Introduction
Palliative care is associated with two major components. The first component is related to the emotional and psychological care of the patient and family members. The second component is based on the identification of pain and utilizing pain relief interventions based on current evidence. Palliative care is mainly provided by healthcare providers with a support from a team of experts trained and experienced in palliative care (Kwon, 2013. p. 910). The main objective of palliative care is relieve the patient from pain and pain symptoms. Palliative care and effective pain management are the cornerstones for a terminally-ill patient. The process of pain management varies depending on the healthcare setting. Nurses play a crucial role in pain management. However, there are many barriers in providing pain management in palliative care. It is important to assess and resolve these barriers (Kwon, 2013. p. 910)
Nurses are concerned with health outcomes and the quality of care for terminally-ill patients. Based on current evidence, nurses face a plethora of barriers in providing best healthcare services with respect to pain management in palliative care (Wilkie, Diana, & Miriam. 2012. p.360). Some of these barriers include complex rules and regulations, lack of knowledge, misconceptions of opiate use, financial restrictionss, terminal-illness other than cancer, cultural attitudes/beliefs, and separation and differences within the inter-professional team, patient, and family members. (Hebert, et al. 2011. 327). Nurses would have to overcome all these barriers to provide best healthcare services to the patient.
Theoretical perspective of pain management in palliative care
Many theories have been developed with respect to end-of-life pain management such as the comfort theory by Katharine Kolcaba. The theory was recognized in 1990 with respect to the comfort of the patient as an important factor to be considered in healthcare prior to all major interventions. The theory is based on the 3 elements of comfort in the patient, i.e. relief, ease, and transcendence. These 3 elements form a major part of the pain management provided by nurses in palliative care. The theory is also based on a fourth element that has a holistic approach towards patient care. This is the most crucial factors that should be considered by nursing professionals involved in palliative care. (Boudiab LD & Kolcaba K. 2015. p.270)
Key concepts in pain management for palliative care
Palliative care forms the fundamental factor in the nursing profession. Since the inception of comfort theory and pain management for terminally-ill patients, many guidelines and polices have been developed in order to provide a standard. Some of the guidelines developed for pain management in palliative care include National Institute for Health and Care Excellence (NICE), American Family Physician (AFP), WHO, and BPAC guidelines. All standard guidelines recommend the use of opioids as the first-line of treatment for pain management. Since most patients are known to be relieved from pain, the comfort theory and the pharmacological approach of opioids on pain management have become the standard of care worldwide. The WHO analgesic ladder for pain relief has been highly criticized. The ladder consist of 3 steps, the first step including a non-opioid, followed by a weak in the second step and a strong opioid in the third step. However, the significance and clinical outcome from the transition has not been established. Thus, it is important to establish a standard for pain management in palliative care by addressing barriers (Fadare, JO et al. 2014. p. 725).
Research methodology
PUBMED, Google Scholar, and COCHRANE library were utilized to search and review papers for this dissertation. The keywords used to search relevant papers include: Palliative care, pain management, pain relief, end-of-life care, barriers in pain management, nurse and pain management, nursing in palliative care, and pain guidelines. Only papers published in English and on or after 2010 were selected. Individual case reports, interviews, and review articles were excluded from the study. Papers with paediatric population were excluded from the study. The inclusion criteria for the study were as follows: Meta-analysis, randomized controlled studies, systematic reviews, and guidelines.
Barriers to effective pain management in palliative care
Nurse face a dilemma while proving palliative care to patients. Most of the patients are terminally-ill and are considered in a vegetative state. Nurses play a critical role by easing out pain and pain symptoms among such patients (Bowen, Liza. 2014. p. 143). However, there are many barriers while providing pain management interventions to such patients based on current evidence. A major barrier in providing palliative care is financial restrictions and burden (Santha, S. 2011. p.25) Most nurses have observed that patients from low-income groups have reached the last stage of the illness and can opt for cheap healthcare services (Prem, et al. 2012. p.125). his restricts the nurses to provide best pain management facilities to the patient. Palliative care is no cheap in developed nations such as US and UK. However, financial restrains force patients to opt out of such programs (Santha, S. 2011. p.25)
Based on current evidence cultural attitudes and beliefs have acted as a major barrier in pain management for palliative care (Steinberg, S. M. 2011. p. 155). Ethic groups and communities based on religion and caste have varying perceptions about treatment interventions and medications. Nurses find it difficult to adhere to such varying and contrast patient perceptions. Many patients have opinions on the disease process, treatment, and management that may affect the overall quality of care provided by the nurse. (Steinberg, S. M. 2011. p. 155). Most culture and religions in Asia would not accept artificial life support and pain relieving medications. This has a direct impact on the conceptual framework and guidelines for pain management in palliative care (Steinberg, S. M. 2011. p. 155).
In the US and other developed nations, a new concept of care management has been adopted by patients (Khosla, et al. 2014. P 152). The new concept has been identified as a new barrier by researchers and healthcare professionals since it hinders with the concepts and policies of pain management in palliative care (Khosla, et al. 2014. P 152). The barrier is based on having different and separate healthcare professionals for each of service. Patients opt for a separate nurse, dietician, physician, caregiver, and doctor in order to provide healthcare services. Nurse identifies this adopted concept as a major barrier in pain management services since it increases time and effort to understand and recognize potential and key stakeholders of the patient (Ersek, Mary, and Joan G. Carpenter. 2013. p. 1185). Furthermore, patients refuse to disclose names of allied healthcare professional and force to provide the selected healthcare service. This has a negative impact on the service provided by the nurse since it creates gaps in care management. This issues has to be addressed and made aware among patients (Khosla, et al. 2014. P 152).
Application of pain management in healthcare practice: Recommendations for practice
Nurses play a critical role in pain management of terminally-ill patients. Nurses are known to act as educators, motivators, and advocator for such patients. Nurses in palliative care are not responsible for the pharmacological management of pain but also the psychological, spiritual, emotional, and physical symptoms of pain (Rome, et al. 2011. p. 350). Nurses should also address and educate the patient’s family members on pain management. Based on current evidence, nurses play a role as a caregiver and bring out a positive impact on the well-being of the patient. Moral support, pain relief, and psychological care are key focus areas that nurses need to focus while providing pain management in palliative care (Rome, et al. 2011. p. 350). Thus, it is of utmost importance to identify the barriers in pain management for the nursing profession. This paper provides an overview on the various barriers observed in pain management in palliative care through a systematic review of current evidence.
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