Article Content


Pain is a common symptom in most progressive, life-limiting illnesses. Pain is defined as "an unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."1 This definition underscores the multidimensional nature of pain, which has an impact on all facets of life, including the emotional and spiritual dimensions. Pain has also been defined as whatever the experiencing person says it is and existing whenever he/she says it does. 2


As a major symptom for adults and children with cancer, pain has been well-documented. 1,3-6 Approximately three fourths of people with advanced cancer experience pain. 7 Pain is also present in many advanced illnesses including heart disease, dementia, and stroke. Prolonged bedrest, pressure ulcers, bowel obstruction, and chronic illnesses (eg, arthritis) all contribute to pain in advanced illness. Additional factors such as anxiety, depression, and spiritual distress influence and are influenced by the experience of pain. Pain can cause profound suffering and impaired quality of life.


Unrelieved pain remains a serious health problem in the United States. Lack of knowledge by healthcare professionals, irrational fears of addiction, inadequate assessment, and a lack of access to opioids are among the more common reasons for under-treatment of pain. 1,6


As one of the most feared symptoms by those at the end of life, unrelieved pain can consume the attention and energy of those who are dying, and create an atmosphere of impotency and despair in their families and caregivers. 8,9 Pain and the emotional suffering it can create are often overwhelming for patients, families, and caregivers. Unrelieved pain can contribute to unnecessary suffering, as evidenced by sleep disturbances, hopelessness, loss of control, and impaired social interactions. Pain may actually hasten death by increasing physiological stress, decreasing mobility, contributing to pneumonia and thromboemboli. 10


Under-treatment of pain is more common in individuals who are unable to speak for themselves. 1 Populations that are particularly vulnerable include infants and children, the elderly, people who speak a different language or whose cultural background differs significantly from the clinician's, and those who are developmentally delayed, cognitively impaired, or severely, emotionally disturbed. 1,11,12 Special efforts must be taken to ensure adequate assessment and interventions for these populations.


Pharmacologic interventions remain the first-line treatment for unrelieved pain. Opioids are needed when pain does not respond to non-opioids alone. Analgesic guidelines are available through several organizations such as the American Pain Society, 1 American Geriatrics Society, 13 and the National Comprehensive Cancer Network. 14 Some clinicians, patients, and caregivers avoid opioids due to a fear of addiction. Clinicians, in particular, need to understand the difference between addiction, tolerance, and physical dependence. Fears of addiction should not prevent appropriate treatment of pain.


In addition to pharmacologic interventions, treatment should include nonpharmacological therapies. Massage, biofeedback, distraction, music therapy, and relaxation therapy are among the nonpharmacological approaches that have been shown to be effective in pain relief. 15



The Hospice and Palliative Nurses Association (HPNA) supports the provision of appropriate pain management for patients in all clinical settings. It is the position of the HPNA Board of Directors that:


* All people, including vulnerable populations such as infants, children, and the elderly, facing progressive, life-limiting illness have the right to optimal pain relief.


* All healthcare providers have the obligation to believe the patient's report of pain.


* Pain assessment and management should incorporate principles of cultural sensitivity as well as patients' values and beliefs.


* All healthcare professionals caring for the patients with progressive, life-threatening illness need to acquire and utilize current knowledge and skills to implement appropriate pain management.


* Healthcare organizations need to adopt policies and procedures that address the assessment, and pharmacologic and nonpharmacologic management of pain.


* Pain management should include, as appropriate, advanced technology.


* Pain assessments and management should be aligned with evidence-based practice.


* The need for regulatory control of opioids must be balanced with access to opioids for all patients who need them.


* Pain management should be part of education for all healthcare providers who are caring for patients with advanced, life-limiting illness.


* Healthcare professionals must advocate for their patients to ensure adequate pain relief.


* Uncontrolled pain should be considered an emergency with all healthcare professionals taking responsibility to provide relief.


* Patients have the right to participate actively in decisions about their pain management.


* Families should be supported in their efforts to observe and relieve pain when appropriate.


* Hospice and palliative care programs should share their knowledge of pain management concepts with others in their communities.


* Use of placeboes for pain management is inappropriate.




Addiction-a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. 16


Pain-an unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. 1


Physical dependence-a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. 16


Suffering-an individual and private experience characterized by a state of severe distress induced by loss of intactness of person or threat that the person believes will result in loss of his/her intactness related to physical pain, unrelieved symptoms, spiritual distress, depression or multiple losses. 17


Tolerance-a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. 16




1. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 4th ed. Glenview, Ill: Author; 1999. [Context Link]


2. McCaffery M. Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions. Los Angeles, Calif: UCLA Student Store; 1968. [Context Link]


3. Wolfe J, Grier HE, Klar N, et al. Symptoms and suffering at the end of life in children with cancer. N Engl J Med. 2000; 342:326-333. [Context Link]


4. McMillan SC, Small BJ. Symptom distress and quality of life in patients with cancer newly admitted to hospice home care. Oncol Nurs Forum. 2002; 29:1421-1428. [Context Link]


5. Meier DE. United States: overview of cancer pain and palliative care. J Pain Symptom Management. 2002; 24:265-69. [Context Link]


6. Foley KM. Pain assessment and cancer pain syndromes. In: Doyle D, Hanks G, MacDonald N eds. Oxford Textbook of Palliative Medicine. 2nd ed. New York, NY: Oxford University Press; 1998:310-331. [Context Link]


7. Cherny NE. Cancer pain: principles of assessment and syndromes. In: Berger AM, Portenoy RK, Weissman DE, eds. Principles and Practice of Palliative Care and Supportive Oncology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002:3-52. [Context Link]


8. Ng K, vonGunten CF. Symptoms and attitudes of 100 consecutive patients admitted to an acute hospice/palliative care unit. J Pain Symptom Manage. 1998; 16:307-316. [Context Link]


9. Coyle N, Layman-Goldstein M. Pain assessment and management in palliative care. In: Matzo ML, Sherman DW, eds. Palliative Care Nursing. New York: Springer; 2001:362-486. [Context Link]


10. Paice JA, Fine PG. Pain at the end of life. In: Ferrell B, Coyle N eds. Textbook of Palliative Nursing. New York: Oxford University Press; 2001:76-90. [Context Link]


11. Pasero C. Pain assessment in infants and young children: neonates. Am J Nurs. 2002; 8:61-65. [Context Link]


12. Kaasalainen S, Middleton J, Knezacec S, et al. Pain and cognitive status in the institutionalized elderly: perceptions and interventions. J Gerontol Nurs. 1998; 24:24-31. [Context Link]


13. American Geriatrics Society. The management of persistent pain in older persons. J Am Geriatr Soc. 2002; 50(6 suppl):S205-S224. [Context Link]


14. Benedetti C, Brock C, Cleeland C, and National Comprehensive Cancer Network. NCCN Practice Guidelines for Cancer Pain. Oncology. 2000; 14:135-150. [Context Link]


15. McCaffery M, Pasero C. Practical nondrug approaches to pain. In: McCaffery M, Pasero C eds. Pain: Clinical Manual. 2nd ed. St Louis: Mosby; 1999:399-427. [Context Link]


16. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. Available at: Accessed June 29, 2003. [Context Link]


17. Cassell EJ. The relationship between pain and suffering. Adv Pain Res Ther. 1989; 11:63. [Context Link]