Management of terminal cancer pain in Sweden: a nationwide survey

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Abstract
The aim of this nationwide survey was to evaluate the extent of pain problems, the principles of pain management and the use of newer drug delivery techniques in terminal cancer patients. ‘Terminal period’ was defined as an expected life span of about 2 weeks. Another aim was to evaluate the level of knowledge of physicians and nurses and to assess their educational needs regarding management of cancer pain. A total of 456 questionnaires were sent to chairmen and head nurses of 6 major specialities (228 departments) that treat cancer patients in Sweden. Depending on the speciality, each questionnaire consisted of 50–60 questions. The response rate was high, ranging from 79% (surgeons) to 100% (gynecological oncologists). During a 1-year period 3767 patients (about 10% of total cancer population) were admitted to hospitals due to severe cancer pain. The results show that almost all physicians follow the analgesic ‘ladder’ principle recommended by WHO, prefer the oral route for morphine administration, prescribe opioid analgesics on a regular ‘by-the-clock’ basis and in unrestricted doses. However, about 30% of physicians believe that all patients have moderate to severe pain at the time of their death. Up to 78% of physicians and nurses believe that periodic severe pain is common in terminal cancer patients. In general physicians do not evaluate different pain types nor do they use any instruments for measurement of pain intensity. Surprisingly intermittent subcutaneous (s.c.) or intramuscular (i.m.) injections of morphine are preferred to continuous s.c., intravenous (i.v.) infusions or to intermittent s.c. administration through an indwelling butterfly needle. Few physicians routinely prescribe prophylactic laxatives. Antidepressive medication is rarely used. Neuropathic and bone metastasis pain appear to be poorly managed. More than 50% of physicians and nurses admit that they have inadequate knowledge about pain evaluation techniques, newer analgesics and newer drug delivery systems. More aggressive use of opioids administered by more humane routes and better use of adjuvant therapy can be expected to improve pain management for the terminal patient. There is also a need for better physician and nurse education.