Pain management in adult palliative and end‑of‑life patients
This concise guide covers pathophysiology, assessment and practical management of pain in adults with advanced illness or in the last days of life, with emphasis on emergency/acute care priorities, safe opioid use, anticipatory prescribing and regulatory safety issues. Recommendations align with UK guidance (NICE CG140, NICE NG31) and MHRA safety advice.
Scope and clinical priorities In the ED or acute setting the immediate aims are:
- Rapidly assess pain severity, reversible causes and concordance with the patient’s goals of care (document ReSPECT/DNACPR where present).
- Relieve distress promptly using safe, titratable analgesia.
- Prevent and treat opioid adverse effects (especially constipation).
- Provide a clear plan for ongoing control or anticipatory (“just‑in‑case”) medicines for community/inpatient teams and arrange follow‑up or specialist input as needed (NICE CG140, NG31).
Brief pathophysiology - implications for treatment Pain in advanced disease is often multifactorial:
- Peripheral nociceptor activation from tissue injury (mechanical, thermal, chemical, metabolic) with mediator release (prostaglandins, bradykinin, substance P) - responds to opioids, NSAIDs and local measures.
- Peripheral and central sensitisation - may require higher opioid doses and adjuvants.
- Neuropathic mechanisms (nerve infiltration, chemotherapy neuropathy) - respond poorly to opioids alone; use adjuvants such as gabapentinoids, tricyclic antidepressants and SNRIs.
- Visceral pain is poorly localised and may be referred; investigate for reversible causes (for example obstruction, urinary retention,...