Published Online November 26, 2008

A pain-free death
Fiona Hicks* and Elizabeth Rees
Department of Palliative Care, Leeds Teaching Hospitals Trust, UK

Background: The time around a patients death is often lled with sadness, but good medical and nursing care can provide comfort to patients and their carers at this critical time. For many, a pain-free death is a priority although there are other aspects to providing good care at the end of life. Honest, open discussion with patients and carers about their wishes is an essential prerequisite to individualized care. Sources of data: Relevant literature was reviewed with regards to policy, education and delivery of end of life care. Areas of agreement: Pain management must be tailored to the individual with due regard to the route of analgesic administration in those unable to swallow, and consideration to the other circumstances surrounding a persons care. All staff caring for dying patients should address pain as a priority in managing end of life care, to promote the best possible death for patients and prevent undue distress for carers and staff. Areas of controversy: This review has approached patient care at the end of life within current UK legislation, outlining what can be done to promote a painfree death. Debate continues about the role of euthanasia within end of life care and the use of analgesics and sedatives in pain management in terminal care. Growing points: There is a range of tools available to help staff to care for dying patients, such as the Liverpool Care Pathway (LCP) for the Dying. It is most effective when introduced as part of a wider system of staff education in relation to terminal care.
Accepted: November 4, 2008 *Correspondence to: Dr F. Hicks, Palliative Care Team, First Floor, Robert Ogden Centre, St James University Hospital, Leeds LS9 7TF, UK. E-mail: fiona.hicks@ leedsth.nhs.uk

Areas timely for developing research: Research into care of the dying will continue to be challenging. Priorities include; whether the use of tools such as the LCP improve the care patients receive, and the development of routine outcome measures including validated reports from patients and proxies.

Keywords: pain/terminal care/end of life care/review

British Medical Bulletin 2008; 88: 2341 DOI:10.1093/bmb/ldn043

& The Authors 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

F. Hicks and E. Rees

Introduction
How people die remains in the memory of those who live on, said Dame Cicely Saunders, founder of the modern hospice movement. The importance that we should attach to the care of dying patients was emphasized by Sir Nigel Crisp, Chief Executive of the National Health Service in the UK when he said Better care for the dying should become a touchstone for success in modernising the NHS.1 Health-care professionals only have one chance to get it right and ensure dying patients receive excellent terminal care and loved ones are not left with unnecessary traumatic memories. It is important we continue to aim to improve the care of the dying to the level of the best.2 This was re-emphasized by Professor Mike Richards, National Clinical Director for Cancer who wrote, How we care for the dying is an indicator of how we care for all sick and vulnerable people. It is a measure of society as a whole and it is a litmus test for health and social care services.3

Diagnosing dying

In order to be able to care appropriately for dying patients, a diagnosis that the patient is dying needs to be made. Making such a diagnosis is an important but difficult clinical skill that requires experience in the field and recognition of the complexity of such decisions. There can be understandable reluctance from staff to make the diagnosis if there is an element of uncertainty as to whether the patients condition may improve or if the cause for the deterioration is unknown. Such uncertainty should be communicated with the patient and their families in order to maintain a good relationship and prevent false hope being given. In the context of advanced illness, signs that a patient is dying can include: a change in colour, gauntness, diminished oral intake, difficulty in taking oral medications, temperature change in the extremities, poor concentration, disorientation, increasing drowsiness, being bedbound and a reducing conscious level.

