Palliative care and hospice pain experts provide best practice care guidelines

One hospice reduces pain 100% in 48 hours

Hospices may be the leaders in pain management, but most could improve their efforts by following best practice guidelines and initiating a quality improvement process, several pain experts say. “It’s been well documented over the years that pain is poorly managed for many reasons,” says Frank Forte, MD, director of medical oncology/hematology and director of palliative medicine at Staten Island (NY) University Hospital.

“Not the least of which is the fear people have of side effects, the fear of becoming addicted, the fear that it will be stigmatized, and a lot of other things that are both patient- and doctor-related,” he says. “Many patients who are older think it’s good to suffer in silence and think good people don’t complain — so, for all of these reasons, chronic pain and cancer pain have been poorly managed.”

Forte has been involved with PC Quick, a collaborative quality improvement project, funded by the RAND Corp. of Santa Monica, CA, and the United Hospital Fund of New York City. “One of the initiatives we did was to see whether or not pain could be better managed at our hospital,” he says. “Before that, we had formed a palliative consultation service, so we did a comparison to see whether pain was relieved better with patient consultations or during the usual and customary way of caring for them.”

After analyzing outcomes among 29 patients, it became obvious that patients who received care from the consultation service had better and faster pain relief than those who didn’t, Forte notes. “So, our goal was to make this an initiative where everyone would do better,” he adds.

The Hospice of the Western Reserve of Cleveland also has a continuous quality improvement process for pain management that was instituted in 2000, reports Mary Kay Tyler, MSN, CNP, pediatric nurse practitioner/team leader and chair of the pain subcommittee. “We are constantly reevaluating our practice and making sure we have the most cost-effective tools to assess pain,” she explains.

The hospice has always followed pain management basics and maintains a transdisciplinary team approach to pain management, notes Bridget J. Montana, MS, APRN, MBA, chief operating officer. “It’s everyone’s responsibility to observe and report,” she says. “Any time a team member is with a patient, they’ll observe the patient’s pain and ask the individual to rate the pain.”

If the patient’s pain level differs from what is usually reported or if the patient reports feeling uncomfortable, then this information is reported to the primary nurse and the rest of the team, Montana adds. Everyone involved in patient care, including the hospice volunteers, are trained and educated about pain assessment and management, she says.

As a result of the hospice’s pain program, a recent chart audit of 109 patient charts showed that of the 64% of patients who experienced pain, 75% had their pain reduced within 24 hours and 100% had their pain reduced within 48 hours, Montana says.

The positive results were achieved partly because of the hospice’s adoption of a tool that can be used to assess pain among patients who are unable to verbally indicate their discomfort, Tyler says. The PAINAD scale, which was developed by nurse researchers through the Department of Veterans Affairs, enables clinicians to use nonverbal cues to determine a patient’s level of pain and discomfort, she explains. (See PAINAD scale.) “PAINAD was developed for patients with dementia, and we have adapted it to use with any patients who are noncommunicative,” Tyler says. “It looks at nonverbal cues, including facial grimacing, crying, things like that.”

Caregivers also are educated

Hospice staff educate caregivers to use the tool so they can observe the loved one and report their observations to a nurse, she adds. “This is particularly important in our elderly and pediatric populations,” Tyler says.

Also, the hospice uses pain management protocol cards, which are continuously updated. These are laminated and placed on a ring so nurses can carry them on patient visits, Montana says. (See principles of pain management chart.) “The cards are tied into our drug list, not only for the proper medication for symptoms, but also for looking at pharmacokinetics and the economics of drug prescriptions,” she says.

The hospice has a preferred drug list, as many hospices have these days, and this helps solidify the best practices, says Janice Scheuffler, PharmD, clinical pharmacist with the Hospice of the Western Reserve.

Staff are audited for compliance

The hospice also uses audits to make certain staff are following pain management best practices and to evaluate why problems have arisen, she says. “We have an audit committee that looks at outcomes measurements on all kinds of topics, including pain, and we hit charts and outcomes research hard,” Scheuffler adds.

Another dimension to the hospice’s pain management best practices is the staff’s focus on a holistic approach to reducing pain and suffering, Tyler says.

Industry taking notice

While the physical aspect of pain and suffering is the easiest to understand, the hospice and palliative care industry increasingly are recognizing that there are many things that cause people to suffer, she notes. For example, patients also might suffer from distress caused by spiritual questions of why this is happening to them and the financial stress of wondering how the family will continue financially without them, as well as emotional problems resulting from loneliness and loss, Tyler explains.

The hospice’s pain management committee has been working to determine the chief circumstances that cause suffering among the hospice’s patient population, she reports. This type of holistic approach to pain management is important because if a patient is suffering from a spiritual, financial, or emotional problem, then it may be difficult to manage the patient’s physical pain unless this other problem is addressed, Tyler says. “The health care community throws pain and suffering together, but they’re very different,” she notes.

Research has shown that patients view pain and suffering as separate entities and, even patients who report no pain frequently will report experiencing some suffering.1

“We’re very conscious that suffering is such an all-encompassing emotion that we don’t want people to go in with a checklist, asking, ‘Are you suffering? Is this bothering you?’” Tyler says. “We want to integrate assessing suffering into our practice and educate staff about how to identify when someone might be suffering.”


1. Baines BK, Norlander L. The relationship of pain and suffering in a hospice population. Am J Hospice Palliat Care 2000; 17(5):319-327.

Need more information?

  • Frank Forte, MD, Director of Medical Oncology/ Hematology, Director of Palliative Medicine, Staten Island University Hospital, Nalitt Institute, 256 Mason Ave., Staten Island, NY 10305. Telephone: (718) 226-6606. E-mail:
  • Bridget J. Montana, MS, APRN, MBA, Chief Operating Officer, Hospice of the Western Reserve, 300 E. 185th St., Cleveland, OH 44118-1330. Telephone: (216) 383-3730.
  • Janice Scheuffler, PharmD, Clinical Pharmacist, Hospice of the Western Reserve, 300 E. 185th St., Cleveland, OH 44118-1330.
  • Mary Kay Tyler, MSN, CNP, Pediatric Nurse Practitioner/Team Leader, Chair, Pain Subcommittee, Hospice of the Western Reserve, 10645 Euclid Ave., Cleveland, OH 44106-2206. Telephone: (216) 502-4440.