2. OUTLINE
Concept of Pain and Terminal Illness
Causes of Pain in Terminally ill Patients
Pain Theory
Assessment and Management of Pain
Causes and Management of suffering in
Terminally ill patients
Fatigue: Causes, Assessment and
Management
Sleep Disorders: Assessment and
Management
Pruritus: Assessment and Management
Conclusion
References
3. Concept of Pain and Terminal Illness
• An irreversible or incurable disease condition
from which death is expected in the
foreseeable future
• A state of actively dying
• At this time, the patients physiological
functions wane
4. DEFINITION OF PAIN
• The international association for the study of pain defines ‘pain as an
unpleasant sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage.’
• McCartney defines pain as whatever the experiencing person says it is
, existing whenever he says it does.
5. CAUSES OF PAIN IN TERMINALLY ILL PATIENT
• Pain in terminally ill patients can arise from various factors
both physical and psychological
Physical Physiological Pain
6. CAUSES OF PAIN CONTD.
1. Underlying diseases progression
2. Invasive procedures and treatments
3. Neuropathic pain
4. Musculoskeletal pain
5. Visceral pain
6. Side effects of medication
7. Psychological and Emotional distress
8. Functional decline
9. Spiritual or existential pain
8. CLASSIFICATION AND TYPES OF PAIN
• LOCATION/SITE OF ORIGIN
1. Somatic pain
2. Visceral pain
3. Sympathetic pain
• OTHERS
1. Mixed pain
2. Referred pain
9. PAIN THEORIES
• Specificity theory
• Intensity theory
• Pattern theory
• Gate control theory
• Biopsychosocial Model
• Cartesian dualistic theory
10. SPECIFICITY THEORY
• Specificity theory holds that specific pain receptors transmit signals to
a pain center in the brain that produces perception of pain.
• This theory is based on the assumption that free nerve endings are
pain receptors
11. INTENSITY AND PATTERN THEORY
• INTENSITY THEORY (Erb, 1874)
This is also called the summation theory and defines pain as an
emotion that occurs when a stimulus is stronger than usual rather than
a unique sensory experience.
• PATTERN THEORY(Goldschneider, 1920)
This theory holds that there is no separate system for perceiving pain
and the receptors for pain are shared with other senses such as touch,
however, non damaging as well as damaging stimuli give rise to non
painful or painful experience as a result of difference in the pattern of
signals sent through the nervous system.
13. BIOPSYCHOSOCIAL MODEL
• Biopsychosocial model states that pain is not simply a
neurophysiological phenomenon but also involves social and
psychological factors.
16. ANALGESIC LADDER
• By the clock
• By the mouth
• By the ladder
1. Mild pain;non opiods (e.g acetaminophen,nsaid etc) with or
without adjuvants.
2. Moderate pain; weak opiods (e.g codeine, tramadol ) with or
without adjuvants or non opiods
3. Severe and persistent pain; strong opiods (e.g morphine) with or
without adjuvants or non opiods
17. NON-PHARMACOLOGICAL
• Physical therapy
• Cognitive Behavioural Therapy
• Mindfulness and relaxation techniques
• Biofeedback
• Acupuncture and Acupressure
• Nutritional and Dietary interventions
• Education and Support groups
18. CAUSES OF SUFFERING IN TERMINALLY ILL
PATIENTS
• Suffering in terminally ill patients often result from a combination of
distressing symptoms, emotional challenges and existential concerns.
• Some common causes of suffering in terminally ill patients includes;
• PHYSICAL SYMPTOMS
Pain, Fatigue. Dyspnea, Nausea and vomiting, constipation.
• PSYCHOLOGICAL DISTRESS
Anxiety, Depression, Existential angst.
19. CAUSES OF SUFFERING IN TERMINALLY ILL
PATIENTS
• SOCIAL AND EMOTIONAL CHALLENGES
Isolation and loneliness, Caregiver stress, Loss of independence,
• SPIRITUAL AND EXISTENTIAL CONCERNS
Loss of meaning, unresolved grief, search of meaning and purpose
• SYMPTOM BURDEN
Inadequate symptom management and Lack of palliative care support
20. NURSING MANAGEMENT OF SUFFERING
1. Pain management
2. Symptom control
3. Psychosocial support
4. Communication and advance care planning
5. Spiritual and existential support
6. Family and caregiver support
7. Comfort ad dignity
8. Continuity of care
21. CAUSES OF FATIGUE IN TERMINALLY ILL
PATIENTS
• Disease progression
• Anemia
• Medication side effects
• Nutritional deficiencies
• Sleep disturbances
• Psychological distress
• Deconditioning and reduced mobility
• Cachexia
22. CACHEXIA
• Cachexia is a multifactorial syndrome
characterized by
• involuntary weight loss,
• muscle wasting and
• metabolic abnormalities.