Pain in terminal illness

Pain is the most common and the most feared symptom of advanced malignant disease,4 and a fear of dying in pain is common regardless of diagnosis. Although we know how many people die each year in the UK according to age and cause of death, we do not routinely record how many patients actually die in pain. It has been widely reported
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that terminally ill patients experience substantial pain although the prevalence varies between studies.5 In 2004 in England and Wales, there were over 500,000 deaths of which 26% were due to cancer, 37% circulatory disease, 14% respiratory disease, 3% diseases of the nervous system and 20% from other causes.6 Most deaths occur in NHS hospitals, with  18% dying at home, 17% in care homes, 4% in hospices and 3% elsewhere.3 In a recent review, pain was reported to be prevalent in the majority of patients with an advanced illness: 35 96% in cancer patients, 63 80% in AIDS patients, 41 77% in heart diseases, 34 77% in chronic obstructive pulmonary diseases and 47 50% in renal diseases.7 The high prevalence of pain in the dying could indicate poor quality of care at the end of life, although this should be viewed with caution, as pain control alone is not the only quality indicator for a good death. Addington-Hall8 reported the differences in pain control in the last 3 days of life according to bereaved relatives of cancer patients and found that pain was completely controlled in over 70% of patients in hospices, . 60% at home and in , 50% of patients in hospitals. There is clearly room for improvement in all settings but particularly within the acute hospitals.

A Good Death

Characteristics of a good death have been described by both patients and health-care professionals as being pain-free/adequately symptom controlled, respectively.9 The consequences of a bad death because of poor pain control or other issues can result in a complicated grieving process and can cause an increased risk of morbidity and mortality for carers in the bereavement phase.10 Staff groups can be left with feelings of failure if they have been unable to control patients symptoms, leading to increased levels of stress and a feeling of guilt.

Cultural aspects of care at the end of life

It is important to understand that people hold different views on what constitutes a good death.11 For many people brought up in western secular cultures or Judeo-Christian traditions, a pain-free death is an important component of a good death. This may not be the case in other traditions such as Buddhism, where an emphasis on clarity of mind may be more important or some Muslim traditions, where pain may be seen as a punishment to be endured.12 There is no substitute for taking time to find out from patients and families about their
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beliefs and priorities for end of life care as assumptions based solely on a general knowledge of culture and religion are often inaccurate.13

Myths about morphine

Nearly all health-care professionals will be involved in caring for a person in the last days of life at some point in their career although it may only happen occasionally for some. This can be a challenging part of their role which is often compounded by myths concerning morphine. Fears about the use of morphine at the end of life remain prevalent among patients and staff.5,14 For example, some people think that the use of morphine always causes tolerance and addiction or that as death approaches doctors may escalate the dose in order to hasten death. These misconceptions can lead to difficulties in treating pain due to a resistance by patients and carers to accept the appropriate usage and required doses of morphine. Portenoy et al. 15 addressed this in a survey of opioid use at the end of life in a hospice population and concluded that opioid doses titrated over time do not induce sleep or stop patients breathing. It is important that health-care professionals are confident in this knowledge in order to be able to discuss such issues with patients and carers.

Pain in children

Pain management in children at the end of life follows many of the same principles, but is not the subject of this review. Further guidance on prescribing can be found in the BNF for children.16

Assessment of pain
An essential prerequisite to good pain management in any context is thorough and accurate pain assessment. Dying patients may have several different sources of pain. Where possible, each should be assessed, as treatment tailored to the sites and causes of pain is most likely to be effective.

Changes in pain at the end of life

The type of pain experienced by patients at the end of life varies according to the underlying diagnosis. Early attention to the diagnosis of pain syndromes during the palliative phase of a patients life will
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help with pain management during the dying phase, as the causes of the pain will have already been established. Patients and their doctors often associate a diagnosis of cancer with an expectation of pain, but patients with other terminal illnesses, such as chronic respiratory diseases, report similar incidences.17 There is a body of evidence to suggest that under-treatment of pain in patients with cancer and nonmalignant disease remains a significant issue.5 As patients become increasingly frail towards the end of life, they may lose muscle mass and become less mobile which may cause musculoskeletal pains to become more prevalent. Pain from pressure areas may also become troublesome, even with excellent nursing management. Conversely, some pains may improve, especially those related to movement and exertion, such as angina or pain from osteoporotic fractures.

