Guidelines for a Palliative Approach in Residential Aged Care

Dame Cicely Saunders first described the concept of ‘total pain’, articulating the view that
pain is not limited to physical distress but also includes psychological, social and spiritual
elements. [121] Recognition of an emotional and psychological component to pain points to the
need for a multidimensional assessment for effective pain management. [122]
Although the notion of total pain is accepted when using a palliative approach, this section
of the Guidelines will focus on physical pain only. However, it is important to recognise
that pain in any of the domains (spiritual, social, etc) will impact on the other domains of
pain. Attention to these dimensions will be discussed further in the relevant sections of the
Guidelines (see Chapters 7, ‘Psychological support’, 9, ‘Social support, intimacy and sexuality’
and 11, ‘Cultural issues’).
6.2.1 Incidence of pain in residents of RACFs
Studies have found that older persons may experience more pain than younger persons, yet are
less likely to complain [123] (Level IV). Pain management in RACFs does not appear to be well
addressed. One US study found that nearly one-sixth of all residents in RACFs are in daily pain
and, when reviewed 60 to 180 days later, two-thirds were again reported to have been in daily
pain (either moderate or excruciating) [124] (Level IV). A further study found that residents over
85 years of age were more likely to receive no analgesia than younger residents [123] (Level IV).
A similar finding regarding pain was also found in an Australian study, which reported that
22% of residents who stated that they had pain had no medication administration recorded in
their case notes, and 16% did not have analgesics ordered [125] (Level QE).
One reason for this inattention to pain may be inadequate assessment tools, especially for those
with advanced dementia who cannot articulate their care needs [91] (Level IV). Poor care practices
and difficulties with prescribing adequate and appropriate medication, especially in some rural
and remote regions, have also been cited as possible reasons for under-treatment of pain. However,
there is evidence indicating that residents enrolled with a specialised palliative team have better
analgesic management of daily pain than residents who are not [126] (Level III-3).
The following story illustrates the benefits of a palliative approach to pain for a resident.
Vignette 6: Mr Johnson’s story
A month before his 100th birthday, Mr Johnson had fallen and fractured his hip. He
underwent surgery but became virtually chair-bound. Mr Johnson developed a pressure
area on his leg that quickly deteriorated, leading to a necrotic and heavily infected foot
which was extremely painful. He was well aware of his circumstances and, after being
advised of the treatment options available, decided that rather than amputation he would
prefer a palliative approach. This required a specific dressing management routine that
addressed the pain and the smell, together with a regulated pain management regimen
to give him comfort without sedation. Mr Johnson was able to participate in and enjoy his
centennial birthday celebrations.
72 Guidelines for a Palliative Approach in Residential Aged Care