• The metabolic changes associated with
cachexia including increased energy
expenditure and altered cytokine levels, these
factors contribute to fatigue and weakness.
23. ASSESSMENT
• The FACIT Fatigue Scale
• Priority nursing assessment for fatigue and lethargy involve the following ;
1. Persistent tiredness
2. Difficulty concentrating
3. Decreased motivation
4. Physical weakness
5. Sleep disturbance
6. Irritability and mood changes
7. Reduced tolerance to stress
25. NURSING MANAGEMENT
• Assessment and identification of underlying causes
• Symptom management
• Medication review and adjustment
• Nutritional support
• Sleep optimization
• Physical activity and rehabilitation
• Psychosocial support
• Monitoring of symptoms
26. CAUSES OF SLEEP DISORDERS IN TERMINALLY
ILL PATIENTS
• Sleep disturbances are common in terminally ill patients and can
significantly impact quality of life. Factors contributing to sleep
disorders include;
1. Pain and discomfort
2. Dyspnea and respiratory symptoms
3. Gastrointestinal symptoms
4. Neuropathy and neuropathic pain
5. Medication side effects
27. CAUSES OF SLEEP DISORDERS IN TERMINALLY
ILL PATIENTS
1. Functional decline and bed rest
2. Unmet psychological and spiritual need
3. Environmental factors
4. Psychological distress
5. Circadian rhythm disruption
28. NURSING MANAGEMENT
• Management of sleep disorder in terminally ill patients require a
multifaceted approach that addresses
• underlying physical symptoms,
• psychological distress,
• medication management,
• environmental factors and
• supportive care needs
29. CAUSES OF PRURITUS IN TERMINALLY ILL
PATIENTS
• Dry skin
• Real failure; uremic pruritus
• Liver dysfunction;
• Medication side effects; opiod use, antibiotics, chemotherapy agrnts
• Neuropathic itch
• Circulatory changes
• Environmental factors
• Systemic illness
30. ASSESSMENT
• History taking
• Medical history
• Physical examination including skin integrity
• Assess severity, intensity and impact of itching using numerical scales
• Psychosocial assessment
• Environmental factors
• Documentation
31. NURSING MANAGEMENT
• Management of pruritus in terminally ill patient requires a multidisciplinary
approach aimed at identifying and treating underlying cause, alleviating
discomfort and improving patients quality of life
1. Identify and address underlying cause
2. Skin care and hydration
3. Topical treatments
4. Pharmacological management
5. Cooling measures
6. Non pharmacological interventions such as distraction techiques
7. Regular monitoring and reassessment
32. Conclusion
• Although, terminally ill patients are actively dying and on a way to a
journey of no return, but the professional and active role of nurses
can cushion their pain and make their journey to the world beyond
more peaceful and less stressful.
33. REFERENCE
• Textbook: Bruera, E., Higginson, I., Von Gunten, C. F., & Morita, T.
(2015). Textbook of Palliative Medicine and Supportive Care, Boca Raton:
CRC Press.
• Ferris, F., Von gunten, C.F. Fast Facts and Concepts #37. Pruritus. May
2015.
• Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH,
Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-
inflammatory drug (NSAID) therapy in patients with hypertension,
cardiovascular, renal or gastrointestinal comorbidities: joint
APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut. 2020
Apr;69(4):617-629. [PubMed]
34. REFERENCE
• Cuomo A, Bimonte S, Forte CA, Botti G, Cascella M. Multimodal
approaches and tailored therapies for pain management: the trolley
analgesic model. J Pain Res. 2019;12:711-714. [PMC free article]
[PubMed]
• Trachsel LA, Munakomi S, Cascella M. Pain Theory. [Updated 2023 Apr
17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK545194/
