CHAPTER 33 Nursing patients who need palliative care

Introduction

Caring effectively for people with a progressive, life-limiting illness presents a number of challenges for the multiprofessional team. Nurses have an important role to play in assessing care needs and managing the impact of an incurable illness on the patient and their family. Nursing knowledge and skills are vital contributions to the delivery of high-quality palliative care that enables patients to experience a good quality of life and a peaceful, dignified death, and their family to cope with bereavement.

The first part of this chapter defines palliative care and explores the fundamental principles of this approach. Consideration is given to how palliative care is provided within different settings and the range of services and teams which may be involved. The middle section has two parts: first it focuses on how the principles of palliative care may be applied in clinical practice, including communication with patients and families, and secondly on the evidence-based strategies for the management of common, distressing symptoms. The chapter concludes by exploring issues specific to the final phase of the patient’s illness and considering how these may be addressed by effective end-of-life care.

What is palliative care?

The most widely accepted definition of palliative care was first provided by the World Health Organization (WHO) (1990). The most recent version states:

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

This clearly portrays palliative care as an active approach to assessing and managing care needs, far from the perspective that ‘nothing more can be done’ for the patient when their illness cannot be cured. The aim is to support the patient in living as comfortable and fulfilling a life as possible as their illness progresses towards death. It is important for health care professionals to recognise that dying is more than a physical experience and that suffering has psychological, social and spiritual dimensions which can also envelop those closest to the patient. This requires consideration not just of the physical disease process, but also the effects on the patient as an individual and their family when planning and delivering care. The palliative care approach is therefore person-centred, holistic and multidimensional (Box 33.1).

Box 33.1 Reflection

Principles of palliative care

The World Health Organization sets out what palliative care involves, for example relieving pain and other distressing symptoms, and a holistic approach through the integration of the physical, psychological and spiritual aspects of care (WHO 2009).

Effective palliative care is essential, especially so when you consider that in most countries the majority of people will first access medical services when their illness is already advanced (WHO 2009).

Resource

World Health Organization (WHO) – WHO Definition of Palliative Care, 2009. Available online http://www.who.int/cancer/palliative/definition/en/.

Historically, a number of terms have been associated with palliative care. These include ‘care of the dying’, ‘hospice care’, ‘supportive care’, ‘terminal care’ and ‘end-of-life care’. Birley & Morgan (2005) highlight that these terms are often used interchangeably and thus are open to misinterpretation.

A number of factors may have contributed to the varied terminology used to describe palliative care. Improved health and social care alongside advances in medical technologies have caused an epidemiological shift in the main causes of death within the developed world. From the late nineteenth century onwards, mortality rates from infectious diseases, childhood illnesses and maternal deaths have gradually declined. As a result, the average life expectancy has significantly increased and has now reached the highest level on record for both men and women (Office for National Statistics 2008). This has led to a steady rise in the incidence of life-limiting illnesses with more prolonged disease trajectories such as cancer, chronic respiratory and cardiovascular disease, for which more sophisticated diagnostic and treatment options have improved prognosis and length of survival. This means that an increasing number of people are living longer with progressive and ultimately fatal conditions. Kellehear (2007) provides a comprehensive and thought-provoking account of how in modern society the predominant conception of dying has shifted from an event characterised by a rapidly fatal or sudden demise, to that of a process of transition. This is now commonly referred to as ‘living whilst dying’ and ‘the dying process’, which can extend over weeks, months, even years.

Following the World Health Organization definition, the palliative approach is applicable from the time a life-limiting illness is diagnosed, throughout the patient’s illness and into bereavement support for the family (Figure 33.1). This includes all stages of the disease trajectory including whilst the patient is receiving treatments which, although cure is not possible, may prolong their life or help control symptoms. Supportive care is integral to the palliative approach in helping the patient and family cope with the impact of the disease and the uncertainties and losses of the dying process. Terminal care refers to the last stage of the patient’s illness, where there is increasing disability and dependence and death is anticipated in the near future. End-of-life care is delivered in the last days of the patient’s life and will be considered in more depth later in this chapter.

Figure 33.1 The scope of palliative care.

The development of palliative care

In the United Kingdom, the palliative care approach was pioneered by Dame Cecily Saunders, attributed as founding the modern hospice movement with the opening of St. Christopher’s Hospice, London, in 1967. This was a milestone in the history of palliative care, from which has evolved the person-centred, holistic approach underpinned by research and evidence-based practice that is now recognised worldwide.

