Guidelines for a Palliative Approach in Residential Aged Care

6.2.2 Barriers to effective pain management
The evidence suggests that lack of knowledge of pain assessment among some nurses [127] (Level
QE) and doctors [128] (Level EO) is contributing to poor pain management of residents. An
additional concern is the low level of knowledge of pain management of some doctors, as they
have had little formal education in this area. [129–131] The literature citing these deficiencies calls
for a collaborative approach between doctors and nurses to manage pain consistently and well
in the aged care setting [131] (Level QE). It also cites the need for educational programs that give
definitive and objective information on drugs [128,129] (Level EO; Level EO). Some practices have
begun to change. These changes have included improved education of doctors and nurses about
pain assessment and prescribing, development of more responsive assessment tools, improved
treatment strategies, and better practices for monitoring of residents’ pain levels. [130] However,
other barriers to effective pain management still need to be addressed.
There is some evidence that difficulties may be encountered when members of the aged care
team lack the necessary skills for adequate reporting and also lack observation skills [90] (Level
QE). Accurate reporting based on good observation skills is particularly important for those
residents who do not articulate their pain symptoms verbally and rely on a skilled person to
assess their level of pain based upon behavioural cues [132] (Level III-3).
Effective pain management may also be difficult for some residents due to their cultural beliefs.
For example, a recent study found that in some Indigenous Australian communities there was
considerable fear regarding morphine being given at the end of life [133] (Level QE). The common
belief was that morphine was the drug that was given to “get rid of me [them]”. [133, p. 146] This
study also noted that many Indigenous Australians had a fear of needles and did not understand
about drugs and palliative care. This study highlights the need to identify cultural issues for each
resident in all aspects of care delivery. (See also Chapters 10, ‘Aboriginal and Torres Strait Islander
Issues’ and 11, ‘Cultural issues’.)
There is a large body of research demonstrating that some aged care team members may have
misconceptions or myths about pain management [128] (Level EO). These misconceptions can
present major barriers to effective pain management. The following table provides an overview
of some of these myths, and the facts in each case.
Table 8: Common myths about pain management
Myths
1. The best judge of whether a resident
has pain is the doctor or nurse caring
for the resident.
2. Residents should not receive analgesics
until the cause of pain is diagnosed.
3. People with advanced dementia are
unable to use pain-rating scales.
Counter-Facts
The resident is the authority on his or her pain. Their selfreport
is the most reliable indicator of the existence and
intensity of pain.
Symptomatic relief of pain should be provided whilst the
investigation proceeds. Unrelieved pain is unacceptable and
if ignored it can make it more difficult for adequate pain
control to be achieved. It is also important to remember that
the clinician’s primary diagnostic tool is not pain.
When an appropriate pain rating scale (e.g. 0–10) is used and
the person is given sufficient time to process and respond,
many cognitively impaired residents can use a pain rating
scale.
Guidelines for a Palliative Approach in Residential Aged Care 73