are currently pending final approval.¹⁴

In the United States, all the guidelines on pain management emphasize that institutional approaches must be interdisciplinary to be most effective. Much of the emphasis on improving interdisciplinary approaches to pain management, therefore, has focused on promoting more effective teamwork between physicians and nurses. In this country, as in England and Canada, nurses have major responsibility for assessing and managing patients' pain day-to-day in most treatment settings. In other parts of the world, the role of nurses in pain assessment and management varies widely.¹⁵

Making pain the "fifth vital sign" on hospital charts on which temperature, pulse, respiration, and blood pressure are routinely recorded is now becoming more widespread in U.S. hospitals. The U.S. Veterans Administration health system recently adopted this as a system-wide policy. In Europe, a similar campaign to improve pain management institution-wide, entitled Vers un hôpital sans douleur, is underway in several countries through the efforts of an international organization called Association Internationale Ensemble contre la douleur.¹⁶ (See Resources and Tools in this issue for their website.) Many international pain and palliative care organizations have been working with the World Health Organization's Cancer Pain Relief Programme to facilitate broad dissemination of its analgesic ladder and cancer pain guidelines.^{17,18, 19}

The practical aspects of implementing and measuring the effects of pain management guidelines on practice and on patient outcomes have not yet received much attention. In this issue of Innovations, we feature one attempt to do this. In their interview, Anna Du Pen, ARNP, MN and Stuart Du Pen, MD provide insight into the effective use of an algorithm they developed that operationalizes the AHCPR guidelines on cancer pain management.²⁰ The algorithm, which is designed for use by physician-nurse teams, promotes better decision making about the treatment of pain at any stage in the cancer trajectory. The Du Pens discuss barriers to effective implementation of the algorithm and suggest ways to promote its use by both hospital-based oncology professionals and community-based providers.

In the International Perspectives section of this issue of Innovations, Dr. Michael Zenz, an internationally recognized expert on pain management at BG University Clinic Bergmannsheilin Bochum, Germany, advocates an interdisciplinary approach to pain assessment, diagnosis and treatment from the first patient visit and a greater role for oncologists in the management of cancer pain.

We encourage readers to join the Du Pens and Dr. Zenz in an On-line Discussion about ways to implement pain treatment guidelines and measure their efficacy. The Du Pens will be available on-line for the next two weeks to respond to queries and mentor readers who may wish to use the Cancer Pain Algorithm in their own settings. Dr. Zenz also will be monitoring the discussion page to respond to readers' questions about how pain is being managed in Germany and other European countries.

Acknowledgement

I am very grateful to my colleague Judith Spross, RN, Ph.D. for her substantive contributions to this editorial.

References

1. Institute of Medicine. Committee on Care at the End of Life. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press, 1997, pp. 128-134. [Return to Editorial]

2. Foley K. Pain assessment and cancer pain syndromes. Chapter 9.2.2. In Oxford Textbook of Palliative Medicine. 2nd ed. Doyle D, Hanks GWC & MacDonald N (eds), 310-330. Oxford: Oxford University Press, 1998.[Return to Editorial]

3. Zenz M & Willweber-Strumpf A. Opiophobia and cancer pain Europe. Lancet. 1993;341:1075-6.[Return to Editorial]

4. Gordon DB. Critical pathways: A road to institutionalizing pain management. Journal of Pain and Symptom Management. 1996;11(4):252-259. [Return to Editorial]

5. Spross J. The Influence of Selected Societal, Institutional, and Individual Factors on Nurses' and Physicians' Pain Management Knowledge. (Ph.D. diss., Boston College, 1999).[Return to Editorial]

6. Foley op. cit. [Return to Editorial]

7. Institute of Medicine, op. cit., pp. 83-84.[Return to Editorial]

8. Max M. Improving outcomes of analgesic treatment: Is education enough? Annals of Internal Medicine. 1990; 113:885-889.[Return to Editorial]

9. Bookbinder M, Coyle N, Kiss M, et al. Implementing national standards for cancer pain management: Program model and evaluation. Journal of Pain and Symptom Management 1996,12(6):334-347.[Return to Editorial]

10. Du Pen SL, Du Pen AR, Polissar N, et al. Implementing guidelines for cancer pain management: Results of a randomized controlled clinical trial. Journal of Clinical Oncology. 1999, 17(1): 361-370.[Return to Editorial]

11. American Pain Society. Quality improvement guidelines for the treatment of acute and cancer pain. Journal of the American Medical Association. 1995, 274(23):1874-1880.[Return to Editorial]

12. Agency for Health Care Policy and Research (US DHHS, PHS). Clinical Practice Guideline Number 9: Management of Cancer Pain. Rockville. MD: AHCPR Publication No. 94-0592. 1994.[Return to Editorial]

13. Oncology Nursing Society. Position statement: Cancer pain management. Oncology Nursing Forum. 1998, 25(5):817-818. [Return to Editorial]

14. See: http://painconsult.com/MainPages/PatientLearning/
NewsStand/Articles/JCAHO.html[Return to Editorial]

15. Cancer Pain Release. 1997;10(1): 5-8[Return to Editorial]

16. Besner GF & Rapin, C-H. The hospital- Creating a pain-free environment: A program to improve pain control in hospitalized patients. Journal of Palliative Care. 1993,9(1):51-52.[Return to Editorial]

17. Foley KM. The World Health Organization Program in Cancer Pain Relief and Palliative Care. In Proceedings of the 7th World Congress on Pain: Progress in Pain Research and Management. Vol 2, edited by GI Gebhart, DL Hammond & TS Jensen, 59-74. Seattle, WA: IASP Press, 1994.[Return to Editorial]

18. World Health Organization. Cancer Pain Relief - Second Edition. Geneva, Switzerland: World Health Organization, 1996. [Return to Editorial]

19. World Health Organization. Cancer Pain Relief and Palliative Care. Geneva, Switzerland: World Health Organization, 1990. [Return to Editorial]

20. Du Pen SL, Du Pen AR, Polissar N, et al. op. cit. [Return to Editorial]