64. The quality of cancer pain management should be evaluated at points of transition in the provision of services (e.g., from the hospital to the home) to determine that optimal pain management is achieved and maintained (C).
65. For pain management to be effective, each practice setting should designate who will be responsible for pain management (C) .
66. Policy and standard procedures, which define the acceptable level of patient monitoring and appropriate roles and limits of practice for health care providers, should govern the use of specialized analgesic technologies (C).
To assure optimal pain management, formal means should be developed and used within each institution for evaluating cancer pain management practices (American Pain Society, Committee on Quality Assurance Standards, 1990; National Institutes of Health Consensus Development Conference, 1987) and should include feedback regarding the adequacy of pain relief. Optimal pain management requires the interaction of all members of the health care team including the patient. A formal process should be developed to evaluate the quality of pain management across all stages of the disease and across all practice settings.
Quality pain management begins with an affirmation by health care professionals that patients should have access to the best level of pain relief that can safely be provided. In any setting, the quality of pain control is influenced by the training, expertise, and experience of clinicians. Practice settings vary considerably in size, complexity, resources, and patient populations. In addition, the goals of pain management may differ depending on the cause of the pain and the stage of the disease. Different pain management programs are therefore suitable in different practice settings, but the responsibility for pain management should always be assigned to the clinicians most knowledgeable, experienced, interested, and available to respond to patients' needs quickly.
One aspect of pain management that should be considered when evaluating quality of care is the multiplicity of settings where cancer care is provided. Patients with cancer receive care in ambulatory care centers, clinicians' offices, hospitals, their own homes, nursing homes, and hospices. Pain management should be evaluated at points of transition in the provision of services to ensure that optimal pain management is achieved and maintained.
The key items to consider when developing a formal program to monitor the provision of pain relief are
The implementation of this guideline requires collaboration across disciplines and among clinicians. Three elements are essential for interdisciplinary collaboration: A common purpose, diverse professional skills and contributions, and effective communication and coordination of services (Spross, 1989). The common purpose is the relief of the patient's pain. To meet this goal, the diverse and complementary skills and contributions of each health care professional should be recognized and used. At times, however, interpersonal issues of power, leadership, and conflict can hamper efforts to relieve pain. Competent leadership and attention to conflict resolution are vital for building teams
and keeping them focused on their shared purpose. The following elements will help ensure effective communication and collaboration:
Clarity among professionals about what they can and will contribute (e.g., who will coordinate pain management--the primary nurse and attending physician or a specialized pain control team? Can consultants write prescriptions or orders?).
Decision making that reflects the input and preferences of the patient and family, such as providing a number of pain control choices that include pharmacologic and nonpharmacologic options.
Contingency planning, including orders to avert or treat possible side effects; a range of analgesic doses to deal with varying pain intensity; ongoing followup of cancer-related pain problems; and clear directions about whom the patient or caregiver should notify if changes in the plan are required.
In institutional settings, regular interdisciplinary meetings of clinicians to maximize communication and information sharing and to ensure appropriate planning. The following recommendations (adapted from American Pain Society, 1992) should be implemented in every practice setting where patients with cancer receive care:
1. Promise patients attentive care. Patients should be informed, orally and in writing, that effective pain management is an important part of their treatment, that talking about unrelieved pain is important, and that health care professionals will respond quickly to reports of pain. It should be made clear to patients and families, however, that the total absence of any discomfort is not always an achievable goal.
2. Assiqn responsibility for pain management to clinicians most knowledgeab-le, experienced, interested, and able to respond to patients' needs in a timely fashion.
3. Document the assessment of pain and its relief. An assessment of pain intensity and pain relief should be recorded, regularly reviewed by members of the health care team, and incorporated into the patient's permanent record. The intensity of pain should be assessed and documented regularly (depending on the severity of pain) and with each new report of pain. The degree of pain relief should be determined after each intervention, once a sufficient time has elapsed for the treatment to reach peak effect. A simple, valid measure of intensity and relief should be selected, and the patient and family should be instructed in the use of the tool. For children, age-appropriate measures should be used (see Chapter 2 and Chapter 7).
4. Define pain and relief levels to trigger a review. Each practice setting should identify values for rating pain intensity and pain relief that will elicit a review of the current pain therapy. The proposed modifications in treatment should be documented, and the effectiveness of the modified treatment should be reviewed subsequently. Cleeland, for example, has shown that when patients indicate a level of "5" or above on a scale from 0 to 10, the patient's ability to function is markedly affected (Cleeland, 1984).
5. Survey patient satisfaction. At regular intervals, as defined by the practice setting and the quality improvement committee (if available), each setting should assess a randomly selected sample of cancer patients who have pain. Patients should be asked to rate their current pain intensity, the worst pain intensity in the past 24 hours, the degree of relief obtained from interventions, side effects associated with pain management, satisfaction with relief, satisfaction with the responsiveness of clinicians, and the extent to which their preferences in pain management were taken into account.
6. Analqesic drug treatment should comply with two basic principles:
Oral analgesics and other noninvasive routes of administration are used whenever possible and administered in accordance with the principles expressed in the WHO analgesic ladder.
Analgesics are titrated to maximally effective doses or the appearance of dose-limiting side effects before specialized invasive analgesic approaches are used.
7. Monitor use of specialized analgesic technologies. The administration of intraspinal opioids, systemic or intraspinal PCA, continuous opioid infusion, local anesthetic infusion, and conscious or deep sedation should be governed by policy and standard procedures that define the acceptable level of patient monitoring and appropriate roles and limits of practice for all health care professionals involved. The policy should include definitions of physician and nurse accountability, physician and nurse responsibility to the patient, and the role of the pharmacist.
8. Offer nonpharmacoloqic interventions: Physical modalities and cognitive- and behavior-based interventions can provide substantial pain relief. Such interventions generally should be used to supplement, not replace, pharmacologic interventions.
9. Monitor the efficacy of pain treatment. Periodically review pain treatment procedures using the practice setting's quality improvement mechanisms.
PAIN IN SPECIAL POPULATIONS
Pain in Neonates, Children, and Adolescents
Assessing the Adequacy of Pain Management Strategies (Children)