In 1987, twenty years after the opening of St. Christopher’s Hospice, palliative care was awarded the status of a medical specialty by the Royal College of Physicians in recognition of the growing body of knowledge and expertise in care of the dying generated within the hospice setting. Since then there have been further significant advances in clinical practice, research and education for health care professionals. As a result, there is now a substantial evidence base underpinning palliative care and greater expectations from both professionals and the public that suffering can be alleviated and a ‘good death’ achieved.

This is reflected in the wide range of guidelines, protocols and standards available to guide clinical practice and the delivery of care, including those from government advisory bodies and regulatory organisations such as the National Institute for Health and Clinical Excellence (NICE), NHS Quality Improvement Scotland (NHS QIS), the Care Quality Commission (CQC) (in England) and the Scottish Commission for Regulation of Care (SCRC).

The need to apply the principles of the palliative care approach developed within hospices to the care of patients dying in their own home, hospitals and nursing homes has received increasing attention. From reviewing place of death within England and Wales over the past 30 years, Gomes & Higginson (2008) highlight that most people with a life-limiting illness are cared for and die in these settings. The full breakdown of place of death is approximately:

• 5% within a hospice

• 17% within a care or nursing home, or other residential setting

• 18% at home

• 58% in hospital

• 2% other.

Furthermore, Gomes & Higginson (2008) project that, in line with an aging population, the demand for palliative care in general hospitals and the community setting will rise significantly by 2030.

As the majority of care for the dying is delivered within hospitals, the community and nursing homes, palliative care is a core responsibility of all health and social care professionals in these settings. Yet, increasing societal awareness and expectations of palliative care contrast sharply with reports of variation and deficiencies in care provision and the unmet needs of dying patients (Costello 2004, National Audit Office 2008). This has prompted development in two main areas:

• the expansion of hospice and specialist palliative care services

• introduction of frameworks to support professionals in delivering palliative care within mainstream services in both hospital and community settings.

The expansion of hospices and specialist palliative care services

Hospices were the first specialist palliative care services and there are currently over 200 inpatient units in the UK (Audit Scotland 2008, National Council for Palliative Care 2007). Patients may be admitted for a variety of reasons including assessment, rehabilitation and symptom management, respite stays to give families and carers a short break, and terminal care.

From the 1990s onwards, the specialty of palliative care expanded with the development of services within the hospital and community. These include specialist hospital palliative care teams, day hospices and community palliative care teams. Some of these specialist services are partly funded and hosted by independent and charitable organisations, such as Marie Curie Cancer Care, whilst others are fully funded and based within the NHS. Charities such as Macmillan Cancer Support have provided the financial backing to initiate a number of specialist posts and developments to support the delivery of palliative care within general, mainstream services. The contribution of these charities is recognised by the continued use of their name and this has led to a plethora of titles for similar posts, for example clinical nurse specialists in palliative care may also be known as Macmillan Nurses and Marie Curie Homecare Sisters.

The core dimensions of specialist palliative care services are:

• Multiprofessional teams of health and social care professionals with advanced knowledge and skills in palliative care, having completed post-qualification accredited education and substantial clinical experience. They include palliative medicine consultants and clinical nurse specialists, together with a range of expertise provided by physiotherapists, occupational therapists, dietitians, pharmacists and social workers.

• The provision of specialist interventions and direct care for patients and families with moderate–high complexity of palliative care needs.

• The provision of advice and support for other professionals within general hospital and community care settings in applying the principles of palliative care in clinical practice.

• Advancing the specialty of palliative care through research, audit, education and practice development initiatives (National Council for Hospice and Specialist Palliative Care Services 2002, NHS Quality Improvement Scotland [NHS QIS] 2004).

Specialist palliative care services are not involved in the care of all patients with a life-limiting illness but operate on an advisory and referral basis. Other health and social care professionals, such as GPs and district nurses in the community and ward teams in hospitals, can request advice regarding how to address the needs of patients and families under their care. They can also refer patients and families with more complex needs for specialist assessment and direct intervention, for example in managing difficult pain and other symptoms, and psychological and spiritual distress. In this way, the expertise of the specialist team is shared through joint-working to address palliative care needs, although the referring team retains overall clinical control and responsibility for the patient (Box 33.2).