Types of pain
Nociceptive pain

Nociceptive pain occurs when there is mechanical, thermal or chemical stimulation of peripheral nociceptors in skin, muscle, bone or connective tissue. It is usually well localized to the area of damage. Examples include pain from pressure sores, arthritic joints or bone metastases.
Neuropathic pain

Neuropathic pain is caused by direct damage to or disturbance of the peripheral or central nervous system. It is often described as shooting or burning and may be well or poorly localized with associated areas of decreased or abnormal sensation. Examples include compression or invasion of peripheral nerves by cancer, or compression due to vertebral collapse.
Visceral pain

Visceral pain is usually a mixture of neuropathic and nociceptive aetiologies caused by stimulation of nerve plexuses in the thoracic, abdominal or pelvic viscera. This may be due to stretch or compression by tumour masses, intestinal obstruction/constipation. It is usually poorly localized.

Taking a pain history

Experience of pain is entirely subjective. As such, the pain history is the primary source of information. In patients who have and retain the cognitive ability and verbal skill to describe their pain during the terminal
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phase of their illness, a detailed history can be taken. This should include the site of pain, radiation, character, duration, severity, precipitating and relieving factors. A medication history is also invaluable, outlining previously effective or ineffective treatments and associated side-effects. An exploration of the patients understanding of the cause of their pain and their wishes for treatment can help to guide future management. Special care should be taken for those with intellectual disability, as described in a review by Tuffrey-Wijne and McEnhill18 and the National Council for Palliative Care,19 and in the elderly.20
Use of care-givers as proxies

In the last days of life, it is not uncommon for patients to become unable to verbalize their pain. This may be due to a falling level of consciousness or development of delirium. Prior knowledge of the patient, their condition and previous pain can be very helpful. If a patient is admitted to hospital or hospice at this stage, it is essential to get a good history from their previous care-givers, such as their GP, district nurse, nursing home staff and/or family members. Several studies have looked at the relationship of the assessment of pain and other symptoms between the patient, family members and doctors to see if caregivers are reliable proxies in this context. Unfortunately, although the correlation on incidence of symptoms is good, in the assessment of severity of symptoms it is poor.21 23

Assessment tools

There are many tools that have been evaluated in the assessment of pain, such as visual analogue scores, simple numerical rating scales, verbal rating scales, body charts and questionnaires such as the Brief Pain Inventory.24 These are of limited value in the last days of life as patients become more fatigued and less able to talk, although the use of simple numerical (010) or verbal (none, mild, moderate or severe) scales can be used to assess the effectiveness of treatment.

Behavioural assessment of pain or distress

For patients who are unable verbally to express or describe their pain, observation of behaviours must be relied upon. Skilled, multiprofessional assessment with input from close family and friends can be very helpful. Non-verbal cues such as crying or grimacing however, cannot distinguish pain from other causes of distress. There are tools that have been developed to help in such situations.25,26 Treatment
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may need to be empirical with attentive review of its effectiveness on the behaviours exhibited. Clear documentation of this is essential for continuity of care among staff members.

Physical examination

For patients in the last stages of life, a routine, full examination may not be necessary, but examination focussed on finding the cause of pain can inform management. This should be done on all patients, asking patients where possible to report areas of pain and tenderness, but also looking for facial grimacing and withdrawal responses in those patients unable to vocalize. Special attention should be given to assessment of pain from pressure areas, pain on movement and the patients mouth, which may become dry and sore.

Investigations

Most dying patients will not need investigation before managing their pain.10 Many will have had previous X-rays and scans that may reveal the likely cause of their current pain and these do not need repeating.

