Managing Pain at the End of Life: Medicines and Beyond
Navigating pain in the last phase of life is both a clinical and deeply human challenge. For people approaching the end of life, pain can come from a variety of causes – such as the underlying illness, treatment side effects, or other conditions that develop as health declines. It is not just a physical experience but often tied to emotional and psychological distress, which can make it feel more intense. In the UK, palliative care focuses on the holistic needs of the individual and their family, aiming to relieve suffering and promote comfort through a combination of evidence-based medical treatments and compassionate, non-pharmacological support. Good pain management helps people maintain dignity, connection with loved ones, and the best possible quality of life in their final days.
Pharmacological Approaches: Medicines in Palliative Care
- Individualised Treatment Planning
- Clinical guidance from NICE emphasises reviewing and stopping medications that no longer offer symptom relief or may cause harm, while focusing treatment on comfort and patient preferences NICE.
- Selecting the Right Medication and Route
- Opioids — Morphine remains the cornerstone for moderate to severe pain. Alternatives like oxycodone or fentanyl may be used, especially in cases of kidney impairment.
- Routes of administration — When swallowing is difficult, subcutaneous injections or syringe pumps (continuous infusions) ensure consistent relief. Other options include transdermal patches or sublingual methods.
- Managing Breakthrough Pain
- Sudden spikes in pain, known as “breakthrough pain,” are managed with fast-acting opioids such as Oramorph, Sevredol, or oxycodone, given on an as-needed basis to supplement background medication.
- Titration and Regular Monitoring
- Begin with the lowest effective dose and carefully adjust as needed. Daily reassessment helps maintain comfort, minimise side effects like sedation or constipation, and ensure symptom control remains appropriate .
- Specialist Input
- If symptoms persist despite treatment or if side effects become problematic, referral to a specialist palliative care team is essential.
Non-Pharmacological Methods: Alleviating Total Pain
Pain at the end of life is often a mix of physical discomfort and emotional, spiritual, or psychological distress—a concept known as “total pain.” Addressing only the physical component may leave suffering untreated.
Here are supportive measures that can make a real difference:
- Repositioning and Simple Comfort Measures
- Small adjustments—like helping with repositioning to reduce pressure or applying a fan to ease breathlessness—can bring significant relief.
- Physical Therapies
- Tools such as TENS (transcutaneous electrical nerve stimulation), massage, or even palliative radiotherapy for bone pain can provide relief; while rigorous evidence is limited, many people find them helpful.
- Mindfulness and Relaxation Techniques
- Programs like Mindfulness-Based Pain Management (MBPM), rooted in mindfulness and self-compassion, support people living with chronic illness and can also be adapted to end-of-life contexts.
- Complementary Therapies
- Interventions such as music therapy, aromatherapy, acupuncture, and hypnotherapy may ease emotional and physical tension—even if evidence is modest, they offer low-risk comfort.
- Spiritual and Pastoral Care
- The WHO and UK palliative frameworks emphasise holistic care—including spiritual support—as vital to addressing suffering beyond physical pain.
Integrated Care: A Balanced Approach
Combining medicines with non-medical strategies offers the most compassionate and effective path to pain relief. This dual approach ensures the person’s physical symptoms are managed, while also honoring emotional, spiritual, and psychological needs.