Supporting general palliative care within community and hospital settings

Current health care strategy emphasises the need to ensure access to a high standard of palliative care for all patients with a life-limiting illness within all care settings (Department of Health [DH] 2008a, Scottish Government 2008). Traditionally, hospices have provided care predominantly for people with cancer. It would appear that this is generally still the case from reports that during 2006–2007, 93% of those referred to specialist palliative care services across the UK had a diagnosis of malignancy (National Council for Palliative Care 2007). Cancer remains a leading cause of death in the developed world (see Ch. 31). Studies have identified, however, that people dying from non-malignant life-limiting illnesses such as advanced cardiac and respiratory diseases, dementia and stroke have just as great a need for palliative care as those with cancer (Solano et al 2006).

It has already been highlighted that the incidence of both malignant and non-malignant life-limiting illnesses is rising, with a corresponding increase in demand for palliative care. In addition, greater awareness of inequity of access to effective care across settings and for some patient groups has made strengthening the delivery of palliative care within mainstream hospital and community services a priority. Developments towards this include the introduction of The Gold Standards Framework (Thomas 2003) and the Liverpool Care Pathway for the Dying (Ellershaw & Wilkinson 2003) to support the delivery of a high standard of palliative care in all settings.

The palliative care approach in practice

This part of the chapter considers the palliative care approach in clinical practice. A model of palliative care is presented which can be used as a guide to applying the principles of palliative care when caring for patients and families.

The palliative care approach – a model for practice

The model for practice is presented as a guide for the clinical nurse in the twenty first century (Figure 33.2). In accordance with the Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Professional Practice, this nurse is a critical thinker. This means challenging assumptions and looking for creative and workable solutions to problems, critically reading literature and appraising research and, in partnership with the multiprofessional team, implementing reflective, evidence-based practice.

Figure 33.2 The palliative care approach – a model for practice.

Each dimension of the model is presented and discussed. It is important to recognise that these dimensions are interrelated and interdependent.

Fundamental to person-centred palliative care is therapeutic communication with the patient and family, therefore this forms the core of the model. Holistic assessment and care management relates to the overarching aim of palliative care and the patient experiencing a quality of life and a dignified death. This requires consideration of the wide range of physical, psychological, social and spiritual issues which may arise from a life-limiting illness and the individual responses of the patient and family to their situation. Multiprofessional teamwork emphasises that the knowledge and skills of different health and social care professionals are vital contributions to the provision of holistic palliative care. Effective symptom control maximises independence and comfort and thus allows both the patient and family to focus on goals and activities which are important to them. The dimension of advance care planning identifies palliative care as a proactive approach to care as well as responsive to the current needs of the patient. Planning ahead for anticipated changes in condition allows the patient’s wishes to be considered regarding their future care and treatment, a quality of life to be maintained and the distress of unnecessary hospital admissions avoided.

Therapeutic communication

Effective communication with the patient and family is central to the delivery of palliative care. Knowing how the illness affects the person, what they think and how they feel about their situation provides the basis for care appropriate to their individual needs and goals. If a key aim of palliative care is that the patient experiences a quality of life, then professionals need to understand exactly what that means for them. Quality of life is a subjective experience and therefore we need to consider what is important to the patient and what gives their life meaning. How do they perceive the illness affects them, their family and their quality of life?

Eliciting this information requires effective and sensitive communication between professionals and patients. This can be termed therapeutic communication, which differs from the social communications integral to everyday life in relation to context, purpose and the communication skills used by the professional.

The purpose of therapeutic communication is primarily supportive to the patient and family in the context of care provision and provides the medium by which professionals can gain an accurate understanding of care needs. Therapeutic communication also allows information needs to be identified and addressed, at a level appropriate to the individual patient and family to ensure their understanding. From summarising research in this area, Duke & Bailey (2008) report that the effective provision of information has been shown to reduce distress and enhance compliance with treatment and the ability to cope with the practicalities of living with and dying from a life-limiting illness. Professionals have a responsibility to be aware of how well they communicate with patients and families, and this can be supported by critical reflection on practice. This responsibility extends to then developing the necessary knowledge, skills and confidence in the use of strategies which support effective interaction with the patients and families under their care.

A full discussion regarding skills and strategies for therapeutic communication is beyond the scope of this chapter, however some key points are considered below.