Pain thresholds

Co-existent symptoms, such as nausea and vomiting, or fear and anxiety, may lower a patients ability to cope with their pain. Good end of life care should address the whole person, in the context of their friends and family, rather than treating physical pain in isolation.27

Pain management
Towards the end of life priorities for treatment and care often change. Although patients may be willing to cope with the side-effects of treatment while hoping for cure or prolongation of life, when the dying phase is reached, treatment should largely be aimed at immediate comfort.28 Good pain management is therefore a priority for most. Interventional methods of analgesia, such as nerve blocking techniques, radiotherapy or orthopaedic interventions are rarely appropriate at this stage, although where possible treatment should be directed at the cause. This may include immobilization of a fractured limb or painful joint, pressure relieving mattresses to reduce incident pain caused by turning and good mouth care.
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In the last days of life, many patients become unable to swallow their analgesics. For those with enteral feeding tubes, their usual drugs may be continued but for most, alternative methods of administration are needed. There are many formulations for convenient parenteral administration of analgesics for nociceptive, somatic and visceral pains, but options for the management of neuropathic pain are more limited.

Use of drugs beyond licence

As with much prescribing in palliative care, many of the drugs recommended for pain management at the end of life are used outside their product licence. Care should be taken to ensure that such prescribing is done in accordance with published best practice and that patients are appropriately informed in discussions on their medical treatment. This has been addressed by a position statement from the Association for Palliative Medicine of Great Britain and Ireland and the British Pain Society.29

General principles of pain management for dying patients

The plan for terminal care should be discussed with patients and their families/carers wherever possible. Drugs not directly needed to promote comfort may be discontinued.30 Expressed priorities for care should be understood and recorded. For most this will include a pain-free death.9 Pain in dying patients tends to be constant and therefore requires regular or continuous analgesia. Exacerbations of pain on movement and turning should be anticipated and managed pre-emptively with supplementary analgesia. In addition, pain may escalate as death approaches and prescriptions should include as required breakthrough analgesics to enable nursing staff to respond promptly should pain occur. As a general rule, the dose of breakthrough medication should be equivalent to one-sixth of the daily around the clock opioid dose. For example, a patient receiving a continuous infusion of 30 mg of subcutaneous morphine over 24 h would require a breakthrough dose of 5 mg.

Patients with good pain control, now unable to take oral medication
Patients not on opioids

Many patients, especially those dying from non-malignant disease may have little background pain. They may be taking simple analgesics such
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as paracetamol, or nothing at all. A prescription for a small dose of opioid, such as morphine 2.5 5 mg as required,31 would allow prompt treatment should pain occur, but may not need to be used (Fig. 1).
Patients already on opioids

For patient on opioids, it can be safely assumed that their current dose should be continued in some form. If their pain is managed with a transdermal preparation, such as fentanyl or buprenorphine, this should not be altered.

Fig. 1 Flowchart for the management of pain in patients unable to take oral medication at the end of life.

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For those taking oral opioids, an alternative route is needed and subcutaneous medication is usually preferred. It is advisable to continue the type of oral opioid prescribed and convert it to subcutaneous use as this is less likely to cause loss of pain control as the change is made. Thus, patients on oral morphine should be prescribed a continuous infusion of subcutaneous morphine or diamorphine (Fig. 1). Those on oral oxycodone should be prescribed a subcutaneous infusion of oxycodone. All opioids are more potent through the subcutaneous route as they undergo first pass metabolism in the liver. For dose equivalents, a standard text such as the BNF or Palliative Care Formulary should be consulted.32,33 This is not an exact science as the bioavailabilty of oral opioids, especially morphine, shows a large inter-individual variation. For patients on large doses, conservative conversions may be used for the continuous infusion, supplemented by subcutaneous bolus doses of one-sixth of the daily dose as required. Advice from specialists in pain or palliative care should be sought. If more than two extra doses are required in a 24 h period, they should be added to the infusion to ensure good, continuous pain control and the breakthrough prescription adjusted accordingly.
Neuropathic pain

Two of the most common co-analgesics used for neuropathic pain, gabapentin and amitriptyline cannot be given parenterally, although carbamazepine can be given by suppository and dexamethasone by subcutaneous infusion. For many patients who are now less mobile, neuropathic pain is adequately managed with standard opioids alone. For those taking gabapentin or amitriptyline, a decision is needed as to whether neuropathic pain has been of sufficient severity to require continued medication during the dying phase. Two drugs that have been used by subcutaneous infusion in this situation are clonazepam34 or ketamine,35 although the evidence base is not extensive and these are best used on specialist advice. Methadone has also been shown to be effective for neuropathic pain,36 but its complex pharmacokinetics make it unsuitable for non-specialist use in this context.
Musculoskeletal pain