Therapeutic interaction with patients and/or families may take the form of an assessment interview, a one-to-one discussion or interaction with patient and family together. Preparation is important in ensuring that the nurse has as much information as is available regarding the patient’s condition, history and circumstances. Patients often feel they have to repeat information over and over again to different professionals and this can be frustrating and extremely tiring for those already fatigued because of their illness. The patient’s case notes should be read, as they may contain a great deal of the required information regarding diagnosis, previous treatment, current issues and problems. Members of the multiprofessional team may be able to provide further details, including those in other care settings: for example the district nurse may be able to provide useful information for hospital staff regarding the care needs of the patient at home and any family issues. It is wise to remember, however, that the nature of a life-limiting illness means that issues and problems change over time and that how they are perceived by the team caring for the patient may be different from those causing the greatest concern for the patient. This means the nurse should work from an informed basis but check and expand their understanding of the patient’s situation and importantly, related perceptions and concerns.

The ideal situation for therapeutic communication is one in which privacy is provided without interruption. The patient’s physical comfort should be attended to. The purpose should be made explicit and the patient’s consent obtained to proceed. Patients and families need to feel secure that confidentiality will be maintained. It is often believed that patients realise that they are being cared for by a multiprofessional team and that they therefore implicitly agree that information given to one professional may be openly shared with others. This should not be assumed. It is useful to remind patients and families that information which is relevant to their care is shared within the multiprofessional team and to emphasise that they do not have to talk about areas they prefer to keep private. The ethics of confidentiality are beyond the scope of this chapter (see Nursing and Midwifery Council 2008 and Further reading, e.g. Dimond 2008, Griffith & Tengah 2008).

Attention to non-verbal behaviours such as maintaining appropriate eye contact, sitting rather than standing beside the patient and adopting an open posture, slightly leaning forward rather than sitting back with crossed arms and legs, can display warmth and respect. The use of paralinguistic responses can encourage the patient to continue to talk and shows the nurse is paying attention. Active listening is a key skill and incorporates close attention to not just what the patient is saying verbally, but their facial expression, tone of voice and behaviour, which can convey the meaning and emotion behind their words.

The flow of discussion should be paced according to the patient, who is encouraged to talk about their main problems and concerns. Open questions such as ‘Can you tell me how this affects your day-to-day life…?’ give the patient the opportunity to provide rich and detailed information from their perspective. In contrast, closed or focussed questions such as ‘How many times a day does this happen?’ provide more specific information, particularly when clarification is needed or when the patient is too tired or breathless for a lengthy discussion.

From skilful use of questioning it should be possible to appraise the patient’s understanding of their illness and expectations regarding care. Patients are individuals in how they cope with a life-limiting illness. This includes what they understand about their illness from the information provided by professionals, how they interpret changes in their condition and their social circumstances and their psychological coping style. This can also influence what they wish to discuss and when, and their choice to do so should be respected. Asking an open question such as ‘Can you tell me what you understand about…?’ allows the patient to exert some control over what is discussed and how they respond. If the patient becomes tired or upset at any time, the nurse must enquire if they wish to stop. The patient may wish to conclude the interview or, where the expression of the emotions is appropriate and needed by the patient, they may simply wish some time. In this situation, the importance of sensitivity and the nurse’s presence should not be underestimated. An upset or distressed patient should not be abandoned. If, however, they require some private time alone or with their family, then reassurance should be given that the nurse will return at an agreed time in the very near future or sooner, should they request.

There may be occasions where the nurse does not have the information required to answer a question or address a concern. Honesty is the best policy, alongside acknowledgement that the question or concern is important to the person. Reassurance can be given that the nurse will direct their question or concern to an appropriate member of the multiprofessional team. Dying patients and their families do not expect every professional to have all the answers; however, dishonesty or failing to acknowledge their concerns can undermine their trust, confidence in and openness with the multiprofessional team (Costello 2004).

When speaking to families it is important to note that where the patient has capacity their permission and wishes should be ascertained regarding disclosure of information. Family members can offer useful information regarding care needs and may be the greatest source of support for the patient, including supporting their wish to be cared for at home. Family dynamics do vary, however, and therefore an understanding of roles and relationships ensures that the patient’s wishes can be respected whilst addressing the concerns of the family, reinforcing the principle that family support is an integral part of palliative care (Payne 2007).

In concluding the interaction, summarising key points which have been discussed is a useful strategy. This lets the patient and/or family see that the nurse has listened and understood what they have said and provides the opportunity for them to add more detail or correct any misunderstandings. The summary should include agreeing any required actions or changes to plan of care and allows the nurse to ensure their understanding of any information given. Screening for any other issues gives patients and/or families the opportunity to raise any concerns which they have not yet mentioned. Following such interactions, the nurse will clearly and succinctly document relevant information and communicate any immediate issues to the appropriate multiprofessional team member. In this way, care is patient-centred and consistent whilst avoiding the need for patients to repeatedly provide the same information to different team members.

Holistic assessment and care management

Holistic assessment is a key activity in palliative care and directs the use of appropriate strategies for care needs associated with the physical, psychological, spiritual and social impact of the illness on the patient and family. A number of approaches may be used. These include quantitative measures such as rating scales to measure the severity of a symptom, for example pain assessment tools (see Ch. 19), and more qualitative approaches such as history taking. Whatever approach is used it is imperative that it is multidimensional so that the assessment captures a full and comprehensive picture of the palliative care needs of the patient and family. Some key assessment questions which can be adapted for a holistic assessment include:

• Can you describe what …… is like?

• How bad is it – at worst/at best?

• How often does … … happen?

• What makes … … better/worse?

• What do you think is causing … …?

• How does … … make you feel?

• What does … … mean to you?

• How does … … affect your day-to-day life?

A plan of care can then be devised which reflects the principles of palliative care. Attention to detail is important, as is continuous review because of the complex and progressive nature of the dying process.

Multiprofessional teamwork

From review of the principles of palliative care it can be identified that no one profession can meet all the care needs of the patient and family. A holistic approach requires the skills and expertise of different professionals. Nurses play a central role within the multiprofessional team which includes facilitating communication and coordinating the input of other team members in patient care. This may include a range of professionals including the physiotherapist, occupational therapist, chaplain, social worker and dietitian.

Effective multiprofessional teamwork is, however, more than just a group of professionals involved in the care of the same patient and family. Speck (2006) outlines a number of challenges for the multiprofessional team in palliative care. These include ensuring a shared understanding of goals and objectives and that a blurring of traditional role boundaries can occur when all professionals share a holistic perspective. Effective communication and coordination of activity across a wide team is essential to avoid the risk of fragmented care and key needs not being identified and properly addressed.

Advance care planning

A thorough understanding of the pathophysiology of the patient’s illness offers direction for anticipating likely disease progression and associated issues. Effective palliative care requires consideration of what problems may arise and, where possible, the instigation of measures to prevent them or facilitate their timely management. This includes ensuring adequate medications are available, including on a prn ‘as required’ basis should the patient’s symptoms worsen. Unnecessary hospital admissions can potentially be avoided by providing ready access to equipment and increased social support should the patient’s condition deteriorate and ensuring that out-of-hours services have essential access to information.

Ascertaining the wishes of the patient regarding future care and treatment is an important part of care planning and nurses play a key role in acting as the patient’s advocate and supporting an informed choice. This may include decisions concerning resuscitation which can present a number of ethical and practice issues for nurses. The General Medical Council GMC (2010) and the Scottish Government (2008) have produced guidance regarding this sensitive area of care.

The patient’s preferences regarding place of care during their illness and at the end of life should also be explored using therapeutic communication. Patient’s wishes may change over time and therefore decisions should be sensitively revisited as appropriate when circumstances change. Recently, the use of the Preferred Place of Care document to communicate and support patient choice across care settings has been advocated in England and Wales (Department of Health 2008b).

Effective symptom control

The key components of symptom control in palliative care are well described (see Further reading, e.g. Hanks et al 2009). In summary, the multiprofessional team must work with the patient to:

• make a thorough assessment of each symptom

• discuss causes and treatment options

• plan symptom management in light of the patient’s expectations and priorities

• evaluate regularly with changing condition and progressive disease.

When administering medications for symptom control the most appropriate route for the patient must be considered. If, for example, the patient is regularly nauseated or is vomiting, then they are unlikely to fully absorb oral medications and likewise, if drowsy at the end of life, may be unable to swallow. In such situations parenteral administration is appropriate, usually via continuous subcutaneous (s.c.) administration by syringe driver. This avoids the need for repeated injections and is less invasive than the intravenous route. Patient choice must also be considered: for example, some patients with stable pain may prefer an adhesive transdermal analgesic patch which is changed every 3 days to taking oral analgesics regularly by mouth.