Musculoskeletal pain may increase or diminish during the dying phase as patients are less mobile, although attention must be paid to pressure area care and pain on movement. For some, a continuous infusion of opioids will be sufficient, but for those with severe pain, alternatives may be needed. Diclofenac may be given in suppository form if that is acceptable to the patient. It can be irritant if used subcutaneously by infusion and ketorolac may be the preferred alternative. Both should be
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used only on specialist advice as side-effects of renal impairment and peptic ulceration may outweigh the analgesic benefit achieved.37

Patients with new or uncontrolled pain

Establishing the cause of any new pains is important before embarking on management as interventions such as positioning or providing spiritual support may be more effective than escalating analgesia.
Patients not on opioids

Patients not previously taking opioids should be started on a low dose given subcutaneously as required until comfort is achieved. Morphine is usually the drug of choice (Fig. 1). Once pain relief is achieved, this can be converted to a continuous infusion of equivalent dose over 24 h.
Patients already on opioids

For patients already taking opioids, an assessment should be made as to whether there is a problem with absorption of their usual dose (e.g. vomiting) or whether they have escalating pain. For the former, a straight conversion to a subcutaneous infusion will suffice, although a bolus dose equivalent to one-sixth of the daily dose should be given in addition to gain immediate control. For patients with escalating pain, bolus doses of opioids will be needed as required until pain control is achieved. It is usual to increase the dose by increments of 1/4 to 1/3 each time. When pain control is achieved, a syringe driver should be set up with an infusion containing the equivalent 24 h dose used. In such difficult circumstances, specialist advice may be required.
Neuropathic pain

New neuropathic pain is unusual in the dying phase but if it has been difficult to control before, it can continue to cause a management problem. The drugs listed before may be tried but this situation is likely to require specialist advice.
Musculoskeletal pain

New musculoskeletal pain is not unusual in this context as muscle wasting can cause strain on joints and immobility can lead to stiffness. Good nursing care is essential. Topical NSAIDs such as piroxicam gel can be effective.
Pain from wounds

Skin breakdown in pressure areas and surgical wounds can cause substantial local soreness. When wound healing is unlikely, the pain from
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such areas can be well managed with topical morphine gel applied under a non-adhesive, occlusive dressing.38

Special considerations on route of administration

Nursing homes

Although the gold standard for pain control in dying patients who need opioids is often seen as providing analgesics as a continuous subcutaneous infusion through a syringe driver, this may not always be the best or safest method. Some nursing homes who do not have frequent use for these devices, may struggle to keep their staff appropriately trained in their use. As such, it may be preferable to use analgesics in the form of transdermal patches, suppositories or regular 4 hourly injections.
Patients own home

Where there may be concerns about patient safety or diversion of drugs in the community, alternative routes of analgesic provision may be required.

Patients on high dose opioids

Patients requiring substantial doses of subcutaneous opioids may encounter problems with the volume of infusion needed for subcutaneous use and bolus doses. This is particularly true for oxycodone and morphine. Diamorphine is available for use in the UK and may be preferable because of its high solubility, but specialist advice may be required before conversion.

Patients with organ failure

Many patients suffer from some degree of organ failure towards the end of life. Renal failure has the most significance in practice. Morphine and diamorphine are converted to active metabolites that are renally excreted and therefore accumulate in renal failure causing toxicity. This may occur with only slightly raised creatinine and care should be taken in this population. Codeine should be avoided as it is converted to morphine and accumulates in the same way. In practice, generalists usually manage this situation by reducing the morphine dose and prolonging the dosing intervals. Oxycodone may be safer, but requires dose reduction and should be avoided in severe renal failure.39
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Buprenorphine, fentanyl or alfentanil40 44 may be used safely but specialist input is advised.