The effective control of some common distressing symptoms is discussed below.

Nursing management and health promotion: common distressing symptoms

This part of the chapter focuses on the management of four common distressing symptoms: pain, nausea and vomiting, constipation and breathlessness. See Further reading (e.g. NHS Lothian 2008, Fallon & Hanks 2007) for information about other symptoms, such as cough, hiccup, delirium, etc.

Pain

Pain is one of the most feared symptoms of a terminal illness and is estimated to occur in up to 70% of patients with cancer and 65% of patients dying from non-malignant diseases (Fallon & McConnell 2006). Despite the complexity of this symptom, a vast amount of knowledge is available regarding strategies for effective management. However, pain that is not identified will not be treated, and pain will not be treated vigorously enough if its severity is underestimated.

It has now been accepted that the patient’s self-report is the most reliable indicator of pain. However there are challenges to this in practice. Self-report of pain may not be an option in the confused or non-verbal patient. Observation of behaviour and proxy reporting from carers then becomes the main method of assessing the pain of these individuals (Royal College of Physicians, British Pain Society and British Geriatrics Society 2007).

In addition, there are personality, attitudinal and cultural reasons why people do not reveal their pains. These range from being loath to admit to an increase in pain as they perceive this may signify progression of their disease, to being unwilling to admit that the best efforts of the multiprofessional team have been to no avail.

Patients who are dying commonly have more than one pain. The nurse committed to helping the patient must therefore systematically assess and document the following information about each pain the patient is experiencing:

• location

• severity

• radiation – does the pain move or travel from its original site?

• type – is the pain described as dull/gnawing/shooting/burning/spasmodic?

• when started

• aggravating factors

• alleviating factors.

The severity of pain can be assessed using visual or numerical analogue scales, for example by asking the patient to score their pain on a scale of 1–10 where 0 equals no pain and 10 equals the most severe pain possible (see Ch. 19). Some patients may prefer rating their pain as none/mild/moderate/severe or simply using their own terms. It is important to find a way of rating pain severity that is clearly understood by both the patient and the multiprofessional team. From this shared understanding of how bad the pain feels, management strategies can be targeted most effectively and patient distress minimised. Professionals must remember that in a palliative context, the patient may have been experiencing pain for some time. The physiological indicators common to those with acute pain, e.g. tachycardia and raised blood pressure, may therefore be absent.

It is also important to ask the patient about their pain now and when at its worst. This can detect the presence of ‘incident pain’ which is pain that only happens at certain times or is triggered by specific events, for example the patient may rate their hip pain as 0 out of 10 when sitting at rest but 9 out of 10 when trying to walk or bend. This has obvious implications for the patient’s quality of life and maintaining their independence for as long as possible.

How the patient describes the character of their pain helps determine the type of pain they are experiencing. Pain which is described as shooting or burning may denote nerve or neuropathic pain whilst aching and gnawing pain over a joint may indicate bone pain from secondary cancer or severe arthritis. The type of pain is a key factor in selecting the most appropriate choice of analgesics and interventions.

The nurse should discuss the findings from the assessment with medical staff and other relevant members of the multiprofessional team, such as the physiotherapist. It is essential that this be done in an informed manner by giving a detailed description of the pain as outlined above. It is poor practice when requesting medical attendance or input from other professionals for the nurse just to give the blank statement that the patient is in pain.

An accurate diagnosis of new pains is usually derived from observation, discussion and physical examination by the doctor. A full assessment is essential, as new pains may require laboratory or radiological investigations and other treatments, as well as analgesics.

Analgesic medications, given regularly to prevent the recurrence of pain, are central to effective pain management in palliative care. It is essential that an adequate, regular dose is calculated and administered, enabling the patient to be as comfortable as possible without being drowsy.

Principles have been established by the WHO (1986, 1996) to guide health care professionals in the effective management of pain. In addition, guidelines such as the Scottish Intercollegiate Guidelines Network (SIGN) (2008) publication Control of Pain in Adults with Cancer are readily available online. Registered nurses must have a working knowledge of these principles and guidelines to promote good multiprofessional understanding and patient confidence.