Management of opioid side-effects

Respiratory depression

For patients who have been on long-term opioids, respiratory depression is not a problem, except in the case of overdose. Careful dose titration, especially when switching between opioid drugs and preparations should avoid respiratory depression. It should be noted that drowsiness usually increases during the dying phase and breathing may become slower and more erratic. If opioid overdose is suspected, conservative management is usually all that is necessary, reducing or omitting the next dose of opioid, or stopping the infusion and restarting it at a lower dose. Naloxone should only be considered if the respiratory rate is , 8/min, the patient is barely rousable and/or cyanosed and the cause is thought to be opioid related rather than the underlying terminal condition. Use of naloxone may precipitate severe pain and agitation.45
Constipation

Constipation is almost universal in patients taking opioids and those on long-term opioids will have been taking aperients. When they become unable to swallow, it is likely that time is short and that symptomatic constipation will not arise. If symptomatic constipation is suspected, rectal measures should be considered.
Nausea and vomiting

For patients new to opioids,  30% will suffer from nausea and vomiting. Many others may have the symptom related to their underlying condition. Prescribing antiemetics as required in anticipation of this and including them in the subcutaneous infusion for those affected is therefore advised. A broad spectrum antiemetic such as Levomepromazine 6.25 mg once daily, repeated as necessary up to a dose of 25 mg/day would be a good first choice.
Myoclonic jerks

Myoclonic jerks are not uncommon in dying patients and may reflect accumulation of excitatory opioid metabolites, especially in patients with renal failure on morphine or diamorphine. This may be distressing for patients and families and a switch to an alternative opioid may be necessary.
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Terminal agitation

Terminal agitation describes the observed behaviour of a patient who is no longer able to verbalize the cause of their distress. It is likely to be multifactorial. The causes should be sought where possible and reversed. Delirium is common in dying patients and may be distressing. It is best treated with Haloperidol, starting at 1.5 mg/day, either as a single injection or as part of a subcutaneous infusion. For some patients, the cause cannot be defined or reversed and sedation is necessary, as described in Fig. 2.

Use of tools to improve end of life care

Improving the care of the dying has been highlighted as a key priority in a number of national guidance publications in the UK over recent years. The publication of a National End of Life Strategy in 20083 highlights the importance the Government has placed on improving the care that the dying receives within our society. Patients dying from illnesses other than cancer have often been referred to as the disadvantaged dying. However, over the last 10 years there has been a move towards ensuring that all patients regardless of diagnosis receive good quality care in a place of their choice at the end of life. This is reflected in the numbers of National Service Frameworks46 48 published which highlight the need for good terminal care. Within the NICE Guidance on Supportive and Palliative Care49 it is acknowledged that care given to dying patients in hospitals, at home and care homes can be below standard. The NICE guidance addressed this by suggesting that, Provider organisations should ensure that managed systems to ensure best practice in the care of the dying are implemented by all multi-disciplinary teams.49 One such way to undertake this is suggested to be the implementation of the LCP for the Dying.

The Liverpool Care Pathway

The LCP50 has been developed to transfer the hospice model of care into the acute hospital setting, and was primarily developed for use with dying cancer patients. It has now been adapted for use with all terminal illnesses. It is a multi-professional document which guides staff on best practice for end of life care when a diagnosis of dying has been made (Table 1). The LCP has become an accepted and almost standard tool for care of the dying in hospitals. It is also widely used for patients at home, hospice and care homes. It incorporates guidance on all areas of care,
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Fig. 2 Flowchart for the management of terminal restlessness.

including comfort measures, anticipatory prescribing (Figs 1 and 2) discontinuation of inappropriate interventions, psychological care, spiritual care and family support. The LCP empowers generic health-care workers to provide optimal care to dying patients.51 The LCP advocates that all patients are prescribed analgesia preemptively regardless of whether they are experiencing pain. This enables the nursing staff to act autonomously and deliver care promptly according
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Table 1 The multi-professional team have agreed that the patient is dying.
Name......................... Signature ...................Date......................... In all cases the following four statements must have been agreed to by a senior member of the patients medical team and the staff nurse co-ordinating the patients care

1. The patient has a known irreversible life-threatening illness of any aetiology. 2. Reversible causes for the patients current deterioration have been considered and appropriately managed. 3. Intensive care and resuscitation have been discussed by the team and have been deemed to be inappropriate for the patient. 4. There is day by day deterioration.

to a change in a patients condition. For patients who are already receiving analgesic regimens it recommends conversion to an injectable form for use when the patient is unable to take medications orally.

Gold standards framework and preferred priorities for care

Advance care planning forms part of the Gold Standards Framework (GSF) which is a model aimed at improving the communication between palliative care patients, their families and health-care professionals to ensure patients wishes are identified and planned for in advance.52 This includes the provision of medications for pain control in the event of a patient developing pain at home and discussions with patients about where they would prefer to be cared for at the end of life.53

Education

Failure to recognize or acknowledge that a patient is dying can hinder good terminal care. This can be due to a lack of education about care of the dying and assessment of symptoms at the end of life.49 Within the National End of Life Strategy 2008, a need for education for all staff groups caring for the dying has been highlighted as a national priority. The NHS Knowledge and Skills framework (KSF)54 2004 clearly defines and describes the skills and knowledge that NHS staff should use in their work in order to deliver a high quality of care. The NHS KSF has been developed to ensure services are developed to meet the needs of users and the public better by investing in the development of all members of staff. The framework encourages staff to develop
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knowledge relevant to their post continually throughout their career and is assessed annually in an appraisal according to the standards agreed for each individual post. The KSF does not apply to medical staff, but recognition of dying and management of the terminally ill patient are included in the Foundation Competencies for all doctors in the UK. The Royal College of Physicians has emphasized the need for this to be enhanced for doctors of all grades and specialties, in their report Palliative Care Services, Meeting the Needs of Patients.55

Conclusion
Pain management is an important part of good terminal care. Systematic education for staff caring for patients at the end of life, alongside the use of recognized care pathways and access to specialist advice and intervention, should make this possible for most patients. Providing the care to enable a good death can be a highly rewarding part of medical practice and provides the backdrop to enable the bereaved to grieve appropriately.

References
1 2 3 4 5 6 7 Department of Health (2003) End of Life Care Programme, available at: www.endoflifecare. nhs.uk/eolc Department of Health (2000) The NHS Cancer Plan: A Plan for Investment, A Plan for Reform, available at: www.dh.gov.uk Department of Health (2008) End of life care strategy. Promoting High Quality Care For All Adults At The End of Life. London, available at: www.dh.gov.uk Stone P, Rees E, Hardy JR (2001) End of life care in patients with malignant disease. Eur J Cancer, 37, 10701075. Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ (2001) Understanding the experience of pain in terminally ill patients. Lancet, 357, 13111314. Office for National Statistics (2006), available at: www.statistics.org.uk Solano JP, Gomes B, Higginson IJ (2006) A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage, 31, 58 68. Addington-Hall, available at: www.wun.ac.uk/wunnursing/seminars/2006 Payne SA, Langley-Evans A, Hillier R (1996) Perceptions of a good death: a comparative study of the views of hospice staff and patients. Palliat Med 10, 307312. National Council for Palliative Care (2006) Changing Gear - Guidelines for Managing the Last Days of Life in Adults, available at: www.ncpc.org.uk Steinhauser KE, Christakis NA, Clipp EC et al. (2000) Factors considered important at the end of life by patients, family, physicians and other care providers. JAMA, 284, 2476 2482. Firth S (2001) Wider Horizons. Care of the dying in a multicultural society. National Council for Hospice and Specialist Palliative Care Services. Gatrad AR, Brown E, Notta H, Sheikh A (2003) Palliative care needs of minorities. Br Med J, 327, 176177.

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